Noncommunicable diseases refer to a wide range of diseases that are not passed from person to person. They have long duration and generally slow progression and are, therefore, generally preventable.1 , 2 The 4 main types of NCDs include cardiovascular diseases, cancers, chronic respiratory diseases (including chronic obstructed pulmonary disease and asthma), and diabetes. According to the World Health Organization, NCDs constitute one of the leading causes of mortality, being responsible for 38 million deaths a year worldwide.2 , 3 Noncommunicable diseases cause not only premature death but also major adverse effects on the quality of life of affected individuals and create substantial adverse economic effects on families, communities, and societies.2 , 4 , 5
Vietnam has been undergoing a rapid epidemiological transition characterized by an increase in the burden of chronic NCDs. Chronic NCDs have been shown to be major causes of morbidity and mortality in hospitals for the whole country.6–8 The rising burden of chronic NCDs in Vietnam is associated with an increase in the demand for health care services, so there is an urgent need to improve the capacity of the health care system for NCD prevention and management.8 , 9
In the context of health care system reform in Vietnam, especially moving toward better responses to the NCD-related health needs of the population, health planners, managers, and policy makers have increasingly been recognizing the need to have scientific evidence on the demand-side perspective of the health care system. However, there have been relatively few studies (10-12) in Vietnam on this important public health issue. To provide some up-to-date population-based information on the responsiveness of the health system in Vietnam with regard to chronic NCDs, this study aims to describe the situation of health service utilization among people with NCDs in a rural area and identify association between the situation of health service utilization among people with chronic diseases and their socioeconomic status.
This was a cross-sectional study, using quantitative approaches.
People were 15 years of age and older. They were classified into 2 groups: (1) adults: 15 to 59 years of age and (2) older people: 60 years of age and older. Health service utilization was analyzed only among people who reported having NCD.
The study was conducted in Quoc Oai district, a rural site located in the North of Vietnam, 20 km west of Ha Noi capital. Quoc Oai district covers an area of 147 km,2 including lowlands and mountains, spreading over 20 communes and a town. The number of households and population of Quoc Oai in 2014 were 46 455 and 175 835, respectively. Per capita income of Quoc Oai in 2014 was VND 26 000 000 (US$ 1100). The health care system in Quoc Oai includes the district health bureau, district hospital, district center for preventive medicine, district center for population, and 21 commune health stations. Ninety percent of commune health stations in Quoc Oai had medical doctors, all of which had midwives or obstetric and pediatric assistant doctors, and most had enough essential drugs.
Sample size and sampling
The data used for this article were obtained from a community health survey conducted in Quoc Oai in 2016. The sample size of the original study was estimated on the basis of the World Health Organization formula for estimating the proportion of households in the district incurring catastrophic expenditure in the setting (catastrophic heath expenditure occurs when a household's total out-of-pocket health payments equal or exceed 40% of household's capacity to pay, an important indicator for measuring universal health coverage). Using the expected proportion of household in the district incurring catastrophic expenditure of 3%, level of significance of 5%, absolute precision of 1%, design effect of 2, and nonresponse rate of about 10%, the final sample size was estimated to be 2.400 households. To select the sample for the study, the district was divided into 2 strata (lowland and mountain). We randomly selected 30 clusters (villages) from the 2 strata (21 lowland clusters and 9 mountainous clusters). In each cluster, 80 households were chosen by simple random sampling technique (total of 2400 households). The interviews on household characteristics were done with the heads of the selected households. The interviews on self-reported health problems, including chronic NCDs, were conducted with up to 2 people per household (1 person 15-59 years of age and 1 person 60 years of age and older). The selection of people for interviews on self-reported health problems was done using the Kish method.10 In this article, health service utilization was analyzed only among people who reported having NCD.
Data were collected through a personal household interview conducted by 12 trained data collectors. Data quality was controlled in the field by supervisors from Hanoi University of Public Health as well as by the investigators of this study.
In this article, the dependent variable is health service utilization (including inpatient, outpatient services) during the last 12 months among people with chronic NCDs. The health care providers include national, provincial, district, and communal health care facilities (both public and private providers). The explanatory variables include (1) gender (male, female); (2) age group (15-29, 30-39, 40-49, 50-59, 60-69, and 70-79 years); (3) ethnicity (Kinh, majority, ethnic minority); (4) completed level of education (illiterate, primary school, secondary school, high school, and college); (5) main occupation (farmer, other jobs); (6) economic status of household classified by local authorities (poor, near poor, nonpoor); (7) living area (lowland area, mountain); and (8) health insurance status (yes, no).
Health service utilization was analyzed only among people who reported having NCD. Both descriptive and analytical statistics were carried out using Stata12 software (Stata Corporation, College Station, Texas). Proportions of the dependent variable of interest (utilization of health care service among people with NCDs during the last 12 months) by sociodemographic status of the study respondents were calculated. Chi-squared tests were used for comparing the rates of utilization of health care service among people with NCDs during the last 12 months by sociodemographic status of the study respondents (bivariate analyses). Multivariable logistic regression modeling was performed to detect the relationships between health service utilization among people with NCD and their sociodemographic status. A significance level of P < .05 was defined.
The protocol of this study was approved by the Scientific and Ethical Committee in Biomedical Research, Hanoi University of Public Health. All human subjects in the study were asked for their consent before collecting data, and all had complete rights to withdraw from the study at any time without any threats or disadvantages.
Table 1 shows the general characteristics of the study sample, including 2168 adults 15 to 59 years of age and 802 older people (60 years of age and older). In both groups, there were more women than men. Most of them belonged to the Kinh majority ethnic group and lived in lowland areas. The proportions of study subjects who had a low education level (primary education or below), working as a farmer were more prevalent among the older people than the younger group. The coverage of health insurance was higher among older people.
Figure 1 presents the prevalence of self-reported NCDs among the study respondents. The overall prevalence of self-reported NCDs among people 15 to 59 years of age and those 60 years of age and older was 18% of the adults and 51%, respectively. In both groups, the most common NCDs were high blood pressure and other cardiovascular diseases, followed by diabetes and chronic respiratory diseases.
The proportions of people with NCDs who used at least 1 outpatient service and used at least 1 inpatient health service during the last 12 months were 68.1% and 10.7%, respectively (the nonutilization rates of 31.9% and 89.3%, respectively). Figure 2 describes the patterns of access to different health care providers among people with NCDs during the last 12 months. In general, the health service utilization rates were higher among older people. The 3 most frequently visited facilities for outpatient service by the adults 15 to 59 years of age were (1) district health centers (19.7%), (2) central hospitals (17%), and (3) provincial hospitals (11.3%). The older people mostly visited (1) district health centers (39.7%); (2) central hospitals (10.6%), and (3) commune health centers (7.4%). For inpatient health services, the health care providers mostly used by both the adults 15 to 59 years of age and the older people were (1) district health centers (6.9%), (2) provincial hospitals (2.1%), and (3) central hospitals (1.8%).
The rates of utilization of health services among people with NCDs during the last 12 months by socioeconomic status are shown in Table 2. The overall rates of utilization of health care service were higher among (1) women; (2) older people; (3) Kinh ethnic group (majority); (4) people with secondary education; (5) nonfarmer groups (those who are government staff, small traders, temporary workers, housekeepers, handicraft makers, jobless); (6) the poor; (7) people living in lowland areas; and (8) health insurance holders as compared with the counter part of the same category. All the aforementioned differences, except the difference by occupation, were statistically significant (P < .05, χ2 test).
Table 3 reports odds ratios and 95% confidence interval from the multivariate logistic regression analyses of relationships between health service utilization among people with NCDs during the last 12 months and their socioeconomic status. After adjusting for other factors in the model, the statistically significant correlates of health service utilization among people with NCDs were (1) ethnicity: ethnic minority was significantly associated with a lower odds of using health service during the last 12 months (odds ratio = 0.4, 95% confidence interval: 0.2-0.8) and (2) health insurance: no health insurance was significantly associated with a lower odds of using health service during the last 12 months (odds ratio = 0.4, 95% confidence interval: 0.3-0.7).
The overall prevalence of self-reported NCDs (18% among the adults and of 51% among the older people found in this study) indicates that the NCD already afflicted a large proportion of the population in Quoc Oai district. This is in line with the findings from a previous research conducted in Bavi district (a rural district of Hanoi capital) in 2007, which found the prevalence of self-reported NCDs of 39.4% among people aged 25 to 74 years.11 Another study conducted in Vo Nhai district, a rural area of Thai Nguyen province in Vietnam, in 2010, also showed that the prevalence of NCDs among the population was 33.4%.12 The result of this study supports the evidence that the burden of disease from NCDs is one of the major health issues in Vietnam13 as well as in other low-resource settings.14–16
Of particular interest in this article is the pattern of health service utilization among people with NCDs. We found that the proportions of people with NCDs who used outpatient and inpatient health services during the last 12 months were low (68.1% and 10.7%, respectively, the nonutilization rates of 31.9% and 89.3%, respectively). This reflects the fact that the health care services for NCDs have not been readily available in Vietnam. The findings on the low rates of utilization of outpatient service at commune health centers (2.9% among the adults and 7.4% among the older people) and inpatient service at district hospitals (3.7% among the adults and 6.9% among older people) raise a big concern about the capacity of grassroots primary health care systems in Vietnam for prevention and control of NCDs. A previous health system study in rural Vietnam also proved that the primary care system in Vietnam has not been ready to serve the NCD-related health needs of the population.9 Another Vietnamese study revealed that commune health centers had not had enough autonomy to implement NCD services.17 The service delivery system was also reported as being fragmented and discontinuous, especially between preventive and curative subsectors. Integrated care and continuity of care are not yet effectively implemented.13
The weaknesses of the health system for prevention and control of NCDs in low-resource settings were also documented from some international studies. A study on initial utilization of community health care services among patients with major NCDs in Southern China found that the proportion of NCD patients who had initial use of community health care services was relatively low (25.56% in rural areas vs 20.79% in urban areas).18 An investigation from Soweto, South Africa, found that only 33.3% of people with NCDs reported accessing a health care service in the last 6 months.15 Similarly, a study from rural Malawi revealed that 37.3% of people with NCDs did not seek any care.19 A systematic review and qualitative meta-synthesis documented 3 major barriers of access to health care among people with NCDs, including geography, availability of health care professionals, and rural culture.20 Another study from Ghana demonstrated that the provision of primary health care services for NCDs is not accessible, equitable, or responsive to the needs of target communities.21
We found 2 significant barriers to health service utilization among people with NCDs in the setting, including (1) ethnicity and (2) health insurance status. Ethnic minority was significantly associated with a lower odds of using health service during the last 12 months. Inequities in health by ethnicity have also been clearly addressed in some recent studies in Vietnam. Malqvist et al22 found that ethnic inequity in maternal health service utilization tends to increase in Vietnam. Ethnic minorities are shown to be more vulnerable than the other groups during this period of economic transition.22 In other research, Malqvist et al23 further suggested that the presence of severe health inequity in health along ethnic lines in all these areas.
Our study showed that having no health insurance was significantly associated with lower odds of using health service during the last 12 months. This affirms the fact that health insurance is an important approach to ensure equitable access to health care in this study. The coverage of health insurance found in this study (47.2% among adults and 72.6% among older people) is lower than the national coverage of 82% in 2017. Data from 48 low- and middle-income countries showed that insurance was associated with higher treatment likelihood for NCDs in low- and middle-income countries. Insurance serves as an important tool in improving NCDs' treatment and in reducing inequities in NCDs' treatment.24 In Vietnam, the draft instrument of the 12th Party Congress on Social-Economic Development for the period 2016-2020 targets to reach the health insurance coverage of more than 80% of the population in 2020. As the poor, the children, the people living in remote, mountainous areas are now already covered by health insurance, the attention for health insurance expansion should be paid to other vulnerable groups such as the near-poor, the farmer, informal workers, and so forth.
We need to note several limitations of this article. First, as our study used self-reported NCD, it may over- or underestimate the reality. In addition, there could be some misclassification such that people who were living with NCD but not aware of, accordingly, were inevitably classified as person without NCD through self-report method by study design per se. Second, in this study, we cannot differentiate “health service utilization for any conditions” and “health service utilization for NCDs.” Third, because the proportion of the people with NCD is significantly smaller than the whole samples, the findings from our analyses may reflect the whole picture of health service utilization among people with NCD in the setting. Because the number of people with NCD was small, we could not perform regression analyses separately for inpatient versus outpatient services. Further studies are needed to give further insights into the issue. The nature of cross-sectional design may preclude the causality.
Implications for Policy & Practice
- The rising burden of chronic noncommunicable diseases (NCDs) in Vietnam is associated with an increase in the demand for health care services. As a result, there is an urgent need to improve the capacity of the health care system for NCD prevention and management.
- This article provides up-to-date population-based information on the responsiveness of the health system in Vietnam with regard to chronic NCDs.
- Given the evidence from this study, actions to improve access to health care services among people with NCDs are clearly needed.
- The capacity of the primary health care system for the prevention and control of NCDs should be ranked a top priority.
- More attention should be paid to health care for the ethnic minority population.
- Strategies to expand the coverage of health insurance also need to be immediately implemented.
Our research has shown that NCD already afflicted a large proportion of the population in rural Vietnam. However, the rate of health service utilization among people with NCD was still low and there existed socioeconomic inequity in the access of NCD services. Given the current study evidence, actions to improve the access to health care services among people with NCDs are clearly needed. Improving capacity of the primary health care system for prevention and control of NCDs should be set as a top priority. More attention should be paid to health care for the ethnic minority population. Strategies to expand the coverage of health insurance also need to be immediately implemented.
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