Nguyen Phuong Hoa

Antibiotic sales in rural and urban pharmacies in northern Vietnam: an observational study

BackgroundThe irrational overuse of antibiotics should be minimized as it drives the development of antibiotic resistance, but changing these practices is challenging. A better understanding is needed of practices and economic incentives for antibiotic dispensing in order to design effective interventions to reduce inappropriate antibiotic use. Here we report on both quantitative and qualitative aspects of antibiotic sales in private pharmacies in northern Vietnam.MethodA cross-sectional study was conducted in which all drug sales were observed and recorded for three consecutive days at thirty private pharmacies, 15 urban and 15 rural, in the Hanoi region in 2010. The proportion of antibiotics to total drug sales was assessed and the revenue was calculated for rural and urban settings. Pharmacists and drug sellers were interviewed by a semi-structured questionnaire and in-depth interviews to understand the incentive structure of antibiotic dispensing.ResultsIn total 2953 drug sale transactions (2083 urban and 870 rural) were observed. Antibiotics contributed 24% and 18% to the total revenue of pharmacies in urban and rural, respectively. Most antibiotics were sold without a prescription: 88% in urban and 91% in rural pharmacies. The most frequent reported reason for buying antibiotics was cough in the urban setting (32%) and fever in the rural area (22%). Consumers commonly requested antibiotics without having a prescription: 50% in urban and 28% in rural area. The qualitative data revealed that drug sellers and customer’s knowledge of antibiotics and antibiotic resistance were low, particularly in rural area.ConclusionOver the counter sales of antibiotic without a prescription remains a major problem in Vietnam. Suggested areas of improvement are enforcement of regulations and pricing policies and educational programs to increase the knowledge of drug sellers as well as to increase community awareness to reduce demand-side pressure for drug sellers to dispense antibiotics inappropriately.

Knowledge, attitudes, and practices about tuberculosis and choice of communication channels in a rural community in Vietnam

OBJECTIVES To describe the TB knowledge in the general population and to analyze which methods and tools should be used for health education in community. METHODS A population-based cross-sectional survey was carried out within a demographic surveillance site in a rural district in Vietnam. A random sample of 12,143 adults was included. RESULTS The average knowledge score was 4.3+/-2.1 (maximum=8). Men had a significantly higher knowledge score than women (4.8 vs. 4.0). More than half of the respondents thought TB was hereditary. In a multivariate analysis, gender, occupation, economic status, education, and sources of information were significantly associated with level of TB knowledge. Commonly, reported sources of information included television (64.6%) and friends/relatives (42.7%). Sources of information differed between men and women. Commonly, television and loudspeakers were suggested as good ways of supplying information (70.4% and 55.1%). CONCLUSIONS A large proportion of general population had limited knowledge of TB, especially among women. Traditional beliefs such as a hereditary cause of TB persists in the population, despite many years of health education on TB. Access to information should be taken into consideration when choosing methods and channels for health education programmes.

Mortality patterns in Vietnam, 2006: Findings from a national verbal autopsy survey

BackgroundAccurate nationally representative statistics on total and cause-specific mortality in Vietnam are lacking due to incomplete capture in government reporting systems. This paper presents total and cause-specific mortality results from a national verbal autopsy survey conducted first time in Vietnam in conjunction with the annual population change survey and discusses methodological and logistical challenges associated with the implementation of a nation-wide assessment of mortality based on surveys.Verbal autopsy interviews, using the WHO standard questionnaire, were conducted with close relatives of the 6798 deaths identified in the 2007 population change survey in Vietnam. Data collectors were health staff recruited from the commune health station who undertook 3-day intensive training on VA interview. The Preston-Coale method assessed the level of completeness of mortality reporting from the population change survey. The number of deaths in each age-sex grouping is inflated according to the estimate of completeness to produce an adjusted number of deaths. Underlying causes of death were aggregated to the International Classification of Diseases Mortality Tabulation List 1. Leading causes of death were tabulated by sex for three broad age groups: 0-14 years; 15-59 years; and 60 years and above.FindingsCompleteness of mortality reporting was 69% for males and 54% for females with substantial regional variation. The use of VA has resulted in 10% of deaths being classified to ill-defined among males, and 15% among females. More ill-defined deaths were reported among the 60 year or above age group. Incomplete death reporting, wide geographical dispersal of deaths, extensive travel between households, and substantial variation in local responses to VA interviews challenged the implementation of a national mortality and cause of death assessment based on surveys.ConclusionsVerbal autopsy can be a viable tool to identify cause of death in Vietnam. However logistical challenges limit its use in conjunction with the national sample survey. Sentinel population clusters for mortality surveillance should be tested to develop an effective and sustainable option for routine mortality and cause of death data collection in Vietnam.

Road traffic related mortality in Vietnam: Evidence for policy from a national sample mortality surveillance system

BackgroundRoad traffic injuries (RTIs) are among the leading causes of mortality in Vietnam. However, mortality data collection systems in Vietnam in general and for RTIs in particular, remain inconsistent and incomplete. Underlying distributions of external causes and body injuries are not available from routine data collection systems or from studies till date. This paper presents characteristics, user type pattern, seasonal distribution, and causes of 1,061 deaths attributable to road crashes ascertained from a national sample mortality surveillance system in Vietnam over a two-year period (2008 and 2009).MethodsA sample mortality surveillance system was designed for Vietnam, comprising 192 communes in 16 provinces, accounting for approximately 3% of the Vietnamese population. Deaths were identified from commune level data sources, and followed up by verbal autopsy (VA) based ascertainment of cause of death. Age-standardised mortality rates from RTIs were computed. VA questionnaires were analysed in depth to derive descriptive characteristics of RTI deaths in the sample.ResultsThe age-standardized mortality rates from RTIs were 33.5 and 8.5 per 100,000 for males and females respectively. Majority of deaths were males (79%). Seventy three percent of all deaths were aged from 15 to 49 years and 58% were motorcycle users. As high as 80% of deaths occurred on the day of injury, 42% occurred prior to arrival at hospital, and a further 29% occurred on-site. Direct causes of death were identified for 446 deaths (42%) with head injuries being the most common cause attributable to road traffic injuries overall (79%) and to motorcycle crashes in particular (78%).ConclusionThe VA method can provide a useful data source to analyse RTI mortality. The observed considerable mortality from head injuries among motorcycle users highlights the need to evaluate current practice and effectiveness of motorcycle helmet use in Vietnam. The high number of deaths occurring on-site or prior to hospital admission indicates a need for effective pre-hospital first aid services and timely access to emergency facilities. In the absence of standardised death certification, sustained efforts are needed to strengthen mortality surveillance sites supplemented by VA to support evidence based monitoring and control of RTI mortality.

Community patterns of stigma towards persons living with HIV: A population-based latent class analysis from rural Vietnam

BackgroundThe negative effects of stigma on persons living with HIV (PLHIV) have been documented in many settings and it is thought that stigma against PLHIV leads to more difficulties for those who need to access HIV testing, treatment and care, as well as to limited community uptake of HIV prevention and testing messages. In order to understand and prevent stigma towards PLHIV, it is important to be able to measure stigma within communities and to understand which factors are associated with higher stigma.MethodsTo analyze patterns of community stigma and determinants to stigma toward PLHIV, we performed an exploratory population-based survey with 1874 randomly sampled adults within a demographic surveillance site (DSS) in rural Vietnam. Participants were interviewed regarding knowledge of HIV and attitudes towards persons living with HIV. Data were linked to socioeconomic and migration data from the DSS and latent class analysis and multinomial logistic regression were conducted to examine stigma group sub-types and factors associated with stigma group membership.ResultsWe found unexpectedly high and complex patterns of stigma against PLHIV in this rural setting. Women had the greatest odds of belong to the highest stigma group (OR 1.84, 95% CI 1.42-2.37), while those with more education had lower odds of highest stigma group membership (OR 0.45, 95% CI 0.32-0.62 for secondary education; OR 0.19, 95% CI 0.10-0.35 for tertiary education). Long-term migration out of the district (OR 0.61, 95% CI 0.4-0.91), feeling at-risk for HIV (OR 0.42, 95% CI 0.27-0.66), having heard of HIV from more sources (OR 0.44, 95% CI 0.3-0.66), and knowing someone with HIV (OR 0.76, 95% CI 0.58-0.99) were all associated with lower odds of highest stigma group membership. Nearly 20% of the population was highly unsure of their attitudes towards PLHIV and persons in this group had significantly lower odds of feeling at-risk for HIV (OR 0.54, 95% CI 0.33-0.90) or of knowing someone with HIV (OR 0.32, 95% CI 0.22-0.46).ConclusionsStigma towards PLHIV is high generally, and very high in some sub-groups, in this community setting. Future stigma prevention efforts could be enhanced by analyzing community stigma sub-groups and tailoring intervention messages to community patterns of stigma.

Survival and causes of death among HIV-infected patients starting antiretroviral therapy in north-eastern Vietnam

Abstract Background: There is a lack of knowledge on mortality and causes of death among human immunodeficiency virus (HIV)-infected patients after initiation of antiretroviral therapy (ART) in Vietnam. We investigated the mortality rate, risk factors, causes of death, and impact of enhanced adherence support on survival among 640 Vietnamese treatment-naïve HIV-infected patients receiving ART in a cluster randomized controlled trial. Methods: Patients in the intervention group received enhanced adherence from peer-supporters. Data were collected through medical records and a verbal autopsy questionnaire. We used Kaplan–Meier analysis to describe the survival trends and the Cox proportional hazard model to identify predictors of acquired immune deficiency syndrome (AIDS)-related deaths. Results: After a median follow-up of 15.2 months, there were 60 deaths, 73% of which occurred within 6 months. The mortality rate was 7.4/100 person-y and survival probability was 91% after 1 y. There was no significant difference in mortality rate between the intervention and the control groups. At baseline, the predictive factors for AIDS-related death were age >35 y, clinical stage 3 or 4, body mass index (BMI) <18 kg/m2, CD4 count <100/μl, haemoglobin level <100 g/l, and plasma viral load >100,000 copies/ml. Tuberculosis (TB) was the most common cause of death (40%). Conclusions: Early deaths occurred after ART, and delay of ART caused a significant decrease in CD4 count and a high mortality. Adherence support had no impact on survival at the early stage of ART. Early ART initiation and intensive follow-up of patients during the first 6 months of ART are therefore necessary to reduce AIDS-related mortality.

Expanding HIV Testing Efforts in Concentrated Epidemic Settings: A Population-Based Survey from Rural Vietnam

Background To improve HIV prevention and care programs, it is important to understand the uptake of HIV testing and to identify population segments in need of increased HIV testing. This is particularly crucial in countries with concentrated HIV epidemics, where HIV prevalence continues to rise in the general population. This study analyzes determinants of HIV testing in a rural Vietnamese population in order to identify potential access barriers and areas for promoting HIV testing services. Methods A population-based cross-sectional survey of 1874 randomly sampled adults was linked to pregnancy, migration and economic cohort data from a demographic surveillance site (DSS). Multivariate logistic regression analysis was used to determine which factors were associated with having tested for HIV. Results The age-adjusted prevalence of ever-testing for HIV was 7.6%; however 79% of those who reported feeling at-risk of contracting HIV had never tested. In multivariate analysis, younger age (aOR 1.85, 95% CI 1.14–3.01), higher economic status (aOR 3.4, 95% CI 2.21–5.22), and semi-urban residence (aOR 2.37, 95% CI 1.53–3.66) were associated with having been tested for HIV. HIV testing rates did not differ between women of reproductive age who had recently been pregnant and those who had not. Conclusions We found low testing uptake (6%) among pregnant women despite an existing prevention of mother-to-child HIV testing policy, and lower-than-expected testing among persons who felt that they were at-risk of HIV. Poverty and residence in a more geographically remote location were associated with less HIV testing. In addition to current HIV testing strategies focusing on high-risk groups, we recommend targeting HIV testing in concentrated HIV epidemic settings to focus on a scaled-up provision of antenatal testing. Additional recommendations include removing financial and geographic access barriers to client-initiated testing, and encouraging provider-initiated testing of those who believe that they are at-risk of HIV.

Risk factors for chronic disease in Viet Nam: a review of the literature

Introduction Chronic diseases account for most of the disease burden in low- and middle-income countries, particularly those in Asia. We reviewed literature on chronic disease risk factors in Viet Nam to identify patterns and data gaps. Methods All population-based studies published from 2000 to 2012 that reported chronic disease risk factors were considered. We used standard chronic disease terminology to search PubMed and assessed titles, abstracts, and articles for eligibility for inclusion. We summarized relevant study information in tables listing available studies, risk factors measured, and the prevalence of these risk factors. Results We identified 23 studies conducted before 2010. The most common age range studied was 25 to 64 years. Sample sizes varied, and sample frames were national in 5 studies. A combination of behavioral, physical, and biological risk factors was studied. Being overweight or obese was the most common risk factor studied (n = 14), followed by high blood pressure (n = 11) and tobacco use (n = 10). Tobacco and alcohol use were high among men, and tobacco use may be increasing among Vietnamese women. High blood pressure is common; however, people’s knowledge that they have high blood pressure may be low. A high proportion of diets do not meet international criteria for fruit and vegetable consumption. Prevalence of overweight and obesity is increasing. None of the studies evaluated measured dietary patterns or total caloric intake, and only 1 study measured dietary salt intake. Conclusion Risk factors for chronic diseases are common in Viet Nam; however, more recent and context-specific information is required for planning and monitoring interventions to reduce risk factors and chronic disease in this country.

Stroke Mortality Variations in South-East Asia: Empirical Evidence from the Field:

Background Stroke is a leading cause of death in Asia; however, many estimates of stroke mortality are based on epidemiological models rather than empirical data. Since 2005, initiatives have been undertaken in a number of Asian countries to strengthen and analyse vital registration data. This has increased the availability of empirical data on stroke mortality. Aims The aim of this paper is to present estimates of stroke mortality for Indonesia, Myanmar, Viet Nam, Thailand, and Malaysia, which have been derived using these empirical data. Methods Age-specific stroke mortality rates were calculated in each of the five countries, and adjusted for data completeness or misclassification where feasible. All data were age-standardized and the resulting rates were compared with World Health Organization estimates, which are largely based on epidemiological models. Results Using empirical data, stroke ranked as the leading cause of death in all countries except Malaysia, where it ranked as the second leading cause. Age-standardized rates for males ranged from 94 per 100 000 in Thailand, to over 300 per 100 000 in Indonesia. In all countries, rates were higher for males than for females, and those compiled from empirical data were generally higher than modelled estimates published by World Health Organization. Conclusions This study highlights the extent of stroke mortality in selected Asian countries, and provides important baseline information to investigate the aetiology of stroke in Asia and design appropriate public health strategies to address the rapidly growing burden from stroke.

Assessing the quality of evidence for verbal autopsy diagnosis of stroke in Vietnam

Background: Information on the leading causes of mortality will continue to rely on verbal autopsy (VA) in developing countries. The accuracy of VA methods in correctly ascertaining the cause for each individual death is crucial in order to have confidence in the data collected through the procedure. Accuracy of the VA procedure is generally established by carrying out validation studies involving a comparison of the underlying cause of death derived from the VA with a reference underlying cause from medical records. Such validation is only possible in cases for which clinical records are available, and this is clearly not the case for most deaths in developing countries. We attempt to verify the accuracy of VA evidence by reviewing the responses to specific symptom questions and other information recorded in verbal autopsy questionnaires that were assigned cerebrovascular conditions (stroke) as causes of death upon physician review in Vietnam. Materials and Methods: A national sample mortality surveillance activity identified deaths and causes of death that had occurred during 2008 in selected communes in 16 provinces distributed across Vietnam. All cases from the northern provinces of Hanoi, Hai Duong, Quang Ninh and Thanh Hoa with ICD codes pertaining to cerebrovascular diseases were identified. A total of 326 VA questionnaires for deaths from cerebrovascular diseases were reviewed and analysed in detail for the presence of symptoms pertaining to stroke. The respondents’ narration of the chronological disease history and the hospital diagnosis was also examined with an aim to explore supporting signs for diagnosis and to verify the quality of VA interview. Differences between responses among cases with and without hospital admission were examined using Chi-squared test of statistical significance. Results: Ninty percent of the cases diagnosed as stroke were found to have positive response to the key symptoms; viz., paralysis (in structured question or free text) and history of stroke. For the remaining 10% of cases, stroke was assigned as a cause-of-death based on other suggestive cardiac signs and symptoms such as hypertension, unconsciousness, or headache, etc. Community had different perspectives of “paralysis” and “stroke” which might have affected the diagnosis of stroke in some aspects. Respondents of cases with hospital admission or visit were found to have a better recall of disease symptoms than those without hospital admission. Conclusion: The results of this study suggest the possible utility of VA content analysis method to back up the low coverage of conventional validation studies in developing countries owing to nonavailability of medical records. The understanding of the VA content would also form the basis for improvement in the quality of interviews and collection of data to achieve better quality information in future.