Impact of peer support on virologic failure in HIV-infected patients on antiretroviral therapy - a cluster randomized controlled trial in Vietnam.

BACKGROUND: The effect of peer support on virologic and immunologic treatment outcomes among HIVinfected patients receiving antiretroviral therapy (ART) was assessed in a cluster randomized controlled trial in Vietnam. METHODS: Seventy-one clusters (communes) were randomized in intervention or control, and a total of 640 patients initiating ART were enrolled. The intervention group received peer support with weekly home-visits. Both groups received first-line ART regimens according to the National Treatment Guidelines. Viral load (VL) (ExaVir™ Load) and CD4 counts were analyzed every 6 months. The primary endpoint was virologic failure (VL >1000 copies/ml). Patients were followed up for 24 months. Intention-to-treat analysis was used. Cluster longitudinal and survival analyses were used to study time to virologic failure and CD4 trends. RESULTS: Of 640 patients, 71% were males, mean age 32 years, 83% started with stavudine/lamivudine/nevirapine regimen. After a mean of 20.8 months, 78% completed the study, and the median CD4 increase was 286 cells/µl. Cumulative virologic failure risk was 7.2%. There was no significant difference between intervention and control groups in risk for and time to virologic failure and in CD4 trends. Risk factors for virologic failure were ART-non-naïve status [aHR 6.9;(95% CI 3.2-14.6); p < 0.01]; baseline VL ≥100,000 copies/ml [aHR 2.3;(95% CI 1.2-4.3); p < 0.05] and incomplete adherence (self-reported missing more than one dose during 24 months) [aHR 3.1;(95% CI 1.1-8.9); p < 0.05]. Risk factors associated with slower increase of CD4 counts were: baseline VL ≥100,000 copies/ml [adj.sq.Coeff (95% CI): -0.9 (-1.5;-0.3); p < 0.01] and baseline CD4 count <100 cells/µl [adj.sq.Coeff (95% CI): -5.7 (-6.3;-5.4); p < 0.01]. Having an HIV-infected family member was also significantly associated with gain in CD4 counts [adj.sq.Coeff (95% CI): 1.3 (0.8;1.9); p < 0.01]. CONCLUSION: There was a low virologic failure risk during the first 2 years of ART follow-up in a rural low-income setting in Vietnam. Peer support did not show any impact on virologic and immunologic outcomes after 2 years of follow up. TRIAL REGISTRATION: NCT01433601 .

HIV sero-discordance among married HIV patients initiating anti-retroviral therapy in northern Vietnam.

BACKGROUND: In many countries in Asia, the HIV epidemic is in a concentrated phase, with high prevalence in certain risk groups, such as men who inject drugs. There is also a rapid increase of HIV among women. The latter might be due to high levels of sero-discordant couples and increasing transmission from male to female partners over time. METHODS: All adult married patients initiating antiretroviral treatment at four out-patient clinics in Quang Ninh province in north-eastern Vietnam between 2007 and 2009 were asked to participate in the study. Clinical information was extracted from patients' records, and a structured questionnaire was used to collect social, demographic and economic data. RESULTS: Two hundred eighty-eight married patients for whom information on the HIV status of their spouse was available were included in the study. Overall, the sero-discordance rate was 58%. The sero-discordance rate was significantly higher among married males, 71% had spouses not infected, than married females, of whom 18% had spouses not infected. Other factors associated with a high rate of sero-discordance were injection drug use (IDU) history, tuberculosis (TB) history and the availability of voluntary counselling and testing (VCT) in residential locations. High sero-concordance was associated with college/university education. CONCLUSION: The sero-discordance was significantly higher among married males than married females. Other factors also related to high sero-discordance were history of IDU, history of TB and the availability of VCT in residential locations. In contrast, college/university education and female sex were significantly related to low sero-discordance. To contain the increasing HIV prevalence among women, measures should be taken to prevent transmission among sero-discordant couples. Trial registration NCT01433601.

Reproductive Tract Infections in Rural Vietnam, Women's Knowledge, and Health-Seeking Behavior: A Cross-Sectional Study.

We interviewed 1,805 women in a rural setting in Vietnam with the aim of investigating women's knowledge regarding reproductive tract infections (RTIs) and their health-seeking behavior. We found that women's overall knowledge was poor. Furthermore, only one-third of the symptomatic women sought health care. RTIs affect millions of women globally each year. Most vulnerable are women in low- and middle-income countries where poverty and gender inequities affect their access to health care services. Findings from our study can be used in similar rural settings worldwide to understand and manage the widespread problem of RTIs.

Nordic School of Public Health NHV and its legacy in global health.

This article describes the legacy of the Nordic School of Public Health NHV (NHV) in global health. We delineate how this field developed at NHV and describe selected research and research training endeavours with examples from Vietnam and Nepal as well as long-term teaching collaborations such as BRIMHEALTH (Baltic RIM Partnership for Public HEALTH) in the Baltic countries and Arkhangelsk International School of Public Health in Russia.

Improved knowledge and reported practice regarding sexually transmitted infections among healthcare providers in rural Vietnam: a cluster randomised controlled educational intervention.

BACKGROUND: Healthcare providers (HCPs) play a critical role in controlling the spread of sexually transmitted infections (STI) through early and accurate diagnosis, appropriate treatment and prevention counselling. This study aimed to assess the effectiveness of an educational intervention about STI on knowledge and reported practice among HCPs and to explore which determinants may influence the intervention's effects. METHODS: A cluster randomized controlled educational intervention was carried out in a rural district, Vietnam. 32 communes of the district were randomized into two arms, with 160 HCPs in an STI intervention arm and 144 in a control arm. The STI intervention comprised interactive training with basic STI knowledge, case scenarios, and poster distribution. Questionnaires to evaluate knowledge and reported practice were completed three times: before, during and after the intervention. Correct answer was scored as 1; "do not know", incorrect answer was scored as 0. Univariate and multilevel multivariate analyses were applied. RESULTS: Of the maximum 56 points, the mean knowledge score increased significantly in the STI intervention arm and in the control arm post-intervention (37.2 to 48.4, and 32.7 to 41.7, respectively). In multivariate regression analysis, knowledge improvement in the intervention arm was significantly higher than that in the control arm (regression coefficient = 2.97, p = 0.008). Other factors which positively influenced the increase in knowledge were being between 35 and 50 years old, having intermediate professional training, being a pharmacist or working at a village level (regression coefficient: 2.81, 4.43, 5.53 and 7.91, respectively). Post-intervention, the mean reported practice score increased significantly in the STI intervention arm (from 17.6 to 21.8) and insignificantly in the control arm (maximum 36 points). Factors which positively influenced the increase in reported practice were being between 35 and 50 years old, having intermediate professional training, or working at a pharmacy/drugstore (regression coefficient: 2.15, 3.33 and 3.22, respectively). CONCLUSIONS: This study indicates that an educational intervention including interactive training and multi-faceted interventions may be effective in improving STI knowledge and reported practice of HCPs at grassroots level, particularly among pharmacists, HCPs who work in villages or pharmacies/drugstores, and who initially have low STI knowledge.

Symptoms of antenatal common mental disorders, preterm birth and low birthweight: a prospective cohort study in a semi-rural district of Vietnam.

OBJECTIVES: To examine the association of low birthweight (LBW) and prematurity with clinically significant symptoms of antenatal common mental disorders (ACMDs) during the third trimester of pregnancy in a semi-rural area in Vietnam. METHODS: Prospective community-based cohort study. Severity of ACMD symptoms was assessed with the Edinburgh Depression Scale, low birthweight was defined as below 2500 g, and gestational age was estimated according to last menstrual period. Reproductive and socio-demographic risk factors were measured as potential confounders of the association between ACMD and the outcomes. We conducted bivariate analyses of association between ACMD and the perinatal outcomes, employing chi-square tests, crude odds ratios and 95% confidence intervals. Multiple logistic regression analysis was used to adjust for confounding. FINDINGS: We found a prevalence of clinically significant symptoms of ACMDs of 37.4%, which were significantly associated with preterm birth (adjusted OR 1.98, CI95% = 1.14-3.43) and low birthweight (adjusted OR 2.24, CI95%  = 1.02-4.95). Among the examined risk factors for the outcome measures, only maternal age was found to be statistically significant for low birthweight and preterm birth. CONCLUSIONS: This study confirms that clinically significant symptom levels of ACMD in Vietnam are associated with preterm birth and low birthweight. These findings highlight the importance of cost-effective public health interventions for ACMD in Vietnam and further exploration of its physiological link with preterm birth and low birthweight.

The impact of economic growth on health care utilization: a longitudinal study in rural Vietnam.

INTRODUCTION: In many developing countries, including Vietnam, out-of-pocket payment is the principal source of health financing. The economic growth is widening the gap between rich and poor people in many aspects, including health care utilization. While inequities in health between high- and low-income groups have been well investigated, this study aims to investigate how the health care utilization changes when the economic condition is changing at a household level. METHOD: We analysed a panel data of 11,260 households in a rural district of Vietnam. Of the sample, 74.4% having an income increase between 2003 and 2007 were defined as households with economic growth. We used a double-differences propensity score matching technique to compare the changes in health care expenditure as percentage of total expenditure and health care utilization from 2003 to 2005, from 2003 to 2007, and from 2005 to 2007, between households with and without economic growth. RESULTS: Households with economic growth spent less percentage of their expenditure for health care, but used more provincial/central hospitals (higher quality health care services) than households without economic growth. The differences were statistically significant. CONCLUSIONS: The results suggest that households with economic growth are better off also in terms of health services utilization. Efforts for reducing inequalities in health should therefore consider the inequality in income growth over time.

Mortality measures from sample-based surveillance: evidence of the epidemiological transition in Viet Nam.

OBJECTIVE: To report methods and results from a national sample mortality surveillance programme implemented in Viet Nam in 2009. METHODS: A national sample of 192 communes located in 16 provinces and covering a population of approximately 2.6 million was selected using multi-stage cluster sampling. Deaths for 2009 were identified from several local data sources. Record reconciliation and capture-recapture methods were used to compile data and assess completeness of the records. Life tables were computed using reported and adjusted age-specific death rates. Each death was followed up by verbal autopsy to ascertain the probable cause(s) of death. Underlying causes were certified and coded according to international guidelines. FINDINGS: A total of 9921 deaths were identified in the sample population. Completeness of death records was estimated to be 81%. Adjusted life expectancies at birth were 70.4 and 78.7 years for males and females, respectively. Stroke was the leading cause of death in both sexes. Other prominent causes were road traffic accidents, cancers and HIV infection in males, and cardiovascular conditions, pneumonia and diabetes in females. CONCLUSION: Viet Nam is undergoing the epidemiological transition. Although data are relatively complete, they could be further improved through strengthened local collaboration. Medical certification for deaths in hospitals, and shorter recall periods for verbal autopsy interviews would improve cause of death ascertainment.

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

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/m(2), 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.

Health and demographic surveillance systems in low- and middle-income countries: history, state of the art and future prospects.

Health and Demographic Surveillance Systems (HDSS) have been developed in several low- and middle-income countries (LMICs) in Africa and Asia. This paper reviews their history, state of the art and future potential and highlights substantial areas of contribution by the late Professor Peter Byass.Historically, HDSS appeared in the second half of the twentieth century, responding to a dearth of accurate population data in poorly resourced settings to contextualise the study of interventions to improve health and well-being. The progress of the development of this network is described starting with Pholela, and progressing through Gwembe, Balabgarh, Niakhar, Matlab, Navrongo, Agincourt, Farafenni, and Butajira, and the emergence of the INDEPTH Network in the early 1990'sThe paper describes the HDSS methodology, data, strengths, and limitations. The strengths are particularly their temporal coverage, detail, dense linkage, and the fact that they exist in chronically under-documented populations in LMICs where HDSS sites operate. The main limitations are generalisability to a national population and a potential Hawthorne effect, whereby the project itself may have changed characteristics of the population.The future will include advances in HDSS data harmonisation, accessibility, and protection. Key applications of the data are to validate and assess bias in other datasets. A strong collaboration between a national HDSS network and the national statistics office is modelled in South Africa and Sierra Leone, and it is possible that other low- to middle-income countries will see the benefit and take this approach.

The Global South political economy of health financing and spending landscape - history and presence.

The Global South nations and their statehoods have presented a driving force of economic and social development through most of the written history of humankind. China and India have been traditionally accounted as the economic powerhouses of the past. In recent decades, we have witnessed reestablishment of the traditional world economic structure as per Agnus Maddison Project data. These profound changes have led to accelerated real GDP growth across many LMICs and emerging countries of the Global South. This evolution had a profound impact on an evolving health financing landscape. This review revealed hidden patterns and explained the driving forces behind the political economy of health spending in these vast world regions. The medical device and pharmaceutical industry play a crucial role in addressing the unmet medical needs of rising middle class citizens across Asia, Latin America, and Africa. Domestic manufacturing has only been partially meeting this ever rising demand for medical services and medicines. The rest was complemented by the participation of multinational pharmaceutical industry, whose focus on investment into East Asia and ASEAN nations remains part of long-term market access strategies. Understanding of the past remains essential for the development of successful health strategies for the present. Political economy has been driving the evolution of health financing landscape since the establishment of early modern health systems in these countries. Fiscal gaps these governments face in diverse ways might be partially overcome with the spreading of cost-effectiveness based decision-making and health technology assessment capacities. The considerable remaining challenges ranging from insufficient reimbursement rates, large out-of-pocket spending, and lengthy lag in the introduction of cutting-edge technologies such as monoclonal antibodies, biosimilars, or targeted oncology agents, might be partially resolved only in the long run.

Compiling mortality statistics from civil registration systems in Viet Nam: the long road ahead.

Accurate mortality statistics, needed for population health assessment, health policy and research, are best derived from data in vital registration systems. However, mortality statistics from vital registration systems are not available for several countries including Viet Nam. We used a mixed methods case study approach to assess vital registration operations in 2006 in three provinces in Viet Nam (Hòa Bình, Thùa Thiên-Hué and Bình Duong), and provide recommendations to strengthen vital registration systems in the country. For each province we developed life tables from population and mortality data compiled by sex and age group. Demographic methods were used to estimate completeness of death registration as an indicator of vital registration performance. Qualitative methods (document review, key informant interviews and focus group discussions) were used to assess administrative, technical and societal aspects of vital registration systems. Completeness of death registration was low in all three provinces. Problems were identified with the legal framework for registration of early neonatal deaths and deaths of temporary residents or migrants. The system does not conform to international standards for reporting cause of death or for recording detailed statistics by age, sex and cause of death. Capacity-building along with an intersectoral coordination committee involving the Ministries of Justice and Health and the General Statistics Office would improve the vital registration system, especially with regard to procedures for death registration. There appears to be strong political support for sentinel surveillance systems to generate reliable mortality statistics in Viet Nam.

The incidence of epilepsy in a rural district of Vietnam: a community-based epidemiologic study.

PURPOSE: Epidemiologic studies of epilepsy from developing countries are scarce. As part of a population-based epidemiologic project in Vietnam, EPIBAVI, we studied the incidence and etiology of epilepsy in people in a representative rural region of the country. METHODS: Two identical field surveys were carried out 3 years apart (January to December 2005, and June to December 2008) in the same population of the Bavi District in Vietnam. On both occasions, close to 50,000 members of approximately 13,000 households were screened using a questionnaire for epilepsy. A clinical examination of all screened positive was performed by a neurologist to verify the epilepsy diagnosis, and all incident cases were offered EEG and a CT scan. RESULTS: In the first survey 2.8% screened positive according to the questionnaire. Of these, 19 had epilepsy onset within 1 year preceding the screening, yielding an incidence rate of 40.2 per 100,000 [95% confidence interval (CI) 22.1-58.3]. In the second survey 1.8% were screened positive, and 21 of these had epilepsy onset within 1 year preceding the screening, giving an incidence rate of 42.9 per 100,000 (95% CI 24.5-61.2). The age-adjusted incidence was 44.8 per 100,000 (95% CI 30.6-59.0). The incidence was higher in those younger than 16 years, among people with lower education, and among people with lower income. CT scan was performed in 29 cases and only two cases were found with some abnormalities. DISCUSSION: The incidence rate of epilepsy in rural Vietnam in our study was lower than in developing countries in Latin America and Africa and similar to rates in Europe and North America.

The treatment gap of epilepsy in a rural district of Vietnam: a study from the EPIBAVI project.

We analyzed the treatment gap by interviewing 189 persons previously identified as having active epilepsy in a population-based epidemiological project in a rural district of Vietnam (EPIBAVI). Only 29 persons were on regular treatment with antiepileptic drugs (AEDs) at the time of the survey; treatment gap 84.7% [95% confidence interval (CI) 79.5-89.8%). The treatment gap was not associated with age, gender, education, income, or seizure control status, but was higher among those living single compared to those who were married (p < 0.05). The most common reason for not taking AEDs expressed by patients who never tried, as well as among those who tried but discontinued, AEDs was the perception that their seizures were too few to justify the trouble and costs associated with treatment.

Lack of knowledge about sexually transmitted infections among women in North rural Vietnam.

BACKGROUND: The serious long-term complications of sexually transmitted infections (STI) in women and newborns are well-documented. Particularly, STI imply considerable social consequences for women. Low STI knowledge has been shown to be associated with unsafe sex. In Vietnam, misconceptions regarding STI exist, and rural women delay seeking care for STI. The aim of the study was to investigate knowledge of STI among women aged 15 to 49 years in a rural district of Vietnam and to evaluate possible associations between socioeconomic factors and STI knowledge. METHODS: A cross-sectional population-based study using face-to-face interviews was carried out between March and May 2006 in a demographic surveillance site in rural Vietnam. In total, 1805 women aged 15-49 years were randomly selected to participate in the study. The interviews were based on a structured questionnaire including questions on sociodemographic characteristics of the women and their knowledge about STI. Each correct answer was scored 1, incorrect or do not know answer was scored 0. Multivariate analyses were applied to examine associations between socio-economic conditions and STI knowledge. Intra-cluster correlation was calculated to examine similarities of STI knowledge within clusters. RESULTS: Of the 1,805 respondents, 78% (73% married vs. 93% unmarried, p < 0.001) did not know any symptoms of STI, 50% could not identify any cause of STI, 59% (54% married vs. 76% unmarried, p < 0.001) did not know that STI can be prevented. Only 31% of the respondents (36% married vs. 14% unmarried, p < 0.001) answered that condom use could protect against STI, and 56% considered partner treatment necessary. Of 40 possible correct answers, the mean knowledge score was 6.5 (range 0-26, median 6). Young, unmarried women and women who lived in the highlands or mountainous areas demonstrated very low levels of STI knowledge (regression coefficients -1.3 and -2.5, respectively, p < 0.001). Experience of an induced abortion was significantly associated with a higher level of knowledge. CONCLUSION: The low levels of STI knowledge found among women of reproductive age in a rural district of Vietnam indicate an urgent need of health education interventions, of which, young and unmarried women should be specifically targeted.

Drug use among children under 5 with respiratory illness and/or diarrhoea in a rural district of Vietnam.

OBJECTIVES: To describe the pattern of drug use among the children with respiratory illnesses and/or diarrhoea; and to analyze the association between various socio-economic factors and pattern of drug use. METHODS: A population-based survey of 4087 children under five was conducted within the framework of an epidemiological surveillance site in a rural district of Vietnam. Through interviewing mothers or caretakers, data on self-reported illness, use of drugs, and use of health services during 2 weeks prior to the survey and other background information were collected. RESULTS: Out of 4087 children, 1836 children had respiratory illness and/or diarrhoea during 2 weeks before the interview and drugs were used in the majority of cases. Antibiotics (72.2%) and analgesics/antipyretics (53.5%) were the drugs most commonly reported. Corticosteroids were used in 11.6% of all cases. Among children with diarrhoea, Oral Rehydration Solution (ORS) was used in 9.7%, while anti-diarrhoea drugs were used in 36.1% of all cases. There was a significant association between the family's socio-economic condition and use of corticosteroids, but to a lesser degree regarding other drugs. There was no significant association between pattern of drug use and type of health service consulted. CONCLUSIONS: There are major problems about irrational drug use among children. The treatment guidelines for respiratory illness and diarrhoea are not followed. Urgent actions are needed and should target all actors in the field, mothers, doctors, pharmacy staff, and authorities in order to improve this situation.

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.

The prevalence of epilepsy in a rural district of Vietnam: a population-based study from the EPIBAVI project.

SUMMARY: A field survey was carried out to determine the prevalence of active epilepsy in northern Vietnam between January and December 2005, when members of approximately 13,000 households were screened for seizure disorders. A clinical examination of all screened positive was performed by a neurologist to verify the epilepsy diagnosis, and all epilepsy cases were offered an EEG. Out of 47,269 screened, 1,338 (2.8%) had a positive response to the questionnaire. Of these, 206 fulfilled the criteria for active epilepsy, yielding a prevalence of 4.4 per 1,000 (95% CI 3.8-5.0), higher among males (5.1) than females (3.7), among those with lower compared with higher education and among single compared with those married. Only 20.6% were seizure-free the year before the examination. The prevalence of active epilepsy in Vietnam is similar to some other Asian countries but lower than in developing countries from Africa and South America.

Choice of healthcare provider following reform in Vietnam.

BACKGROUND: In Vietnam, the health-sector reforms since 1989 have lead to a rapid increase in out-of-pocket expenses. This paper examines the choice of medical provider and household healthcare expenditure for different providers in a rural district of Vietnam following healthcare reform. METHODS: The study consisted of twelve monthly follow-up interviews of 621 randomly selected households. The households are part of the FilaBavi project sample - Health System Research Project. The heads of household were interviewed at monthly intervals from July 2001 to June 2002. RESULTS: The use of private health providers and self-treatment are quite common for both episodes (60% and 23% of all illness episodes) and expenditure (60% and 12.8% of healthcare expenditure) The poor tend to use self-treatment more frequently than wealthier members of the community (31% vs. 14.5% of illness episodes respectively). All patients in this study often use private services before public ones. The poor use less public care and less care at higher levels than the rich do (8% vs.13% of total illness episodes, which decomposes into 3% vs. 7% at district level, and 1% vs. 3% at the provincial or central level, respectively). The education of the patients significantly affects healthcare decisions. Those with higher education tend to choose healthcare providers rather than self-treatment. Women tend to use drugs or healthcare services more often than men do. Patients in two highest quintiles use health services more than in the lowest quintile. Moreover, seriously ill patients frequently use more drugs, healthcare services, public care than those with less severe illness. CONCLUSION: The results are useful for policy makers and healthcare professionals to (i) formulate healthcare policies-of foremost importance are methods used to reduce self-treatment and no treatment; (ii) the management of private practices and maintaining public healthcare providers at all levels, particularly at the basic levels (district, commune) where the poor more easily can access healthcare services, is also important, as is the management of private practices and (iii) provide a background for further studies on both short and long-term health service strategies.

Perceptions and attitudes in relation to reproductive tract infections including sexually transmitted infections in rural Vietnam: a qualitative study.

OBJECTIVE: To explore perceptions, attitudes and health-seeking patterns for reproductive tract infections including sexually transmitted infections (RTI/STI) among men and women in rural Vietnam. METHOD: Ten focus group discussions (FGDs) were conducted with 46 women and 27 men aged 15-49 in Bavi district, northern Vietnam. A pre-designed discussion guide was used during the discussions. Content analysis was applied for data analysis. Each sentence/paragraph was coded. Similar codes were clustered and collapsed into sub-categories and categories. Two main themes 'community perceptions of RTI/STI' and 'attitudes towards RTI/STI' were created, based on the relationship between categories. FINDINGS: Complex terminology with many different terms was used by participants to describe and discuss RTI/STI. "Inflammation" [RTI], Gonorrhoea, Syphilis was described as three stages of STI. Health-seeking patterns for RTI/STI were reported to differ between men and women: self-medication was mentioned as a common practice among women, while men were more likely to seek health care from private providers. Complaints were voiced about clinicians' negative attitudes towards RTI/STI patients. CONCLUSION: Rural dwellers in a district of Vietnam expressed a variety of misconceptions regarding RTI/STI. Designing health education strategies to provide comprehensive RTI/STI information to the community and improving communication between RTI/STI patients and clinicians are urgently needed.