Rural and urban Vietnamese mothers utilization of healthcare resources for children under 6 years with pneumonia and associated symptoms

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Worldwide, pneumonia causes 14% of deaths among children and infants (ages 4 weeks to 5 years). UNICEF and WHO have established treatment guidelines to reduce risk of death from pneumonia including caregiver symptom recognition, appropriate care, and
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  Rural and urban Vietnamese mothers utilization of healthcareresources for children under 6 years with pneumoniaand associated symptoms Linda M. Kaljee  ·  Dang Duc Anh  · Truong Tan Minh  ·  Le Huu Tho  · Nyambat Batmunkh  ·  Paul E. Kilgore Received: June 16, 2010/Accepted: November 16, 2010/Published online: December 3, 2010 ©  Springer Science+Business Media, LLC 2010 Abstract  Worldwide, pneumonia causes 14% of deathsamong children and infants (ages 4 weeks to 5 years).UNICEF and WHO have established treatment guidelinesto reduce risk of death from pneumonia including care-giver symptom recognition, appropriate care, and use of antibiotics. In June 2008, cross-sectional survey data werecollected in Khanh Hoa Province Viet Nam with 329mothers of children under 6 years. In relation to pneumoniaand associated symptoms (fever  [ 38 ° C, strong cough,“fast or difficult” breathing), data were collected on per-ceptions of symptom severity and child vulnerability,reported healthcare utilization including use of antibiot-ics, sources of health information, and barriers to care.Pearson’s chi square, independent  t   tests, and multinomialanalysis were conducted to assess different patterns of reported healthcare utilization in relation to residency(rural/urban), mother’s education, and household income.Outcomes include rural and urban residency-based patternsrelated to perceptions of child’s vulnerability and symptomseverity, health facility utilization and barriers to care, andreported use of antibiotics during previous episodes of pneumonia. Implications include the need to target differ-ent healthcare facilities in urban and rural Viet Nam inrelation to education about symptoms of childhood pneu-monia and associated treatments. Keywords  Pneumonia · Viet Nam · Infants and children Introduction Pneumonia is a severe form of acute lower respiratorydisease with primary pathogenic origins from eitherStreptococcus pneumoniae or Haemophilus influenzaetype b (Hib). Symptoms include labored and rapidbreathing, cough, fever, chills, headache, loss of appetite,and wheezing (Wardlaw et al. 2006). In 2000, there werean estimated 160 million cases of pneumonia worldwideamong children under 5 years, including 13.8 million casescaused by S. pneumoniae. Approximately 36% of the 1.8million pneumonia deaths among HIV negative childrenunder 5 years are caused by S. pneumoniae (O’Brien et al.2009).Among infants and children aged 4 weeks to 5 years,pneumonia is responsible for 14% of deaths worldwide(Black et al. 2010). In 2004, in East Asia and the Pacificregion, there were an estimated 158,000 deaths frompneumonia including 4,000 deaths in Viet Nam. In thatsame period in Viet Nam, pneumonia accounted for 12% of deaths among children under 5 years. Viet Nam is one of 15 countries including six South and East Asian countrieswhich contribute to 75% of worldwide cases of infant andchildhood pneumonia (O’Brien et al. 2009).The United Nations Children’s Fund (UNICEF) and theWorld Health Organization (WHO) have established L. M. Kaljee ( & )Pediatric Prevention Research Center, The Carman and AnnAdams Department of Pediatrics, Wayne State University,Hutzel Building, Suite W534, 4707 St. Antoine, Detroit,MI 48201, USAe-mail: lkaljee@med.wayne.eduD. D. AnhNational Institute of Hygiene and Epidemiology, Ha Noi,Viet NamT. T. Minh · L. Huu ThoKhanh Hoa Provincial Health Services, Nha Trang, Viet NamN. Batmunkh · P. E. KilgoreInternational Vaccine Institute, Seoul, Korea  1 3 J Behav Med (2011) 34:254–267DOI 10.1007/s10865-010-9305-5  prevention and treatment protocols designed to reducenumbers of pneumonia cases and associated deaths amonginfants and young children in resource poor countries.Primary prevention strategies include availability of ade-quate nutrition (including breastfeeding), adherence toimmunization schedules, micronutrient supplementation,reduction of indoor air pollutants, and basic hygienepractices (e.g., hand washing).Treatment protocol includes: (1) caregiver’s recognitionthat a child is sick; (2) caregiver’s seeking appropriate care;and, (3) treatment with a full regimen of antibiotics(Wardlaw et al. 2006). In the Demographic Health Surveyof 2002 (including 38 countries), only 20% caregiversknew danger signs for pneumonia (labored and rapidbreathing), approximately half of children did not receiveappropriate medical care, and less than 20% of childrenreceived antibiotics. In the East Asia and Pacific region,62% of children received appropriate care with children inurban areas, from wealthier households, and havingmothers with higher education more likely to receive care.In Viet Nam, 71% of children’s caregivers sought appro-priate care with only slight differences between urban(75%) and rural (71%) residents (Wardlaw et al. 2006).Health-seeking and healthcare utilization occurs withinthe contexts of complex healthcare systems. Healthcaresystems develop and adapt within local sociocultural his-tories, national and international political and economicconditions, introduction of technologies, policies and pro-gramming, and migration and resettlement patterns (Greenet al. 2006; Gammeltoft and Nguyen 2007; Shaikh and Hatcher 2004).Healthcare systems are dynamic and pluralistic incor-porating biomedicine and a range of homeopathic andtraditional practices (Stoner 1986). Health-seeking andhealthcare utilization occurs within the contexts of thesecomplex healthcare systems. A range of models and the-oretical perspectives have been developed over the pastseveral decades to further understand health-seekingincluding ‘behaviorist’ models such as the Health Belief Model (Harrison et al. 1992) as well as political-economicmodels whereby healthseeking is embedded in socialconstructs (e.g., gender, class, ethnicity), and local,national, and global policies and practices (Harrison 1994;Morgan 1989).In relation to caregivers’ health-seeking for childrensignificant research has been conducted in relation todiarrheal diseases and the advancement of oral rehydrationtherapy (Stanton et al. 1992; Bentley et al. 1988; Pelto 1991). To date, however, much less data is availableregarding acute respiratory infections (ARI). Nichter(1996) notes similarities and differences between ARI anddiarrheal disease in social research. Similarities includehigh morbidity and mortality rates for children, the rangeof etiological agents including both bacteria and viruses,and the frequent use of home-based treatments includingthe misuse of Western pharmaceuticals (e.g., antibiotics).Differences include the often greater difficulty in lay-monitoring for symptoms of ARI especially among infantsand children, as well as greater difficulty in implementinginterventions for decreasing airborne transmitted diseasescompared to oral-fecal transmitted diseases. Nichter (1996)further defines a need for data across regions and socio-economic groups on disease perceptions in the context of illness episodes including perceptions of severity of disease.Among social-behavioral studies of ARI in Asia, qual-itative research in the Philippines revealed that health-seeking behavior was closely related to folk diagnosis of symptoms, household financial conditions, and socialcontacts (McNee et al. 1995). A study of ARI amongchildren in India suggests that not only local taxonomies of illnesses but specific episodes of illnesses affect health-seeking behaviors (Chand and Bhattacharyya 1994). InWest Java, first responses for infant ARI were more likely avisit to an indigenous healer than to an allopathic practi-tioner (Kresno et al. 1994). Research among mothers inBangladesh revealed differential health seeking behaviorsfor infants compared to older children and regular utiliza-tion of “spiritual healers” (Steward et al. 1994). Also, inBangladesh, research indicates that mothers’ use of moderntrained providers for maternal and child health servicesincluding recent episodes of cough and fever were posi-tively related to higher household income (Amin et al.2010).Viet Nam’s health system has undergone changes whichhaveparalleledarecenthistoryofextendedwarfare,conflictand emigration, and political and economic isolationfollowed by rapid market renovation ( đ ổ i m ớ  i ) within theglobal economy, increasing ‘open door’ policies and accessto information (e.g., internet, satellite television), andincreasing liberalization of legal constraints on privateproperty rights and internal migration. Absolute povertyrates have dropped from 75% in the mid-1980s to an esti-mated 18% in the early twenty-first century. However,poverty has also become more concentrated in rural areasand among ethnic minorities (Ekman et al. 2008). Theseethnic minorities include 53 groups living primarily in thehighlands and in the southern coastal regions. The popula-tionsizeoftheseminoritygroupsvariesfromlessthan3,000[e.g., Chut] to between 500,000 and 1 million [e.g., Muong,Tay, Thai, Hmong, Khmer] (Highland Education Develop-ment Organization).Starting in the 1950s in North Viet Nam, and afterreunification in 1975 throughout the country, the newlyformed communist government focused on development of a centralized public sector health system inclusive of both J Behav Med (2011) 34:254–267 255  1 3  traditional and biomedicine. Through this system, nursesand assistant physicians worked within local communehealth centers to provide basic preventive and primary careand health education to the largely rural populace (Ladinskyand Levine 1985). Beginning in the mid-1980s with theestablishment of   đ ổ i m ớ  i,  healthcare services were increas-ingly privatized and user fees were introduced for publicservices provided by commune health centers and govern-ment hospitals. Through the late twentieth and early twenty-first centuries, Viet Nam’s health system has developeddifferentially between regions particularly rural and urbanareas, with increasingly inequitable access to services,equipment and trained personnel (Ekman et al. 2008; Witter1998).In1992,thegovernmentintroducedhealthinsurance.Those persons insured are responsible for 20% of expenses,however, individuals living at or below a government des-ignated poverty level can receive free services. At the timeofthe current study,aninsurance program hadbeen recentlyimplemented to provide free public health care to all chil-dren under 6 years.The Vietnamese public sector includes commune healthcenters, polyclinics, and government hospitals. Staff atcommune health centers includes practitioners with two tothree years training in biomedical sciences (e.g., nurses,assistant doctors, midwives). Polyclinics offer multipleservices including primary health care, short-term inpatientcare, obstetrics and gynecology, minor surgery, and den-tistry. Polyclinic staff includes medical doctors as well asstaffing similar to commune health centers. A majority of hospitals in Viet Nam are in the public sector; however,there are increasing numbers of specialized private hospi-tals in larger urban areas, e.g., Hanoi and Ho Chi MinhCity.Throughout the healthcare system, biomedical and tra-ditional practices are integrated. Commune health centersand polyclinics often include staff trained in traditionalmedicine. Training in traditional medicine can be obtainedthrough formal educational institutions or informalapprenticeships. Traditional medicine in Viet Nam com-bines indigenous practices (thuoˆ´c nam) and Chinesemedicine (thuoˆ´c baˆ´c). Traditional medicine continues to beused in both urban and rural areas of the country and isoften a first response to symptoms (Kaljee et al. 2004).Commune health centers often include small gardenswhere plants and herbs are grown as part of traditionaltherapies. In addition, at the household level herbal andfood-based treatments are commonly used for relief of symptoms associated with a range of illnesses (Kaljee et al.2004). Foods and drink as well as different types of med-ications are classified as “hot” (a˘n  đ oˆ`no´ng) and “cool” ( ă  n đ ồ  mát  ), wet ( n ư ớ  c ) and dry (khoˆ) and the theoretical basisof the traditional medical practice is the need to maintain abalance between these fundamental categories to remainhealthy (Hue 2003). Since western pharmaceuticalsincluding antibiotics are often considered “hot” they maybe used with traditional “cool” foods and medicines. Thisperception of antibiotics as “hot” may also contribute toindividuals not using a full course of treatment.Private clinics offer both evaluation and treatment andinclude both biomedical and traditional practitioners. Manyprivate clinics also sell prescribed medicines to clients.Pharmacies are generally small private enterprises. Twotiers of pharmacy education are available in Viet Namincluding 2-year technical training and university-leveltraining. Western pharmaceuticals including antibiotics arereadily available without prescription.Recent research on general healthcare utilization in VietNam suggests several patterns. Overall, residents in poorrural areas are more likely to use commune health centers(Nguyen et al. 2009). Poor households are also more likelyto engage in self-treatment, to defer engagement withhealth services, and to forgo other household and personalneeds and/or borrow money to meet healthcare costs.However, poor households do utilize both public and pri-vate providers with one study indicating that the poor tendto use less public healthcare facilities (Segal et al. 2002;Khe et al. 2002; Thuan et al. 2008). And, while private care is often preferred to public facilities, data from an inde-pendent study which included a survey of public andprivate clinics in 30 randomly selected rural communes inHung Yen Province, indicate 25% of private practitionersalso work in the public sector and 11% had no professionalqualifications. These data further suggest while both publicand private services were evaluated as below nationalstandards, public services were deemed better than privateservices (Tuan et al. 2005).A few studies conducted in rural Viet Nam in relation toARI and health-seeking also reveal regular use of self-treatment. In one study, respondents used both western andtraditional self-treatment for cough and over 27% of the505 survey households stocked drugs for future useincluding 96 different antibiotics (Okumura et al. 2002). Inother research, mothers of children under 5 years used self-treatment with antibiotics for acute respiratory infections.Mothers seemed to respond appropriately to the severity of the symptoms by using antibiotics, but used them inap-propriately by stopping treatment too soon (Halfvarrsonet al. 2003).In the current paper, we explore Vietnamese mothers’perceptions of severity and vulnerability for fever [ 38 ° C,strong cough, and “fast or difficult” breathing and reportedhealthcare utilization patterns for episodes of these symp-toms and pneumonia. We assess differences in use of public and private facilities in relation to residency (rural/ urban), mother’s education and household income. Inaddition, we present data on sources of health information 256 J Behav Med (2011) 34:254–267  1 3  in regards to providing children’s healthcare and barriers tocare. We discuss these findings within the context of socio-cultural, economic, and health infrastructure changes inViet Nam and implications for meeting the UNICEF/WHOguidelines for effective treatment of childhood pneumonia.While Viet Nam has made strides in decreasing the prev-alence of many infectious diseases over the past 15 years,pneumonia continues to contribute significantly to infantand childhood morbidity and mortality rates. Data pre-sented in this paper are important toward the developmentof targeted health education programs and messages in VietNam which recognize differences in healthcare utilizationpatterns for childhood pneumonia between demographicgroups. And while specific to a single province in VietNam, similar research at national or regional scales willprovide critical data to develop interventions in Viet Namand other low-income and transitional countries to increaselikelihood of adherence to WHO guidelines with thepotential of decreasing high morbidity and mortality ratesassociated with childhood pneumonia. Methods Study areaKhanh Hoa Province is located in South Central coastalViet Nam. The province is bordered to the east by theSouth China Sea and to the west by a rural mountainousregion. The total population of the province is nearly 1.6million. Nha Trang City is the provincial capital and apopular seaside destination for both domestic and interna-tional tourists. The population of Nha Trang City isapproximately 389,000. Ninh Hoa is a rural district 35 kmnorth of Nha Trang City with a primarily agricultural andcommercial fishery-based economy. The organization of the healthcare infrastructure in Khanh Hoa Province issimilar to other provinces in Viet Nam. The provincial 500-bed hospital (Khanh Hoa General Hospital) is located inNha Trang City and delivers both primary and tertiary care.There are four specialty hospitals also located in Nha TrangCity and one general 210-bed hospital in Ninh Hoa district.Both Khanh Hoa Provincial General Hospital and NinhHoa District Hospital have pediatric wards includingintensive care units. Primary public healthcare for residentsis available through commune health centers (CHCs) andpolyclinics. In Nha Trang City and Ninh Hoa district, thereis one commune health center per commune for a total of 27 health centers in each site. There are five polyclinics inNha Trang City and two polyclinics in Ninh Hoa district.With the implementation of the new children’s insuranceplan, polyclinics in Nha Trang City were designated toprovide free health care and referrals. In both sites, thereare a number of biomedical and traditional private pro-viders and numerous small private first and second tierpharmacies.Research population and samplingSix communes (three each in Nha Trang City and NinhHoa district) were purposively selected as research sites toprovide a range of socioeconomic conditions and types of residency (rural, semi-urban, and urban). Using availablecensus data, all households with at least one child under6 years were eligible and assigned an identification num-ber. Utilizing the identification number and randomnumber selection (SPSS version 11), a total of 150households per commune were selected for participation.These household lists were provided to local communehealth center staff to recruit survey participants. The targetsample size was 60 respondents per commune. The finalnumber of respondent households was 362. A total of 329(91.1%) respondents were the mother of the “focus” child.EthicsThe research was submitted and approved by the Institu-tional Review Boards at the International Vaccine Institute,Seoul, Korea and the National Institute of Hygiene andEpidemiology, Hanoi, Viet Nam. Study approval was alsoobtained from the Vietnamese Ministry of Health EthicsCommittee. Staff members were trained in internationalresearch ethics and consenting procedures. All participantssigned a written consent form prior to the survey.Survey development and measurementsThe survey was designed to assess household demograph-ics and composition, general and specific householdbiomedical and traditional healthcare facility and resourceutilization practices for children under 6 years, perceptionsof disease symptom severity and vulnerability, healthinformation sources and perceptions of barriers to care.Specific health service conditions in Viet Nam wereincluded as response options. In addition, items andresponses were developed based on a series of qualitativecase studies with parents/guardians of children with clini-cal diagnosis of pneumonia. The survey was translatedfrom English to Vietnamese by trained bilingual staff. Apilot (  N   =  10) was conducted to assure item/responseclarity, respondent comprehension, and as a check forlanguage/translation errors. The pilot also provided the datacollectors with field experience with the survey prior toimplementation. The specific measures used in the analysisfor the current paper are described in Table 1. J Behav Med (2011) 34:254–267 257  1 3  Data collectionData were collected by experienced survey researchers.Training included a review of the full survey with a focuson ensuring understanding of the intent of the items andresponses. Data were collected in June 2008. Respondentswere provided with information about the study and con-sented. Data collection was conducted at the communehealth centers. Respondents were told to think about the“focus” child when responding to the questions. If ahousehold had more than one child under 6 years, therespondent was asked to think about the oldest child in thatage category. The data collector read items and responsesand recorded the respondent’s answers on a survey form.The survey took approximately 20–25 min. Respondentswere given a small stipend (~US$3) after completion of thesurvey.Data management and analysisData were double entered into SPSS Data Entry (version4.0) by trained staff. Data analysis was conducted withPASW Statistics (SPSS version 18.0). For purposes of thecurrent analysis, variables were created for number of health information sources, number of sources used forspecific symptoms, number of barriers to care, andhousehold composition (one or more grandparent, numberof siblings). Education was recoded into three categories(primary school or less, secondary school, high school orgreater). Monthly income was converted from Vietnamesedong to U.S. dollars (17,000 VND  =  US$1) and catego-rized into four quartiles ( \ US$106, US$107 to US$159,US$160 to US$235,  [ US$235). The per capita monthlyincome for Viet Nam in 2009 was US$88 (U.S. StateDepartment 2010).General descriptive analysis (means and standard devi-ations) and frequencies were used to describe demographicdata. Cross-tabs with Pearson’s chi square test were used todetermine significant differences for categorical data.Independent samples t-tests were used to assess signifi-cance between categories for continuous variables.Multinomial logistic regression analysis was used to assessindependent association of demographic factors includingresidency, mother’s education, and household income withuse of antibiotics, traditional medicine, and public and Table 1  Healthcare utilization survey items and scales  Demographics Respondent: (1) gender; (2) age; (3) relationship to child; (4) education; (5) employed (  yes/no);  (6) hours work/week; (7) how much of yourchild’s care do you provide on a regular basis [ less than 25%, 25 to 50%, 50% to 75%, over 75% ]; (8) who provides care for your child on aregular basis (multiple responses possible) [  father, grandmother, grandfather, other relative, non - relative ]“Focus” child: (1) gender; (2) age (  years/months ); (3) in school/daycare (  yes/no) Household: (1) list relationship (to child) and age of each household member; (2) total monthly household income General health information (1) Where do you obtain information about caring for your child when he/she is sick (multiple responses possible) [ older relatives, friends/ neighbors, pharmacy, CHC or polyclinic staff, private doctor, books/magazines/newspapers, health promotion programs ] Pneumonia Experience, Treatment and Healthcare Utilization (1) Has your child ever had pneumonia (received a diagnosis of pneumonia from a doctor or other healthcare provider)? Pneumonia is aninflammation of the lung and symptoms include a cough and fast, difficult breathing. Fever and muscle aches may occur (  yes/no);  (2) If yes,did your child take antibiotics (  yes/no);  (3) If yes, when your child was first sick, what did you use or where did you go to treat him/her(multiple responses possible) [ traditional medicines, medicine from pharmacy, go to commune health center, go to polyclinic, go to privatedoctor, go to hospital ] Symptom experience and treatment  (1) [three separate items] has your child ever had a fever [ 38 ° C [strong cough, fast/difficult breathing] (  yes/no);  (2) [for each symptom] did yourchild take antibiotics (  yes/no) ; (3) [for each symptom as applicable] what did you use or where did you go to treat (fever [ 38 ° C, strong cough,fast/difficult breathing) (multiple responses possible) [ traditional medicines, medicine from pharmacy, go to commune health center, go to polyclinic, go to private doctor, go to hospital ] Severity and vulnerability (1) How serious do you think a fever [ 38 ° C [cough, fast/difficult breathing] is for your child [ very serious, serious, a little serious, not serious] ;(2) How likely is it that your child will get a fever [cough, fast/difficult breathing] in the next six months [ very likely, likely, a little likely, not likely ]; (3) Overall, how would you rate your child’s health [ very weak, a little weak, average, strong, very strong ]  Barriers to care (1) Which of the following makes it difficult to obtain healthcare for your child when he/she is sick (multiple responses possible) [ distance tocommune health centers/polyclinic, distance to hospital, cost of medications, cost of treatment, difficulty getting free referral, cost of private physician, need to take time off work, need to find someone to care for other children, lack of transportation, long wait at the healthcare facilities, poor quality of care at the healthcare facilities, lack of equipment at the healthcare facilities, fear that child will become sick fromother children at the healthcare facility, not understanding information provided by the healthcare providers ]258 J Behav Med (2011) 34:254–267  1 3
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