The development of a conceptual framework and model for sexual health education in upper secondary schools in Northern Viet Nam Nearly half the Vietnamese population is under 25 years, and among this group, there is a rapidly rising incidence HIV and STDs. There is an urgent need to develop strategies to improve young peoples knowledge and understanding of sexual health. Currently, teachers lack the knowledge and confidence to effectively teach sexual health and there was no conceptual framework underpinning the curriculum (Thanh, 2010). This study developed a conceptual framework and model for sexual health education programmes for upper secondary schools in North Viet Nam and made recommendations for education policy and practice. The study methods were based on the first cycle in action research, an approach recognised in Viet Nam for changing professional practice. Key to this study was Jarvis (2004) description of lifelong learning, Kolbs (1984) experiential learning cycle and Problem Based Learning teaching documentation and discussions with Vietnamese government officials and NGOs working in sexual health. The findings revealed that most pupils did not understand or did not practice safe sex, and all wanted more knowledge and information. Teachers reported limited knowledge and a reluctance to teach this subject. When the new conceptual framework and models were piloted, they were seen as accessible, acceptable and appropriate for the education system in Viet Nam, and demonstrated measurable changes in teaching and learning. The study is unique, in that it was designed with ministerial support for strategic implementation and sustainability. The Vietnamese government has accepted it. At their instigation, the research is already being used by an international working group for sexual health education in schools. It is also being used by a second international group, working to improve nurse education, and as a result is being piloted in undergraduate nursing programmes.
B ACKGROUND
Vietnam, classified as a developing country, has a youthful population with over 23 million individuals aged 5 to 19 out of 86 million (UNAIDS, 2009) This demographic presents significant challenges for the government as rapid development and Western influences lead to technological and medical advancements, altering employment needs and raising living standards Consequently, young people require enhanced education to meet employers' demands, while their lifestyles shift towards a more Western model This transition affects healthcare services, particularly reproductive health, as increased sexual activity among youth has resulted in a surge of unplanned pregnancies and reproductive tract infections From 1997 to 2001, reported cases of reproductive tract infections among school children rose dramatically from 575 to 7,391 (Centre for Population Studies and Information, 2003).
In Vietnam, sexually transmitted diseases (STIs) are commonly referred to as reproductive tract infections (RTIs), a term considered more socially acceptable This terminology poses challenges, as the proportion of infections that are sexually transmitted is often unrecorded Additionally, there is a significant concern regarding the lack of detailed records for individuals under 15 years old, as internal physical examinations for this age group are illegal Consequently, while infections may be noted, if symptoms resolve, it is assumed that the RTI has been cured, leaving young individuals at risk of long-term fertility issues and the potential to transmit infections to future partners.
State-run clinics distinguish between RTIs and STIs, but private clinics often do not, leading young people to prefer the latter for confidentiality and avoidance of stigma Health data shows that less than 10% of consultations in the past decade have occurred at public clinics, as youth seek to evade the family issues associated with STI diagnoses (UNICEF, 2010).
Young people face significant challenges due to the lack of comprehensive sexual health education in schools, which is often not introduced until students are 15 years old This limited timeframe leaves educators with only two years to cover essential topics related to sexual and reproductive health Government statistics highlight a troubling rise in reproductive tract infections (RTIs) among youth, indicating a critical health issue Health providers express concern over the insufficient knowledge among Vietnamese youth regarding sexual health, particularly in preventing sexually transmitted infections (STIs), HIV/AIDS, unwanted pregnancies, and abortions The incidence of unplanned pregnancies and RTIs has surged, with abortions increasing dramatically from 700,000-800,000 in the 1980s to 1.5 million in the 1990s, a trend that disproportionately affects young teenagers.
Without appropriate age-sensitive sexual health education, the concerning trends in sexual behavior among youth are likely to persist, contributing to the spread of HIV/AIDS A study by the Vietnamese government in 2010 found that while 77.1% of young people aged 15-18 were aware of condoms, only 15% actually used them Furthermore, many reported a lack of formal sexual health education regarding the risks of unprotected sex and the implications of living with HIV/AIDS.
The alarming lack of awareness among young people in Vietnam is concerning, as the country currently has individuals living with HIV/AIDS across all 63 provinces Historically, intravenous drug use was the primary mode of transmission, accounting for 65% of cases due to shared needles However, with increasing sexual freedom, sexual contact has become a more prevalent means of HIV/AIDS transmission The rate of infection has surged dramatically, rising from approximately 3,000 cases in 1992 to 254,000 cases today, with projections estimating 280,000 cases by the end of 2012, according to the Ministry of Health.
As of 2010, nearly 10% of individuals affected by HIV/AIDS are under 19 years old, with 45% between the ages of 20 and 29 (MOH, 2010) The challenge is exacerbated by traditional Vietnamese values, where young people rely heavily on their families for guidance, yet discussing sexual health remains a taboo topic This cultural backdrop, shaped by over two millennia of Feudalism, fosters an environment that emphasizes obedience and hierarchy, leading to a passive approach to learning among youth, who are taught to prioritize submission to their elders over equality (Jamieson, 1993).
The influence of Western culture is increasingly impacting Vietnamese youth, who face pressure to adopt modern, dynamic lifestyles while still adhering to traditional family and academic expectations This duality creates challenges, particularly in accessing vital information on contemporary issues like safer sex, as cultural taboos discourage them from seeking guidance from elders Consequently, young people may feel vulnerable due to a lack of knowledge and support To address these challenges, it is crucial to develop intervention programs that empower Vietnamese youth, enabling them to make informed decisions about their health and social behaviors in a rapidly evolving society.
Dang (2001) identified three key challenges in promoting effective sexual health practices among Vietnamese youth Firstly, teachers lack adequate knowledge of sexual and reproductive health, leading to discomfort in addressing the topic Secondly, parents struggle to discuss these issues with their children due to cultural barriers and a lack of guidance Lastly, there is a significant shortage of resources and capacity, as many international Adolescent Reproductive Health programs have been short-lived, failing to integrate into the country's health and education systems, resulting in a lack of ongoing support and resources (Country Progress Report, 2010).
In Vietnam, while there are services aimed at providing knowledge about safer sex, contraceptive use, and reproductive health through a national family program, these resources are primarily targeted at young married individuals The societal stigma surrounding premarital sex and contraceptive use leads to a lack of official recognition of the sexual activity among young people who are marrying later, resulting in limited access to necessary services (UNICEF, 2010) This issue is particularly concerning when considering the sexual behaviors of young single men Research shows that motivations for premarital sexual intercourse differ between adolescent men and women, with many young women reporting their first sexual experience occurring with a steady boyfriend and with marriage in mind (Brown et al.).
A study by Bélanger and Hong (1998) found that 95% of 279 unmarried women reported having a boyfriend, typically involving a committed relationship and often sexual intercourse In contrast, many men experienced their first sexual encounters with commercial sex workers or casual friends, showing little concern for sexual health when entering steady relationships (Brown et al., 2009) This highlights a critical need for effective health promotion and sexual education programs to address the low rates of safer sex practices (United Nations in Viet Nam, 2011).
Viet Nam, as a post-communist socialist republic that has recently opened its borders, has historically had limited awareness of developed countries, often grouping them under the terms 'the West' or 'the Western world.' This broad categorization has led to a lack of critical examination of these terms, which now encompass any non-Asian country The influx of aid from developed nations following the relaxation of border controls further solidified this perception, as numerous projects aimed at improving the lives of the Vietnamese people often lacked cultural consideration and sustainability strategies Consequently, the Vietnamese viewed these overseas organizations as transient, leading to the continued use of familiar terms to describe them, reinforcing the notion that 'the West' includes all external entities beyond their immediate region.
While the terminology used in Viet Nam is widely accepted, it can be confusing in academic and international contexts due to the diverse heritage, socio-cultural traditions, and languages of the countries involved This study adopts commonly used terms in Viet Nam but provides descriptions of key academic and practical sources for clarity Language considerations are crucial, as the second language for many health care professionals in Viet Nam has shifted from Russian to English, influenced by the internet's growth The document emphasizes the importance of accessible primary sources, primarily from the English-speaking world Although the study does not delve deeply into the social structures of the various countries, it focuses on their approaches to sexual health education and attitudes toward youth and sexual activity Inclusion or exclusion of these approaches is based on their acceptability in Viet Nam and the effectiveness of their sexual health education programs, highlighting the adaptability of strategies for use in the country.
The leading countries influencing sexual health in Vietnam include Australia, Canada, Japan, the Netherlands, Sweden, Thailand, the UK, and the USA (Thuy 2007) American literature on sexual health services highlights a significant philosophical difference in healthcare provision, complicating the integration of their studies with Vietnam's system Limited Canadian research on sexual health in schools lacks applicability to Vietnam, despite a well-integrated education program that emphasizes culturally sensitive information and participative teaching approaches (McKay and Bissell, 2010) However, there is insufficient guidance for addressing cultural resistance, and little focus on changing teachers' attitudes or introducing sexual health education in late adolescence, contrasting sharply with Vietnam's didactic and taboo approach to the subject (UNESCO, 2010) Japan, initially considered a relevant model due to its cultural similarities, faces similar challenges in sexual health education, focusing primarily on reproduction rather than a holistic approach, as noted by Ishiwata (2011) Although Japan is seeking to reform its sexual health education, it remains inadequate Research from Australia reveals a generational gap, with Vietnam lagging behind in acceptance and attitudes toward sexual health Current Australian strategies for teaching sexual health are often cited without detailed discussion on necessary specialized training for teachers (Dyson, 2010) This study emphasizes the need for research that demonstrates effective methods for engaging educators and students in discussions about sexual health, fostering an environment conducive to interactive teaching methods.
Thailand, often perceived as a more open society compared to Vietnam, shares similar challenges in sexual health education A study by Kay, Jones, and Jantaraweragul (2010) revealed a lack of coordination, absence of a national curriculum, and insufficient training for teachers in this area There exists a disconnect between official educational policies and the liberal lifestyles prevalent in tourist resorts, leaving educators unprepared to guide students through the contrasting messages they encounter in school and public life.
M AIN A IMS
• To review current sexual health education provision in upper secondary schools in North Viet Nam
• To develop a conceptual framework and model for sexual health education programmes for upper secondary schools in Northern Viet Nam
• To make recommendations for the development of policy and practice for sexual health education for upper secondary schools in North Viet Nam.
• To explore the perceptions of upper secondary school pupils of sexual health education in both urban and rural areas in North Viet Nam
• To explore the teachers’ perceptions of teaching sexual health (SH) in upper secondary schools in North Viet Nam
• To review in detail the curriculum and information used to teach sexual health in schools in North Viet Nam
• To gather information from key informants regarding sexual health education in secondary schools in North Viet Nam
This article aims to examine learning theories from Western and Asian educational systems to identify those that can support a conceptual framework and model for teaching sexual health education in schools in Northern Vietnam.
• To explore the teachers perceptions of the proposed conceptual framework and model.
The well-being of young people is essential for the future of the country, and schools play a crucial role in influencing their lives by providing coordinated health and sexual health messages This information is vital, as societal attitudes often prevent young people from seeking timely health checks and treatment A study was conducted to understand young people's knowledge and concerns about sexual health, with detailed methodologies outlined in Chapter 4 The findings contributed to the development of a conceptual framework and model for sexual health education, designed for school teachers to effectively address their students' needs.
A PROJECT WITHIN A PROJECT
This study is part of a larger initiative aimed at enhancing university and college-level nursing education in Vietnam to improve community health Funded by Nuffic, the project addresses the critical need for nursing services in the Vietnamese health sector by strengthening nursing-midwifery capacity, establishing appropriate staffing structures, and developing training curricula Key activities included updating the Bachelor and Diploma of Nursing curricula and creating five accompanying textbooks, as well as establishing the first institutional standards for nursing education These efforts have been approved by the Ministry of Education and Training (MOET) and the Ministry of Health (MOH) and are currently being implemented nationwide Additionally, the project aimed to elevate the education of key nurse educators, with eight educators pursuing Master's degrees in the Netherlands and two senior lecturers selected for PhD studies in the UK, allowing them to choose their research topics with approval from MOET, MOH, and the project director These independent studies are designed and executed by the students, supported by supervisors and aligned with their respective universities' guidelines.
This project, part of two PhD studies, focuses on sexual health education in secondary schools in Vietnam and has received approval from the Ministry of Education and Training (MOET) and the Ministry of Health (MOH) It aims to address the challenges posed by globalization on sexual health and relationships among youth in Vietnam The project is supervised by Vietnam's leading professor in HIV/AIDS and sexual health studies, who also serves as a government advisor on related policies.
In Vietnam, sexual health education involves two main groups: school teachers and community nurses, with teachers playing a crucial role as mandated by the Ministry of Education and Training (MOET) This study primarily focused on teachers, who are responsible for connecting with community health services It began by assessing the needs and attitudes of students towards sexual health education, while also examining the perceptions of teachers and other professionals The research reviewed learning theories and developed a conceptual framework for the Ministry of Health (MOH) and MOET to integrate into mainstream education For effective implementation, the framework must include strategies that promote interaction between students and teachers.
Previous NGO projects in Vietnam, such as VIE97/P13, VIE88/P09, and others from 1996 to 2000, focused on public health but failed to establish formal connections with the school curriculum Consequently, these initiatives lacked strategies for integration into mainstream education, leading to their discontinuation after completion.
As a nurse and educator since 2002, I have been deeply concerned about sexual health, particularly in addressing the persistent rates of STIs and HIV in Vietnam My dual expertise in health and education has equipped me to bridge these fields, facilitating essential changes as identified by the Ministry of Education and Training (MOET) and the Ministry of Health (MOH) Pursuing a PhD as a senior lecturer at a leading Vietnamese university not only contributed to my personal growth but also provided a unique opportunity to implement a sexual health education project at the government level This endeavor has further enhanced the capabilities of nurse educators by allowing me to share the knowledge and expertise acquired with my colleagues.
In developing effective school health programs, it is essential to consider the roles of key health professionals, particularly community nurses These nurses are expected to create community-based care services in disadvantaged areas, focusing on low-income and socially underprivileged populations With the rising prevalence of HIV/AIDS and the lack of home care, nurses are increasingly adopting prevention models and providing compassionate care to affected individuals and communities Involving them in sexual health education programs in schools is a logical progression, given their unique community positioning However, while they excel in one-on-one information delivery, they require further education and training in teaching methods and educational theory To facilitate this, the Ministry of Health (MOH) and the Ministry of Education and Training (MOET) must enhance their collaboration to develop new policies and practices for schools.
O UTLINE OF THE STUDY
Chapter 1: Gives a general introduction to the study, outlining why it was selected
Chapter 2: Gives the context in which the study took place by giving an overview of Viet
Nam including the geography, health care and education system regarding sexual health issue in Viet Nam
Chapter 3: In this section, there are two parts, the first is the sexual health and HIV/AIDS situation in Asia and Viet Nam and the second is a comparison of the situation regarding learning in the West and in Viet Nam
Chapter 4: Outlines and discusses the research methods used and key issues such as ethics and ethical approval
Chapter 5: Outlines the result of the survey of pupils’ knowledge and teachers’ perceptions regarding sexual health This chapter also determines the current situation regarding sexual health education in four schools and overall provides the baseline measures for the study
Chapter 6: Gives the results of the feedback of the initial findings, and the results from interviews with government and non - government officials In addition, the process of the information concerning the text books and teaching education documents related to sexual health reviewed to identify the detailed content of the sexual health education curricula in these schools will be outlined
Chapter 7: Contains the conceptual framework of teaching and learning designed to tailor make an education programme in Viet Nam It also outlines the preferred methodology to be used to enable teachers and pupils to become more actively involved in the learning process
Chapter 8: Describes the introduction of the conceptual framework to the teachers and their response to it Also a description of the implications was arising from the findings in the study, including those for nursing education and training as well as for the future
Chapter 9: The limitation, reflections/critique and recommendations for the study have been integrated into one chapter, as this brings together the key issues regarding the study and its use in Viet Nam.
G EOGRAPHY
Vietnam, shaped like the letter "S," is located on the eastern part of the Indochinese peninsula, bordered by Laos and Cambodia to the west, the East Sea to the east, and the Pacific Ocean to the southeast The country spans 1,650 km from north to south and varies in width from 600 km in the north to 50 km at its narrowest point in Quang Binh Province With a coastline of 3,260 km and an inland border of 4,510 km, Vietnam serves as a crucial transport hub between the Indian and Pacific Oceans The nation, characterized by its tropical monsoon climate, has been recognized as one of the Asian Disaster Preparedness Centres (ADPC) since 2003 Approximately 75% of Vietnam's land is comprised of mountains and hills, and for administrative purposes, it is divided into 63 provinces and cities.
H EALTH
Vietnam's tropical climate contributes to the prevalence of tropical and infectious diseases (MOH, 2008) Despite notable advancements, the healthcare system continues to grapple with significant challenges, particularly in enhancing equity, efficiency, and development within a socialist-oriented market economy (Health Financing in Vietnam, 2008) Disparities in health outcomes among different regions and income groups have widened in recent years While the government has made substantial efforts to improve national health, issues such as child malnutrition, infant mortality rate (IMR), and maternal mortality rate (MMR) persist, especially in poorer, mountainous, and remote areas, where progress remains slow compared to the national average.
Recent shifts in disease patterns indicate a rise in both non-communicable and communicable diseases, despite ongoing efforts to curb transmission and enhance treatment (MOH, 2008) New and unpredictable diseases, such as SARS and Avian influenza A (H5N1), have also emerged While Vietnam was among the first countries to successfully treat SARS (WHO, 2003), significant environmental health challenges, including medical waste management and food safety, persist in the health sector (MOH, 2008) Additionally, the revision of outdated health policies has been progressing slowly.
In 2007, Decree number 188/2007/ND-CP outlined the responsibilities and functions of the Ministry of Health in Vietnam; however, many districts have yet to adopt the designated health system model due to non-implementation of earlier decrees The execution of health policies and strategies has faced significant challenges, including inconsistencies in health management information systems that lead to administrative overlaps and gaps Additionally, the development of service quality management systems is still in its infancy, and both state and private sector inspections remain inadequate The role of medical associations in overseeing the quality of medical and pharmaceutical practices is underutilized, and drug price controls are being adjusted in response to international price increases amid rising global inflation.
P OPULATION
Vietnam has a youthful population, with over 45 million individuals aged 5 to 19, representing 52.3% of the total 86 million citizens (Ministry of Planning and Investment, 2011) This demographic trend significantly impacts health and education, necessitating substantial national budget allocations for the education of those under 18 and addressing childhood illnesses The introduction of Doi Moi in 1986 marked a shift towards a market-driven economy, leading to improved health policies and notable reductions in mortality rates (MOH, 2005) In response to population growth, the government has implemented a two-child policy with mandatory spacing between births, although enforcement is challenging, especially in rural areas As the young population ages, Vietnam faces future challenges in elder care, similar to those currently experienced in Western countries.
Figure 2-2: Viet Nam’s population pyramids in 1989 and 2009 (Ministry of planning and investment, 2011)
Since 1986, Viet Nam has emerged as a leading economy, significantly influenced by Western companies seeking affordable labor and advanced technology This has led to a rapid technological revolution, with widespread access to television, mobile phones, and the internet However, many aspects of life have not evolved at the same pace, resulting in stark contrasts within the country Today, 90% of the population still resides in rural areas, where poverty is prevalent, while urban centers face growing challenges due to increasing migration to industrialized regions.
2.3.1 Youth, their place in the community in Viet Nam :
Young people in Vietnam constitute nearly half of the country's population, yet their needs have historically received little attention from the government, which has focused on population control measures Traditional Vietnamese culture, heavily influenced by Confucianism, views youth as belonging to their parents and under their control, making the concept of a distinct 'youth culture' foreign However, since the Doi Moi reforms, economic and societal pressures have begun to challenge these traditional norms, allowing greater access to the outside world and technology This shift is gradually changing the expectations of young people, who still maintain a strong family identity and are expected to care for elderly relatives, contrasting sharply with practices in Western healthcare settings where strangers provide intimate care.
Young people today find themselves navigating between traditional values and the influences of the internet They are often caught between the ideals they have been taught to respect and the glamorous portrayals seen in popular media, such as American and Australian soap operas and films.
In Vietnam, satellite technology is making online games and various digital content more accessible than ever As a result, English is rapidly becoming the dominant language, surpassing French, Russian, and Chinese This shift is driven by students' ability to choose their preferred languages for learning and the fact that English serves as the universal language of the internet.
Today's youth in Vietnam struggle to establish their identity, balancing traditional values with modern aspirations The older generation often fails to recognize them as a distinct group, leading to familial discord as parents grapple with new technologies and the evolving desires of their children This generational gap mirrors challenges seen in Western societies, where parents question how to engage with their youth The situation is particularly pronounced in poorer rural areas, where young people are migrating to cities in search of work, reminiscent of the 19th-century industrial revolution in the UK However, unlike that era, today's youth are constantly reminded of their unfulfilled aspirations through access to high technology, driving their quest for a better life.
Today, there are significantly more opportunities for economic independence compared to the past, when information was limited to local news and survival was the primary focus of life In those times, social mobility was virtually nonexistent, with individuals remaining in their born positions for life However, today's youth reject this notion, as they have been exposed to a broader world Despite their parents' attempts to cling to traditional values, the door to new possibilities cannot be closed.
One significant source of family conflict is the evolving perceptions of sexuality Traditionally, love and sex were viewed as sacred, confined to marriage, and not open for discussion; couples were expected to learn to coexist and raise children together post-marriage (Anh, 2002) However, societal norms have historically imposed stricter chastity standards on women compared to men, leading to a disparity in how sexual activity is perceived; while boys faced little shame for being sexually active, girls were often seen as dishonoring their families and communities (Chi, 2009) This gender-based difference in attitudes towards sexuality continues to persist to some degree.
Today's youth are increasingly influenced by peer and informal networks rather than formal ones, leading to a heightened awareness of their own sexuality Those pursuing further education tend to enter their first romantic relationships at a slightly older age compared to their peers who join the workforce immediately after school However, both groups are experiencing these relationships earlier than previous generations, largely due to the impact of high technology Concerns arise that young people are prioritizing online relationships over personal social interactions, which are crucial for developing essential life skills and a realistic perspective on life Additionally, the lack of control over internet access raises alarms among youth leaders, who worry that the normalization of rape and violence in films may contribute to a troubling acceptance of such behaviors.
In Vietnam, the portrayal of prostitution in media, such as soaps and games, often glamorizes the practice Alarmingly, there are emerging instances of young girls being sexually traded by their peers for financial gain, highlighting a troubling trend (My, 2005; Thanh, 2010).
Young people face challenges in transitioning from traditional practices to a modern lifestyle, particularly when their parents uphold conventional gender roles While they aspire to embrace a Western lifestyle influenced by industrialization, this shift often conflicts with their home life, especially in rural areas where women are primarily seen as housewives and mothers Although urban areas show a theoretical acceptance of changing gender roles, practical conflicts still exist, leading to pressure on women to adhere to traditional values while navigating new expectations This struggle can result in frustration and confusion, as highlighted by Goodkind (1994) Additionally, Johansson (1996) notes that girls in rural areas often bear a heavier burden of family responsibilities compared to boys, spending significantly more time assisting their parents.
The evolving job market demands a more skilled workforce, leading to longer education periods and a trend of young people marrying later While they remain interested in relationships, they are hesitant to make early commitments, highlighting a shift from traditional norms This necessitates addressing previously overlooked areas in education, particularly regarding sexual health, as young people are increasingly influenced by Western media and technology Despite a rise in early sexual activity among youth, parental expectations still emphasize virginity before marriage, creating a significant gap between generational views Recent studies indicate a growing acceptance of premarital sex in Asia, yet young people face peer pressure without adequate sexual health knowledge, putting them at risk Reports show a concerning lack of understanding about contraceptive methods among youth, with no curriculum updates or government initiatives to enhance sexual health education.
In Vietnam, the rise in sexual freedom has led to a significant increase in sexually transmitted diseases (STDs), with reported cases of reproductive tract infections (RTIs) among unmarried young people soaring from 576 in 1997 to over 8,000 by 2001 This alarming trend continues today, yet the actual incidence is likely underestimated due to the stigma surrounding such infections The term RTIs, while more socially acceptable, obscures the true nature of these infections, making it challenging to determine the percentage that are sexually transmitted Societal attitudes discourage young individuals from seeking sexual health checks, resulting in only 5-10% attending public health clinics for diagnosis and treatment The majority rely on private clinics, which are more expensive and often delay seeking help until they can afford it, leading to untreated infections that can impact future fertility National statistics are based on a small percentage of the population at risk, complicating the development of effective health programs for youth Additionally, the rate of abortion among adolescents is rising, with 2.2% of all abortion cases in 2010 involving those under 18, while premarital sex rates among adolescents with limited sexual health knowledge remain below 10%, indicating a significant under-representation of the issue.
Until the 1990s, sexual health education was largely absent in schools, but as society adopts a more Western model with increased sexual interactions among youth, this issue has gained significance Health providers express concern that Vietnamese youth lack essential knowledge about sexual health, particularly regarding the prevention of sexually transmitted infections (STIs), HIV/AIDS, and unwanted pregnancies The absence of sexual health education contributes to rising rates of unwanted pregnancies, abortions, and the spread of STIs and HIV/AIDS, posing a national crisis in healthcare services The future well-being of the youth and the nation is closely linked to educational services, with schools serving as a vital bridge between traditional and modern life Education must equip children and young people for their roles in the community and family, while also extending its reach into the community Coordinated preventive education through schools can effectively disseminate important messages to both school and community populations.
E DUCATIONAL S YSTEM IN V IET N AM
The primary objectives of education in Vietnam focus on nurturing young individuals by instilling an appreciation for Vietnamese culture and society, as well as promoting moral values, knowledge, physical well-being, aesthetic awareness, and professional responsibilities Schools continue to emphasize loyalty to national identity and socialist ideology, aiming to develop students' personalities, qualities, and skills to fulfill the needs of building and defending the Fatherland.
Figure 2-3: Education system in Viet Nam
As the above diagram shows, the education system is divided in four areas, pre-school, general education, professional education and higher education Primary and lower
Master's Degree Short term Higher education
Professional Second Edu (3-4 years) Vocational Training
In many regions, kindergarten and nursery education for children aged three is compulsory, requiring parents to contribute financially to their child's education While the state offers assistance in cases of extreme poverty, some children still do not attend school, and this issue persists without additional government support For minority ethnic communities facing recognized poverty, the regulations differ, as they benefit from government-provided community facilities and free education.
Since the Doi Moi reforms in 1986, Vietnam's education system has shifted from a collective approach to a market-oriented model, leading to the emergence of private schools that charge significantly higher fees than state institutions Initially established to accommodate students who struggled to pass graduation examinations and progress in the state system, private schools have evolved over the past two decades They are now recognized for their superior standards and better preparation for higher education, making them a preferred choice for parents who can afford the increased costs.
The demand for this type of education is rising, especially in urban areas where both parents are employed While it is not mandatory, families are increasingly opting for it, and the costs are typically borne by the parents.
1 Crèches and groups of baby sitters to care for children from three months to three years old All those running or involved in this level of care have to be registered and are regulated by the government
2 Infant school and infant class admitting children from three to six years old This is a more formal preparation for school, and as with the crèches is government regulated
"Young bud" schools are innovative educational institutions that integrate crèche and infant school services for children aged three months to six years This initiative aims to minimize disruptions caused by transitioning to new groups at age three, allowing children to remain in the same environment until they reach six These schools are subject to government control and regulation, ensuring quality and consistency in early childhood education.
1 Primary education is for all children from six to fourteen years old; it is conducted in five school-years from the first to the fifth form The age of pupils admitted to the first form is six years, and before leaving this level of education all pupils have to take graduation examinations
2 Basic or lower secondary education is also compulsory and is conducted in four school years from the sixth to the ninth form Pupils admitted to the sixth form must have a graduation certificate confirming attendance at primary education and that they have passed the graduating examination They must be eleven years old
3 General secondary education is not compulsory; it is conducted in three school- years from the tenth to twelfth form Pupils admitted to the tenth form must have the graduation certificate of basic or lower secondary education and be fifteen years old
Research on the education management system in Vietnam has been limited over the past 20 years Thuan (2010) highlights the significant power of the Ministry of Education and Training (MOET) at the macro-management level, where their roles are defined by laws, policies, and guidelines However, coordination issues between the MOET and local management levels hinder the effective implementation and review of education programs, resulting in overlapping responsibilities and administrative gaps Thuan argues that this lack of clarity in policy formulation among agencies is evident, as demonstrated by the failure to implement successful sexual health education modules developed by NGOs due to insufficient support from MOET personnel.
The education development plan process in Vietnam highlights the limited power of schools in shaping their programs Initially, schools in a province or city develop educational programs, which are then submitted to the Department of Education and Training (DOET) and the Bureau of Education and Training (BOET) for review and adjustments These agencies collaborate with relevant sectors to finalize the program before submitting it to the local People's Committee for approval Once approved, the program returns to the DOET and BOET before being sent to the Ministry of Education and Training (MOET) This back-and-forth process can be lengthy, often resulting in approved plans that no longer align with the actual needs of the schools (Thuan, 2010).
The complexity and bulkiness of the education management system in Vietnam highlight the challenges faced by the Department of Education and Training (DOET) and the Board of Education and Training (BOET) in managing upper secondary schools under the Ministry of Education and Training (MOET) This lack of clarity in organizational structure regulation, as noted by Thuan (2010), indicates that the decentralization of the education management system is more management-centered than school-centered, which hinders schools' ability to adapt to the evolving needs of their students.
Decentralization in schools poses significant challenges, as institutions rely heavily on higher authorities for budgets, personnel, curriculum, and assessment of student outcomes This lack of autonomy often discourages teachers from implementing changes in their teaching methods While some private schools have adopted new management models, the curriculum across Vietnam remains uniform, dictated by a national standard that mandates the use of approved textbooks for all students.
The current quality of teaching and learning in Vietnam relies heavily on a traditional national approach, with minimal acknowledgment of international trends, despite their influence on students.
Vietnamese researchers have increasingly advocated for school-based management systems; however, the lack of implementation and monitoring mechanisms raises doubts about the success of such changes in Vietnam A review of the education management structure indicates that simplifying the process by eliminating certain stages—retaining only the submission of new programs to the Department of Education and Training (DOET) before piloting, followed by submission to the Ministry of Education and Training (MOET) post-piloting—could enhance the framework's effectiveness and reduce the burden on teachers.
H EALTH CARE IN V IET N AM
Vietnam faces significant health challenges typical of developing countries, prompting the government to implement a series of health policies since 2001, supported by international aid from various donors, including the WHO By 2007, the country had established 1,003 hospitals and 825 general clinics, with an average life expectancy rising to 72 years The infant mortality rate decreased from 31.13 per 1,000 live births in 2000 to 20.9 in 2011, while child immunization rates reached 89% These national strategies reflect the government's commitment to enhancing the quality, effectiveness, and efficiency of health services, marking substantial achievements in a relatively short period.
The Vietnamese government has actively promoted preventive medicine through health facilities focused on disease surveillance, early detection, and treatment (Ministry of Health, 2008) This proactive approach enabled Vietnam to effectively control the spread of SARS; however, the country now faces challenges from the rising incidence of HIV/AIDS since border openings To address these issues, it is crucial to develop intervention programs that empower youth to make informed health and social choices Healthcare professionals must enhance their skills in health education and promotion, supported by government initiatives and WHO interventions targeting adolescent health and sexual health (MOH, 2010).
Historically, healthcare was free, but advancements in medicine and rising public demand made this unsustainable From 1975, during the re-unification, to 1986, the gradual introduction of market mechanisms into the socialist system began Despite these changes, the government continues to oversee the types of services offered, encompassing both curative and preventive medicine.
Since 1975, Vietnam has developed a health insurance system targeting vulnerable groups, including mothers, children under six, and the elderly, who receive free healthcare funded by the government In contrast, other groups must pay for healthcare services at the point of delivery Significant changes occurred after 1986 with the emergence of the private health sector, which has gained popularity and plays an increasingly important role in healthcare provision Notably, there have been improvements in drug availability and healthcare equipment, alongside advancements in medical care, leading to heightened demand for and delivery of healthcare services Despite these developments, formal government structures have seen little change since their establishment.
1945 after the war of liberation from France
Figure 2-4: Structure of health system in Viet Nam
Source: Department of Organization and Manpower, Viet Nam Ministry of Health, 2006
The healthcare system is structured with the Ministry of Health (MOH) at the top and communes at the lowest level, where service components are determined by the MOH Each commune encompasses five to twenty villages within a 10-kilometer radius from its center The provincial health bureau and district health center represent the intermediate levels Each tier, from central to district, consists of four components, with curative services flowing from specialist hospitals down to the district level Additionally, specialized research institutes at the central level focus on specific areas such as pediatrics, obstetrics, tuberculosis, and gerontology, providing patient care.
Preventive health is structured through a network of medical institutions at the central level, including colleges, secondary schools, and training centers like the National Institutes of Nutrition, Hygiene and Epidemiology, Malarial Studies, Parasitology, and Entomology This framework extends to provincial preventive medicine centers and district-level preventive medicine teams, ensuring comprehensive health coverage.
Production &health service provisions unit
Village health Village health Village health worker
Commune People’s Commune health Regional policlinics
District health centres Hospital Preventive medicine centres Training classes/units District Pharmacy
In Vietnam, the term "public health" encompasses two main components, with the first being its widely recognized role in describing health services available to the public This definition emerged after the country's unification, as national public health services were established The term continued to evolve post-Doi Moi, reflecting the shift towards capitalism and international connections, distinguishing state services from newly introduced private healthcare options Today, this understanding is so ingrained that accessing official websites often leads to information about health services for travelers visiting Vietnam.
The second component focuses on hygiene and epidemiology, involving medical health interventions aimed at controlling infectious diseases and enhancing public hygiene This is illustrated by the renaming of the National Institute of Hygiene and Epidemiology to the National Public Health Institute In many developed countries, the concept most akin to public health is Population Health, as noted by the CDC in 2011 Population health initiatives are typically organized and overseen by the Centre for Disease Control & Prevention, which was established in 2001.
Public health in Vietnam is an emerging field, with only a limited number of programs and facilities available This situation is insufficient to effectively address the challenges of enhancing the nation's health.
In 2002, the Vietnamese Public Health Association (VPHA) was established in Hanoi as an independent NGO, driven by the growing interest of health care professionals in public health practices from more developed countries Comprising leading health experts, the VPHA aims to foster inter-professional collaboration and recognize health professionals as public health workers in community activities With a network expanding to nine provinces, the VPHA has become an official member of the Vietnamese government, focusing on cooperative efforts to share knowledge, advocate for public health policies, and promote research and training Although it is still formalizing its terms of reference and setting national and local priorities, the VPHA is expected to play a significant role in advancing holistic public health initiatives over the next decade.
The VPHA has not yet engaged in sexual health education due to its early development stage, remaining focused on other educational areas Currently, Vietnam relies on external funding for health improvements, making it less likely for the VPHA to prioritize initiatives in sectors that already receive significant international support, such as sexual health However, concerns over the lack of strategic planning and integration of various projects into mainstream curricula suggest that the VPHA may soon take a more active role in planning and potentially implementing new sexual health education projects for young people.
The VPHA plays a crucial role in connecting with organizations like UNFPA to influence strategic policymaking and support training initiatives at both central and provincial levels It is essential for the VPHA to guide the development and implementation of National Standards and Guidelines for reproductive and sexual health However, challenges arise in establishing effective collaboration between UNICEF, UNFPA, UNESCO, and the Ministry of Education and Training (MOET), as they often operate in silos without sharing ideas or project reports To address these issues, the VPHA must coordinate fragmented projects and interventions, focusing on eliminating the stigma and discrimination that hinder young people's access to sexual health services.
The decentralization system implemented after Doi Moi has significantly impacted public health service provision in Vietnam While it has empowered local provinces and districts to cater to their communities, it has also disrupted the national standardization and sustainability of health programs The government allows local authorities to determine suitable services and activities; however, many officials adhere to traditional practices, leading to a lack of sexual health education initiatives for adolescents.
The VPHA aims to enhance its role by reestablishing national connections and networks to support public health services for young single individuals A final report on this initiative will be submitted to the VPHA, MOET, and MOH, who have shown interest in projects focused on preventative and public health.
In 2006, a significant shift occurred in Vietnam's health insurance policy, expanding coverage beyond just the impoverished to include all households By the end of 2007, approximately 36.5 million people, or 42% of the population, had health insurance, leading to increased care provision by non-public health facilities, with 70% of commune/ward health stations receiving insurance reimbursements The introduction of subsidy documentation required individuals to pay monthly health insurance premiums, with those eligible for social benefits contributing up to 3% of the minimum salary Additionally, the state budget covers 50% of health insurance premiums for households living in or near poverty, facilitating access to medical services for disadvantaged groups.
E DUCATION AND T RAINING FOR HEALTH CARE IN V IET N AM
The training of health professionals in Vietnam encompasses various institutions, including medical and pharmaceutical universities, medical technology colleges, and training centers at provincial and district levels As the health sector evolves, the production of medical equipment and pharmaceuticals is flourishing, supported by a network of pharmaceutical companies, health facilities, and equipment providers.
In Vietnam, commune health centres (CHCs) integrate both curative and preventative health services, staffed by four types of health workers: a doctor or assistant doctor, a nurse, a midwife, and a pharmacist or assistant pharmacist However, coverage is incomplete, particularly in rural areas, leading to reliance on minimally trained village health workers for preventive tasks The government faces the challenge of developing a well-trained workforce to enhance care quality, as most current workers possess only secondary qualifications This educational gap affects service delivery, highlighting the urgent need for investment in training and human resource development Additionally, outdated training programs and low salaries contribute to staff turnover, as health workers are tempted to transition to the private sector or higher-level positions.
2.6.1 Nurse education in Viet Nam:
Nursing is a vital component of the healthcare system in Viet Nam, particularly in patient education and disease prevention, such as HIV/AIDS The country recognizes the importance of a well-equipped nursing workforce, which is essential for strengthening human resources in health The government prioritizes enhancing nursing-midwifery capacity, establishing appropriate staffing structures, and developing training programs and curricula In 2003, the nurse-to-doctor ratio in Viet Nam was significantly below the WHO recommendations, with a ratio of only 1.3:1, highlighting the need for an additional 78,000 nurses by the end of the decade, including over 31,000 trained at the university and college level Currently, the Ministry of Health is committed to providing guidance and investment solutions to enhance the quality of nursing in the country.
In Vietnam, nurse education and training is structured across four levels: elementary, secondary, college, and university University and college training has emerged over the past decade, with most institutions focusing on lower-level nursing education Currently, there are 20 faculties in Universities of Medicine and Pharmacy, around 40 Colleges of Medicine and Pharmacy, and approximately 100 centers offering secondary-level health care training To foster further development in the nursing field, it is essential to enhance the knowledge and skills of nurse educators.
Nurses and midwives must adapt to socio-economic changes and medical advancements by enhancing their knowledge, skills, and clinical techniques They are expected to develop community-based care services, particularly in disadvantaged areas, and support low-income and socially underprivileged individuals Additionally, they play a crucial role in promoting healthy lifestyles among young people, including sexual health education With the rising prevalence of HIV/AIDS and the lack of home care, nurses require effective prevention models and compassionate care skills for affected communities These significant changes are essential for reducing morbidity, mortality, and disability while promoting health equity However, improving nursing care quality to meet these goals remains a persistent challenge, necessitating alignment with government policies regulating health professionals.
Raising the standards of nursing can significantly enhance both healthcare quality and gender equity in the health sector, as 90% of nurses were women in 2005 By promoting nursing as a scientific and knowledge-based profession, we can improve the health of the population while also elevating the status of nurses To achieve this, it is essential to implement policies that enhance the social and economic standing of nurses Additionally, the adoption of ASEAN competencies in 2009-2010 will influence the nursing curriculum and strengthen the preventive health role of community nurses.