Health status and health service utilization in remote and mountainous areas in Vietnam

Self-reported health status and healthcare services utilization of population are indispensable indicators to assess the performance of health system in the context of limited health administration data [1, 2], particularly in developing countries [2, 3]. They contribute evidences not only to estimate the future demand of healthcare [4], but also to evaluate the health disparities among different groups of people, especially vulnerable subjects such as inhabitants in mountainous and remote areas [1, 3]. This information will help to identify priorities and corresponding solutions to protect and promote health status of the population [4].

Self-rated health status is an important outcomes in primary health care [5], a tool for screening diseases [6] and a reliable predictor of mortality [7]. General health status, measured using a self-rated scale, has been widely used in both clinical trials and population health surveys. However, to better understand the health needs of population, it is essential to incorporate dimensions of health-related quality of life (HRQOL), illness and symptoms [2] as well as health care seeking behaviours and services utilization [8]. Several studies have measured HRQOL of the general population [9] and specific groups in Vietnam, including patients with HIV/AIDS [10–13], chronic conditions [14–16], drug users[11, 12, 17–19], and the elderly [20, 21]. These studies have provided a reference group for future assessment of HRQOL and revealed a high proportion of psychological health problems amongst many patients groups. In addition, people living in the rural and remote areas often perceive poorer HRQOL than those in more advantaged regions [9, 15, 20–24].

The use of health services is associated with not only the availability and quality of services but also preferences of clients which are shaped by their experience, beliefs, health status and socio-economic characteristics [1–4, 25–27]. It has been well documented that health care seeking behaviour is different across regions and socioeconomic status. In developed countries, previous studies reported high prevalence of outpatient clinic visits (e.g., 84 % in Singapore [4], 64.1 % in Taiwan [28]). Meanwhile, most people in developing countries preferred self-medication to treat their disease (e.g., 57–69 % in Vietnam [2, 3], 51.2 % in rural China [27] or 48 % in Thailand’s border [29]). In disadvantaged areas of Vietnam, a study conducted by Toan et al. (2003) showed that only 30 % people used public health services, while this proportion in Thailand’s border was 52 % [29]. Factors associated with public health care utilization in those areas included ethnicity, health status and distance [3, 29].

To promote population’s health and quality of life, Vietnam government emphasizes the role of primary health care, with an emphasis on disease prevention, to achieve “Health for All” as recommended by the World Health Organization. At the grassroots level, community health centres (CHCs) have a responsibility to provide primary health care services, which combine both modern and traditional medicine (TM). TM has a long history and plays an important role in healthcare system of Vietnam [30]. Many people believe that TM is safe and efficacious to use and more accessible than modern medicine [30, 31], especially in difficult-to-reach terrains.

In spite of a large literature about self-rated health and healthcare services utilization in various population, there has been little attention given to communities in mountainous and remote areas [3, 27]. The purpose of this study was to explore HRQOL, health status, healthcare accessibility of remote and mountainous residents in both modern and traditional medicine. The results will help the government develop people-oriented policy for vulnerable population and changing the way to provide health services in difficult-to-reach areas.

This study indicated high proportions of health problems across five dimensions of health-related quality of life among people living in remote and mountainous areas in two provinces of Vietnam. In addition, we found that accessibility and utilization of health care services were not sufficient and associated with various social and structural factors. This included household’s economic status, severity of health problems, health care costs, distance to and quality of health and traditional medical services.

The findings demonstrated that women perceived lower HRQOL and more anxiety/depression problems than men. It confirmed findings from previous studies in Vietnam and worldwide [10, 15, 35, 36]. In Vietnamese tradition, women take primary responsibility for taking care of their children and family. Besides, in mountainous or remote areas with poor infrastructure and know-hows for economic development, people have to work hard to feed their family. Those burdens may contribute to a higher proportion of having problems in mental health and lower HRQOL in women than men. In our sample, we found better HRQOL among those who had higher income, meanwhile, health care expenditure, difficulties in accessing health services, and comorbidity were significantly affecting HRQOL of respondents. These results were also found in a study of Topal et al. [37], which was conducted on Turkish immigrants - a vulnerable population, in London, United Kingdom.

When investigating health-seeking behaviours, the findings suggested that CHC was the most preferable health facilities of respondents. CHC is the closest local station that provides primary care and prevention programs [38]. The Vietnamese principles of health system operating include the integration of modern and traditional medicine at grassroots level as well as health promotion programs [39]. However, the underuse of health services and high frequency of self-medication observed in this study could be related to long distance, quality and availability of demanding services [40]. Additionally, the results of multivariate analysis revealed that distance to health facilities was a remarkable determinant of health service utilization, which is also comparable to observations in previous studies conducted in Vietnam [3, 41, 42] and other countries such as Nepal [43], Ghana [44], China [27] and United States [45]. Poor quality of roads, lack of transportations, and travel costs are found to be significant barriers to health care access.

The results also indicated the role of quality care perception as a predictor of healthcare utilization. A study conducted by Nguyen et al. [46] examining CHC utilization in remote and poor Vietnam communes demonstrated that after enhancing service’s quality, the utilization rates of population were improved significantly. Duong et al. [47] had similar results when investigating factors associated with delivery services among women in rural Vietnam. They also underlined the major impact of provider-client relationships on the quality of services. In Nigeria, Obiechina and Ekenedo found that satisfaction with services was a factor affecting health service utilization in university [48].

It is noteworthy that although one third of respondents reported difficulties in accessing health services, about ninety percent of their sample did not have significant obstacles to approach traditional medications. TM plays an important role in of Vietnamese culture and health system [30]. In accordance to our observation, these residents tended to use TM or go see traditional healers, which are available in their villages.

Differences in services access were found amongst different ethnic groups, specifically, Muong people accessed health care service easier than the ethnic majority (such as Kinh people), but more difficult in access to TM. This finding was different from previous studies. Toan et al. suggested that ethnic minority‘s attendance to public health services was lower than the ethnic majority due to their limited language and transportations [3]. However, in our study setting, for example Hoa Binh, majority of health care workers at a CHS were ethnic people or fluent in local languages. This may reflect the progress in government’s efforts to improve quality and coverage of health care services for the poor and disadvantaged areas over the past decade. Nonetheless, a recent study by Malqvist et al. [49] indicated that the ethnicity-based discrimination were still existed in Vietnam, resulting in the lower utilization of the minority ethnic compared to their counterparts.

This is the initial study to emphasize the health status and disparities in health care and TM access among vulnerable population namely Vietnamese mountainous or remote residents, which has been lack of evidence in literature. The data partly contributes to some implications. First, support of communities, encouragement of family and promotion of women’s empowerment are potential solutions to improve quality of life of women [50]. Second, enhancing quality of care, such as enhancing personnel, equipment and facility, could encourage people using health services in CHC in mountainous or remote areas. Nguyet et al. (2012) suggested that whether in poor or less poor communes, the use of CHC will be increased if services meet the minimal standard [46]. Finally, CHC could develop TM services in parallel with modern medicine and guide the residents to use this available medication appropriately. Future studies should explore potential socioeconomic and structural barriers to the access and use of TM services that are provided at commune health stations for common health problems in the rural and mountainous areas.

The study’s strengths comprise the investigation in vulnerable subjects within large geographical areas. In addition, multivariate analysis was used appropriately to adjust the confounders and find the related factors with health status and health utilization. However, the study has several limitations. First, results were obtained from a cross-sectional study, therefore no causal association was established for health status and health seeking behaviours (include TM access). A longitudinal analysis should be required to explore the causal effects among socio-economic factors, health outcomes and health utilization. Second, the data was only collected in a convenient sample, which may not be representative of mountainous and remote areas in Vietnam. Further research in other mountain areas is needed to provide comprehensive evidence for policy-makers. Third, although patient records were required to confirm if respondents had any illness examination in the past, the results mainly based on self-reported data which may subject to recall bias. Integrating self-reported information and clinical examination or health record diary should be conducted for more reliable assessment. Moreover, it is noteworthy that the sample is slightly skewed towards women (62 %) since more women were at home and thus available to be interviewed. This might affect the representativeness of reported health problems since women might perceive their health status different than men. Finally, some factors such as knowledge, attitude and practice of respondents about disease prevention and TM usage were not comprised in this study. Examining those factors may help to develop further appropriate interventions for this vulnerable population.

In conclusion, these data showed the high prevalence of health problems and low proportion of people approaching healthcare services in Vietnam mountainous and remote areas. Large population preferring community health centre and accessing easily traditional medication were suggestions to develop TM services in grassroots health level, especially in mountainous and remote areas.

CHC, community health centre; EQ-5D-5 L, EuroQol- 5 Dimensions – 5 levels; HRQOL, health-related quality of life; TM, traditional medicine.