Study design and participant recruitment
This study was done as a part of feasibility study in Korea’s official development assistance project, in collaboration with The University of Medicine and Pharmacy at Ho Chi Minh City. It was a cross sectional study conducted in one rural area in Binh Phuoc province, and the other one of suburban area, Da Lat city in Lam Dong province. These areas were selected due to cooperation from commune health centers and convenience of transportation for interviewers.
Located in the Southeast region of Vietnam, Binh Phuoc, a predominantly rural province, covers an area of 6,871 km2, and is divided into 5 commune-level towns, 92 communes, and 14 urban communes. The population of Binh Phuoc in 2015 was 944,400. Dak Nhau, a commune in Binh Phuoc, is in a mountainous area and is 30 to 70 km away from the district hospital. Dak Nhau commune is the residence of ethnic minority peoples, especially the Stieng and Mnong people. Located in the central highlands of Vietnam, Da Lat city, a district level city, covers an area of 395 km2, spreading over 12 urban communes and 4 communes. The population of Da Lat in 2015 was 406,105, of which 55,596 were suburban inhabitants (13.7%). The suburban residents primarily make their money from agriculture, forestry, or handicrafts, and agriculture plays an important part of their local economy. The Ta Nung commune, Tram Hanh commune, and urban commune #7 were selected. These communes are all in suburban areas of Da Lat city, and are 7 to 30 km away from the district hospital.
We selected 203 participants in the Binh Phuoc province and 101 participants in Da Lat city from a list of households from the local authorities, and a total of 304 people were recruited for participation in this study. Among them, 233 people were finally selected after excluding participants less than 19 years old. Well-trained researchers from the faculty of public health of the University of Medicine and Pharmacy at Ho Chi Minh City visited households with help from local health facility leaders and invited family head or any other members of family at home to participate in the survey.
Survey instrument and measurements
Face-to-face interviews were conducted using a structured questionnaire, which included questions about the participant’s socio-economic status, health problems, health service utilization, health service responsiveness and satisfaction, and healthcare services needed. The socioeconomic characteristics included age, gender, marital status, education level, ethnicity, occupation, monthly income, number of family members, and health insurance. Health related factors included self-perceived health status, smoking, drinking, physical activity, and underlying chronic disease, such as hypertension, diabetes mellitus, dyslipidemia, heart disease, stroke, chronic lung disease, and depression. Anthropometric measurements including height, weight, and systolic and diastolic blood pressure (SBP and DBP, mmHg) were taken by the researchers using a portable weight and height measurement device (BSM370, InBody Co., Seoul, Korea) and a blood pressure measurement device (HEM-1020, Omron Co., Tokyo, Japan). Height and weight were measured with the subjects barefoot and lightly clothed. Blood pressure was measured twice and recorded when subjects were sitting.
Body mass index was calculated as kg/m2. Blood pressure was chosen for the mean values of two measurements and categorized as normal (SBP <130 and DBP <85), prehypertension (130≤SBP <140 or 85≤DBP <90), stage 1 hypertension (130≤SBP <140 or 85≤DBP <90), or stage 2 hypertension (SBP ≥160 or DBP ≥100 ).(14)
Questions regarding healthcare service utilization consisted of number of admissions to the hospital or visits to an emergency department and number of visits to an outpatient clinic during the previous 12 months, and expenses during those admissions or visits.
Participants were also asked to evaluate healthcare services they had experienced, that is, how satisfied they were with the healthcare services, and were requested to suggest further improvements they needed. Participants were compensated with a cash equivalent of 5 USD when they finished the interviews.
Unmet healthcare needs group
Participants were asked if they had any kind of health problems during the past 12 months and whether they could see the healthcare providers they needed to solve their problems. Those who had health problems and were unable to see healthcare providers were classified as being in the unmet health needs group and were asked further questions to explore the reasons for not seeing healthcare providers. We classified the questions into three categories of accessibility, availability, and acceptability. For accessibility, we asked about factors such as knowledge of how to find appropriate doctors, fear, transportation, physical disabilities, difficulties in getting appointments at hospitals, language barriers, and insurance or cost issues. For availability issues, we asked about factors such as lack of available doctors, lack of available medicines, lack of available time, lack of support in visiting the hospital, and lack of health insurance. For acceptability issues, we asked about cultural/religious beliefs, communication with healthcare providers, getting enough information, treatment decision making, privacy, treatment choice, waiting time, condition of the waiting room, and hygiene status of healthcare facilities.
Statistical analysis
Both descriptive and analytical statistical analyses were carried out using SAS 9.4 software. Descriptive statistical analysis was used to present the socio-demographic characteristics, healthcare service utilization, and healthcare service evaluation of participants. Student’s t-test and Chi-squared test were used to compare the differences between the unmet healthcare needs group and the healthcare met group. Multivariate logistic regression was performed to determine the factors associated with unmet healthcare needs. The significance level was set at p < 0.05.