Table 4.

Themes categorized as enablers and impediments of ecohealth for this case study

Category	Theme	Explanation	Selected quotations
Impediments	Lack of acceptance	People did not want to change their conventional ways of doing research	“For this school, if you look at the topic of Master’s thesis, almost all topics were done in a classical way: epidemiological survey, cross-sectional study…and what they [students] don’t want is to design a study, going to the field, taking samples like [our MSc student] to do analysis. Because [the students] are already staff in different institution so they have a database… to analyse”.
	Not comfortable talking to highly educated researchers	Differing education levels and professional backgrounds impeded communication among some stakeholders	“They [the researchers] are nice and enthusiastic but just our ability is limited. When we [Village Health Workers] meet them [we don’t feel very comfortable] because we are not highly educated, we can’t keep up with them”.
	Terminology	Lack terminology in their native language which made it hard to express ecohealth concept for others to understand	“Actually it [the Vietnamese language] doesn’t have it [the ecohealth concept] now. I, myself, can’t find any Vietnamese word for researchers to understand it clearly. Maybe if someone can combine all the ideas of those people [perspectives of ecohealth], the definition of ecohealth can be clearer”.
	Past history of extractive research	Community members expressed frustration with years of research and seeing no changes.	“The people hope that after the research is done, [researchers] will soon have solutions so that they know the situation [in our commune]. If you just come and ask many times without results, they will say ’they come here and ask many times, take the water samples but we haven’t seen any results’”.
	Lack of interaction	Difficult to maintain a relationship with stakeholders with whom they didn’t have a lot of direct interaction with	“We go regularly to meet them to update about the work… the outputs of the research…I’m talking about the health worker level because in the end you can’t have a lot of relationship with the participants from the community”.
	Differing priorities	Research that was relevant for what researcher’s deemed important did not match the nature of the problem	“For the project objective, we had to make sure it was an environmental health problem. The community’s main health problems were skin problems and diarrhoea. Microbiologists are more concerned about the chemicals -heavy metals in wastewater but our background is in the health, about the diarrheal diseases and parasitic infections. Our study objective and the main problem in the study site did not match”.
Enablers	Consensus	Agreement among groups	“Need to find compromise between you [researcher], the community, and policy-makers [to plan interventions]. But when you implement, I think we need the strong willingness of the Communal People’s Committee, Health Station, other mass organizations, and the community”.
	Equity	Accounted for differences among different groups (gender, stakeholder level, social status, etc.)	“It’s mainly the Women’s Union. If they have their meeting, I would like to have a meeting in this commune about environmental sanitation. Because they [women] are in charge of housework and going to the field. I would like to have a meeting with them because they mainly clean the road. The men don’t do it. The custom is like that”.
	Evidence	The research provided evidence that the community could use	“The people knew before that there was pollution, but now through the researchers, the main influences have been discovered. Why they are infected with helminths? Or where does the diarrhoea come from? They can be aware of that now. It was vague before”.
	Free to express concerns	Health Station Workers and community members were free to ask researchers questions if they didn’t understand the survey questions	“When they [the researchers] come, they often ask if we have any concerns [regarding research]. If yes, we will discuss with them so that it’s easier to do”.
	Funding	Financial contributions from collaborators	“We need financial support to clean and rebuild the facilities so that the environment can be improved. Without funding, the drains would never be clean”.
	A channel for concerns	Through the Health Station, the community could voice opinions to the Communal People’s Committee	“We will give our opinions to the Head of Health Station in a monthly meeting. The Health Station will collect all the opinions and submit them to the upper levels”.
	Networks	Must be well-known among those working in the area; offers access to other opportunities	“I would go to approach them [policy-makers] once I have more evidence and in particular, a bigger network…people working in the Ministry [of Health]… Environment, in the University, in the Institute. We can have some kinds of recognition when we can talk with them”.
	Pluralism	Multiple methods and perspectives, included multiple stakeholders at different levels	“With one person, the problem can’t be seen comprehensively but a group of researchers with the same idea about improving environment for health, there will be many researchers joining and thus, many ideas contributed from many sides. About research with community’s participation, if we have the participation of the community, the information will be more reliable and timely”.
	Research in partnership	Decisions on research made together among partners involved in the research	“We discuss together, identify the problem together and we will do research together with the resources we already have. We are also willing to discuss with people to find other funds, other support to support our common interest”.
	Sharing process	The responsibility for interventions, the data, and results should be shared by stakeholders; each person has a part	“Because when all unions and department co-operate, they can advocate widely to people, the people can follow, and keep good sanitation. It can’t work if just one does it. They can’t go to each person”.
	Commitment to ongoing testing and monitoring	The desire for project commitment to addressing sanitation beyond data collection and research outputs	“I also want the people from the environment section to come here and take the [water] sample for testing so that we can know. Or when you do research, you know the information and you will share information with us so that we can learn from experience”.
	Sharing knowledge gained through research	Village Health Workers shared what they have learned through the research with others in their community	“By talking, for example, with the women here (Village Health Workers) or the neighbours talk with each other or when we have a [Women’s Union] meeting”.