Self reported illness and use of health services in a rural district of vietnam findings from an epidemiological field laboratory

ORIGINAL ARTICLE 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 Department of Health Management and Health Policy, Faculty of Public Health, Hanoi Medical University, Vietnam, 2Department 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 according 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 This paper has been independently peer-reviewed according to the usual SJPH practice and accepted as an original article 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, deregulate 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 # Taylor & Francis 2003 ISSN 1403-4948 DOI: 10.1080/14034950310015112 Scand J Public Health 31(Suppl 62) Downloaded from sjp.sagepub.com by guest on November 9, 2016 Self-reported illness and use of health services in a rural district needs 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 developed 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 epidemiology of diseases such as tuberculosis, cardiovascular disorders, and injuries, the assessment of health status, perceived illness, and health care utilization is important to give a broad picture of the health situation 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 household economic status METHODS The study was performed in the rural Bavi District in the north of Vietnam It covers an area of 410 km2, including lowland, highland, and mountainous zones The district consists of 32 communes with a population 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 livestock 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 53 health stations (CHS) together with three private pharmacies and some licensed private practitioners A cross-sectional study was carried out between September and December 1999; 11,089 households (48,919 individuals) were included in the study FilaBavi is a multi-purpose epidemiological field laboratory, 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 sampling 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 education 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, educational 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 authorities and community leaders in Vietnam approved the project All households gave informed consent to participate in the study Occurrence of symptoms in relation to socioeconomic 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 socioeconomic variables was checked and multi-collinearity was eliminated; 95% confidence intervals were calculated for estimates of odds ratios Independent Scand J Public Health 31(Suppl 62) Downloaded from sjp.sagepub.com by guest on November 9, 2016 54 KB Giang and P Allebeck variables 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 treatment 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 selftreatment (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 categories 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 studying at or graduating 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 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 shows the prevalence of perceived symptoms Cough, headache, Fig One-month prevalence of self-reported symptoms Scand J Public Health 31(Suppl 62) Downloaded from sjp.sagepub.com by guest on November 9, 2016 Self-reported illness and use of health services in a rural district and 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 conditions 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 55 the most common measure taken irrespective of symptoms, 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, education, occupation, and economic status as covariates in the model The model applied for single common symptoms gave similar figures to the model of general common illness Age was significantly 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 Distribution of four common symptoms by gender and age group Scand J Public Health 31(Suppl 62) Downloaded from sjp.sagepub.com by guest on November 9, 2016 56 KB Giang and P Allebeck Table I Numbers (percentages) of respondents reporting cough, fever, headache, ‘‘bone and joint pain’’ by socioeconomic status Symptoms Socioeconomic variables Cough Fever Headache Bone and joint pain Educational level: Illiterate (n~1,680) School-leavers (n~27,941) Graduate (n~2,807) 424 (25.2) 4,905 (17.6) 428 (15.2) 318 (18.9) 4,258 (15.2) 405 (14.4) 574 (34.2) 7,010 (25.1) 576 (20.5) 313 (18.3) 2,114 (7.6) 205 (7.3) Occupation: Farmer (n~22,268) Employee (n~2,929) Others (n~4,336) 3,823 (17.2) 498 (17.0) 992 (22.9) 3,441 (15.5) 427 (14.6) 743 (17.1) 5,657 (25.4) 695 (23.7) 1,326 (30.6) 1,636 (7.3) 280 (9.6) 685 (15.8) Economic status: Very poor (n~9,280) Poor (n~25,320) Non-poor (n~11,317) 2,148 (23.1) 5,386 (21.3) 2,240 (19.8) 1,925 (20.7) 4,898 (19.3) 1,975 (17.5) 2,049 (22.1) 5256 (20.8) 2,285 (20.0) 462 (5.0) 1,443 (5.7) 570 (5.0) not 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 socioeconomic groups in terms of using traditional healers, CHSs, private facilities, and provincial/central hospitals However, regarding the use of polyclinic/district hospital, occupation remained as the most important 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 substantially 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 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 Gender: Men (n~8,032) Women (n~10,781) 68.1 69.7 1.3 2.2 24.9 23.9 6.0 6.2 4.8 3.8 1.6 1.6 Education: Illiterate (n~930) School- leavers (n~10,360) Graduates (n~888) 68.2 68.4 67.3 3.8 2.2 2.9 24.3 23.4 18.0 6.7 5.5 4.3 3.8 4.2 10.4 0.3 1.9 5.2 Occupation: Farmer (n~8,253) Employee (n~1,105) Other (n~2,239) 69.4 61.4 67.9 2.1 2.9 3.4 23.1 19.1 25.6 3.1 17.8 4.6 1.8 4.3 2.1 1.8 4.3 2.1 Economic status: Very poor (n~3,844) Poor (n~9,777) Non-poor (n~4,081) 70.1 70.3 69.8 1.3 1.8 2.2 23.1 24.6 24.0 6.7 5.9 5.0 3.9 3.6 5.8 0.7 1.5 2.4 Scand J Public Health 31(Suppl 62) Downloaded from sjp.sagepub.com by guest on November 9, 2016 CHS Polyclinic/ district hospital Provincial/ Central hospital Self-reported illness and use of health services in a rural district 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 Male Female Variables OR 95% CI OR 95% CI Education: Graduate Illiterate School-leaver 1.0 0.7 1.1 0.3 – 1.8 0.8 – 1.5 1.0 1.4 1.6 0.9 – 2.4 1.1 – 2.2 Occupation: Employee Farmer Others 1.0 0.2 0.3 0.17 – 0.3 0.2 – 0.4 1.0 0.1 0.2 0.09 – 0.2 0.1 – 0.24 Economic group: Non-poor 1.0 Poor 1.0 Very poor 0.8 0.8 – 1.4 0.6 – 1.0 1.0 0.8 0.8 0.6 – 1.1 0.7 – 1.0 Notes: Pseudo R2~0.052, probabilitywchi-squaredv0.0001 (for men), pseudo R2~0.054, probabilitywchi-squared v0.0001 (women) they used different questionnaires for collecting data In a sentinel survey during 2001 – 02 in seven provinces 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 57 the higher educated women had better living conditions, 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 healthcare 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, occupation 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 Scand J Public Health 31(Suppl 62) Downloaded from sjp.sagepub.com by guest on November 9, 2016 58 KB Giang and P Allebeck worked effectively because of well-trained interviewers and regular checking for data quality during collection of data We did not include in the survey questions on perceived health and psychological well-being Moreover, we have not addressed the severity of illness, which is another aspect that might be included in future surveys Our classification of economic condition, using the local authority’s classification, 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 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