Self-reported illness and use of health services in a rural district of Vietnam: findings from an epidemiological field laboratory Kim Bao Giang1 and Peter Allebeck2 1 Department of Heal
Trang 1Self-reported illness and use of health services in a rural district of Vietnam: findings from an
epidemiological field laboratory
Kim Bao Giang1 and Peter Allebeck2
1 Department of Health Management and Health Policy, Faculty of Public Health, Hanoi Medical University, Vietnam, 2 Department of Social Medicine, University of Gothenburg, Sweden
Scand J Public Health 2003; 31(Suppl 62): 52–58
Aims: The aims of the study were to assess the pattern of self-reported illness as well as use of health services in a rural
district in Vietnam, and to analyse these in relation to gender, age, educational level, occupation, and economic status
Methods: A population-based survey of 11,089 households was conducted in 1999 Through household interviews, data were
collected on self-reported health, use of health services during four weeks prior to the interview, and other background
factors Results: The prevalence of self-reported illness was 48% Cough, fever, and headache were the most commonly
reported symptoms (20%) while cardiovascular disorders were least reported (0.6%) Occurrence of illness was significantly lower in groups with higher education, especially among men, but there was no difference between occupational and economic groups Self-treatment was very common (69%) Private health facilities were used to a large extent, while community health stations played a less important role Use of district hospitals was significantly higher among employed
people Discussion: An epidemiological field laboratory enabled analysis of self-reported illness and use of health services,
which is important for planning of health services We found a high level of reported illness but a very low utilization of community health services Better knowledge about illness patterns could be important for improving quality of and access
to community health services
Key words: epidemiology, health services utilization, self-reported illness, socioeconomic conditions, symptoms.
Kim Bao Giang, Department of Health Management and Health Policy, Faculty of Public Health, Hanoi Medical University, Hanoi, Vietnam e-mail: kbgiangvn@yahoo.com
INTRODUCTION
The major goals in public health are to promote and
improve the health of the population In order to
formulate health strategies and health policies
accord-ing to the needs of the population, knowledge about
the health situation of the population is needed (1 – 3)
The health of the population can be monitored by
following different health indicators over time, which
enables health administrators and decision makers to
get answers to questions like: ‘‘What did we achieve?’’;
‘‘What has failed?’’; ‘‘What interventions are needed
– for whom and when?’’
In developed countries, data on health are regularly
obtained from health registers and population surveys
These are often presented in public health reports, and
several countries have developed solid traditions of
reporting not only mortality and morbidity, but also
self-reported health, lifestyle and other risk factors, as well as socioeconomic conditions and other structural factors (3, 4)
In contrast with developed countries, developing countries have seriously lacked essential data on health for making health plans and setting health policy (1) Vietnam is typical in this respect, with limited availability of health data, especially at the community level (5) In Vietnam, health data are mainly collected from hospital statistics and medical records, whereas population health surveys are still very rare Investigations by the Ministry of Health have shown that self-treatment is common in the community, and the use of public healthcare services
is low Furthermore, use of private healthcare facilities
is increasing (6, 7) Although since 1989 it has been government policy to legalize private practice, dereg-ulate the pharmaceutical industry and allow the sale
of drugs on the open market, etc., there are no official data on use of private health services Thus health This paper has been independently peer-reviewed according to the
usualSJPH practice and accepted as an original article.
Trang 2needs and the use of health services have not been
adequately described and analysed in Vietnam, in
spite of the important changes that have occurred in
the period of health transition originating from
economic renovation since 1986
The process of measuring health raises further
issues When assessing and monitoring the health of
a population, it is important to describe not only
classical mortality and morbidity indicators, but also
perceived health, illnesses, and symptoms Illness refers
to patients’ perspectives and refers to people’s feelings
of pain, discomfort, and disability, which play a major
role in a large part of morbidity in the community, as
well as visits to primary health services and sickness
absence (8, 9) Several instruments have been
devel-oped to assess perceived health, but there are few
attempts to use these in a systematic way to describe
and follow health trends in developing countries
Thus, in this study we have refrained from assessing
self-perceived health, but instead used self-reported
illness, including symptoms
An epidemiological field laboratory (FilaBavi) was
established in 1998 in Bavi District, some 60 km west
of Hanoi, in order to provide valid information for
the health planning and policy process In addition to
several ongoing studies within FilaBavi on the
epide-miology of diseases such as tuberculosis,
cardiovas-cular disorders, and injuries, the assessment of health
status, perceived illness, and health care utilization is
important to give a broad picture of the health
situa-tion in a rural district of Vietnam Our specific aim
here was to describe and analyse self-reported illness,
symptoms, and use of health services in a defined
population in rural Vietnam In particular, we wanted
to analyse illness and healthcare utilization patterns in
relation to educational level, occupation, and
house-hold economic status
METHODS
The study was performed in the rural Bavi District in
including lowland, highland, and mountainous zones
The district consists of 32 communes with a
popula-tion of approximately 235,000 people The climate is
typical of northern Vietnam with two main seasons:
the wet season from June to October and the dry
season from November to May Agriculture and
live-stock breeding are the main economic activities (81%)
and others include forestry (8%), fishing (1%), small
trade (3%), and handicraft (6%) The average income
corresponded to 290 kg rice per person per year
Illiteracy among people over 15 years was 0.4% There is
a district hospital, three polyclinics, and 32 communal
health stations (CHS) together with three private pharmacies and some licensed private practitioners
A cross-sectional study was carried out between
house-holds (48,919 individuals) were included in the study FilaBavi is a multi-purpose epidemiological field labo-ratory, the sample size for which was initially based
on assessing changes in the infant mortality rate of a magnitude of 15/1,000, requiring a 20% sample of the total district population The sampling unit was the
village, with the exception of some small satellite
villages, which were brought together into single units, and some larger villages, which were subdivided into two or more aggregates of hamlets A random sam-pling of village units, with probability proportional to population size in each unit, was performed and 67 clusters were selected from a total of 352 units Data were collected by 32 interviewers who were carefully trained All of them had high school edu-cation and were inhabitants of Bavi District All information was self-reported To increase the validity and reliability of data, random duplicate interviews were performed by field supervisors and researchers in 5% of households All identified errors were corrected Symptoms of illness and the use of health services during the four weeks prior to the interview were gathered by a structured questionnaire, which was developed by the Swedish and Vietnamese experts who participated in FilaBavi technical committee Background information included age, gender, educa-tional level, occupation, and household economic status This questionnaire was tested and revised to
be more appropriate in terms of language and illness patterns
The Research Ethics Committee at Umea˚ University has given ethical approval for the FilaBavi household surveillance system, including data collection on vital statistics (reference number 02 – 420), and local autho-rities and community leaders in Vietnam approved the project All households gave informed consent to participate in the study
Occurrence of symptoms in relation to socio-economic variables and the use of health services was assessed descriptively Logistic regression was applied separately for males and females in order to estimate odds ratios of having the different types of common illness in relation to background variables and then having at least one symptom The same procedure was applied to calculate odds ratios for the use of CHSs, private services, the district hospital, and the provincial hospital as well as self-treatment in each socioeconomic group Interaction between socioeco-nomic variables was checked and multi-collinearity was eliminated; 95% confidence intervals were calcu-lated for estimates of odds ratios Independent
Trang 3variables were age, educational level, occupation, and
economic status In analyses including educational
level and occupation only individuals over 15 years
were included
Illness episode was defined as a report of at least one
of the following conditions: staying in bed or being
absent from work for at least one day; reduced
working capacity; or having used any kind of
treat-ment All episodes of illness that had occurred during
the four weeks prior to the interview were recorded
Any individual could thus have several illness episodes
during the four-week period
Common symptoms were the four most prevalent
symptoms specified in the questionnaires, namely
cough, fever, headache, and ‘‘bone and joint pain’’
Thus, during an illness episode, a person could have
more than one common symptom
Common illness was the occurrence of at least one
of the common symptoms during an illness episode
Use of health services was classified into
self-treatment (which included only self-care without
professional consultation); seeking healthcare from a
traditional healer; visiting a communal health station,
polyclinic/district hospital, provincial/central hospital,
or private health facilities
Educational level was classified in three
cate-gories according to experience of education: illiterate
comprised individuals who could neither read nor
write; school leavers were individuals with less than 12 years of education; and graduates were people
study-ing at or graduatstudy-ing from a university or vocational school after high school
Household economic status was classified into three
categories using the classification of the Ministry of Labour, Invalids and Society adapted for Bavi in
1998 This classification was mainly based on the total
amount of rice per person per month Very poor was less than 15 kg per person per month; non-poor was more than 20 kg per person per month; and poor
was the intermediate group
Occupation was classified according to source of
income and use of time It included the categories of farmers, employees, and others To be counted as a
farmer, one has to do mainly farming Government
staff and those in other paid employment were
counted as employees Others included housewives,
small traders, handicraft-makers, and the jobless
RESULTS There were 26,551 episodes of illness reported by 23,315 individuals Thus, among 48,919 individuals, the prevalence of illness was 47.7% Figure 1 shows the prevalence of perceived symptoms Cough, headache,
Fig 1 One-month prevalence of self-reported symptoms.
Trang 4and fever were most frequent (21.4%, 21.6%, and
19.2% respectively), followed by ‘‘bone and joint
pain’’ (5.8%) and colic (3.7%), while injury accounted
for 1.7% Only 0.6% reported cardiovascular disorders
including high blood pressure, chest pain, and rapid
heart beat The other symptoms included many
con-ditions that were not specified, such as runny nose, eye
diseases, allergy, mycosis, gynaecological diseases,
urinary disorders, etc
In general, women reported more illness episodes
than men (50.8% vs 44.2%) Women suffered more
headache and ‘‘bone and joint pain’’ than men did,
but there was no difference in the occurrence of fever
and cough (21%) The difference between men and
women regarding occurrence of ‘‘bone and joint pain’’
and headache increased with age (Figure 2)
Table I shows that the higher education groups had
fewer episodes of fever, cough, headache, and ‘‘bone
and joint pain’’ These were similar for farmers and
employees, while those with other occupations had
higher proportions Reported occurrence of cough,
fever, and headache was only marginally higher among
poorer groups
Table II shows that there was no difference by
gender in the use of health services Self-treatment was
the most common measure taken irrespective of symp-toms, educational level, occupation, and economic status However, persons with higher education visited hospitals more frequently Graduates had used the district hospital nearly three times more than illiterate people and twice as much as school leavers In contrast, graduates had visited private health facilities and CHSs less than illiterates and school-leavers Employees visited hospitals more than other groups Economic status did not seem to influence the use of health services
The odds ratios (OR) for having each common symptom as well as for having at least one were estimated by logistic regression analysis with age,
covariates in the model The model applied for single common symptoms gave similar figures to the model of general common illness Age was signifi-cantly associated with higher rates of common illness, especially among women (taking the under-16 age group as the reference, the OR for the 20 – 49 age group was1.8 (95% CI 1.6 – 2.1) and for the 50z age group was 4.3 (95% CI 3.7 – 4.9) Female farmers had slightly increased ORs for the occurrence of illness but, as a whole, occupation and economic status did
Fig 2 Distribution of four common symptoms by gender and age group.
Trang 5not influence self-reported illness when controlling for
age in the model Among men, lower education – and
particularly illiteracy – had higher ORs for common
illnesses In comparison with graduates, OR for
reported common illness by illiterates was 1.5 (95%
CI 1.1 – 2.0) and by school leavers was 1.2 (95% CI
1.1 – 1.4) (data not shown)
No interaction between socioeconomic variables
was recorded Logistic regressions were independently
performed for the use of each kind of health service
No significant difference was found between
socio-economic groups in terms of using traditional healers,
CHSs, private facilities, and provincial/central
hospi-tals However, regarding the use of polyclinic/district
hospital, occupation remained as the most
impor-tant factor in the model, with employees making
significantly more use of the district hospital than farmers and others Female school leavers had a significantly higher OR for using the district hospital compared with graduates (Table III)
DISCUSSION The prevalence of self-reported illness was 47.7% This
is similar to findings in health interview surveys from other countries, such as Sweden (10), England (11), and Spain (12), but the prevalence rates vary sub-stantially according to which age groups are included
in the samples Some other studies in Vietnam showed
a lower rate of illness than our study (13, 14) The reasons for this are unclear It may be due to the fact that these studies included urban areas and also that
Table I Numbers (percentages) of respondents reporting cough, fever, headache, ‘‘bone and joint pain’’ by socioeconomic status
Socioeconomic variables
Symptoms
Educational level:
Occupation:
Economic status:
Table II Proportion of individuals reporting illness who had used different healthcare facilities, by gender, education level, occupation, and household economic status
Self-treatment
Traditional healer
Private health sector CHS
Polyclinic/
district hospital
Provincial/ Central hospital Gender:
Education:
Occupation:
Economic status:
Trang 6they used different questionnaires for collecting data.
In a sentinel survey during 2001 – 02 in seven
pro-vinces of Vietnam, the following question was asked
for information about illness: ‘‘During the last two
weeks, was there anyone in your family who got sick?
If yes, specify the disease or symptom/sign.’’ Thus,
minor symptoms could be missed In our survey, after
the question referring to the occurrence of any illness,
questions about the presence of some specific illnesses
then continued Furthermore, the interviewers in our
study were well trained and supervised, which may
have led to a higher level of reporting of illness by the
households visited However, the illness pattern we
found was consistent with other studies in Vietnam (5, 13)
In concordance with previous studies in Vietnam
and other countries, our study showed a higher illness
occurrence at older ages (9, 11 – 13) Although women
reported higher prevalences of illness than men, no
gender difference in reporting fever and cough was
found This finding was similar to several studies in
developed countries such as Sweden (10), Spain (12),
and the United Kingdom (15), as well as in developing
countries including India (16), Vietnam (13, 14), and
others (17)
Several studies have indicated that health problems
decline with increasing educational level (11, 12, 15,
18) Bruce et al found that 45% of those with no
education or with less than high school education
reported fair or poor health compared with 6% of
graduates In our study we could find this association
only among men Regidor et al also found similar
figures from Spain (12) They postulated that although
the higher educated women had better living condi-tions, they may have suffered more stress at work due
to the pressures of working life and relationships with colleagues, as well as a number of indoor illnesses such as sick-building syndrome, tiredness, and pain due to limited physical activities, etc
We did not find any significant association between income and self-reported health This could be explained by the fact that in rural Vietnam there is
no great difference in terms of living and working conditions between the poor and the better off Another possibility is that the poor may not report episodes of illness that occur so frequently that they consider it a normal part of everyday existence In fact, many studies from developing countries have found that richer groups report more ill health Studies from Ghana, Jamaica, Peru, and Bolivia found that the richest 20% of the population reported more illness than the poorest 20% (17) In general, however, higher rates of health problems were reported by lower income groups (9, 12, 17, 19)
As in previous studies on healthcare utilization in Vietnam (5, 13, 14), our findings indicated that the most common measure people took was self-treatment Furthermore, the CHSs did not play the role that might be expected in providing healthcare, while private facilities took an important part This could be explained by a number of reasons First, owing to the legalization of private practices the number of private health providers has been increasing, drugs are widely available and they can be sold without a prescription both in pharmacies and in the markets Second, the availability of subsidized drugs from public providers has decreased as a result of the limited government budget for health Furthermore, the quality of health-care in CHSs has been reported to be considerably lower than in the private sector in terms of drug availability, quality, and attitude of staff (5, 14) Our findings are consistent with previous studies from the Ministry of Health in 1998 and 2001 – 02
on the association between use of healthcare and economic status In our multivariate analysis, occupa-tion remained an important background factor for use
of the district hospital Perhaps health insurance was a reason for this as most employees in Vietnam have a compulsory health insurance card, which was very rare among others in 1999 and the district hospital was the first level of health insurance services (5) Employed persons also have access to cash to a greater extent than farmers This facilitates seeking healthcare at hospitals, which require payment in cash for consultation and treatment
This study was based on a large database with a high number of households selected by random cluster sampling Furthermore, the data collection system
Table III Odds ratios (with 95% confidence intervals) for
using the district hospital, according to educational level,
occupation, and economic status, among men and women
Variables
Education:
School-leaver 1.1 0.8 – 1.5 1.6 1.1 – 2.2
Occupation:
Economic group:
Notes: Pseudo R2~0.052, probabilitywchi-squaredv0.0001
(for men), pseudo R2~0.054, probabilitywchi-squared
v0.0001 (women)
Trang 7worked effectively because of well-trained interviewers
and regular checking for data quality during
collec-tion of data
We did not include in the survey questions on
perceived health and psychological well-being
More-over, we have not addressed the severity of illness,
which is another aspect that might be included in
future surveys Our classification of economic
condi-tion, using the local authority’s classificacondi-tion, is a
simple method Khe et al pointed out, looking at four
different methods, that no indicator is obviously
better for classifying economic groups in Bavi (20)
The illness pattern was limited to one season (i.e
winter), so it may not be typical of the pattern for
other seasons However, we believe that the general
trend, as well as the distribution across subgroups, is
unlikely to be greatly affected by season
In conclusion, this study has given new information
on the overall health status and use of health services
in Vietnam that could provide a baseline for further
analyses as well as valuable data for planning health
services
ACKNOWLEDGEMENTS
This research was conducted within the
Epidemiolo-gical Field Laboratory for Health Systems Research
(FilaBavi) in Vietnam, which is supported by Sida/
SAREC, Stockholm
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