Area-level socioeconomic characteristics, prevalence and trajectories of cardiometabolic risk.

This study examines the relationships between area-level socioeconomic position (SEP) and the prevalence and trajectories of metabolic syndrome (MetS) and the count of its constituents (i.e., disturbed glucose and insulin metabolism, abdominal obesity, dyslipidemia, and hypertension). A cohort of 4,056 men and women aged 18+ living in Adelaide, Australia was established in 2000-2003. MetS was ascertained at baseline, four and eight years via clinical examinations. Baseline area-level median household income, percentage of residents with a high school education, and unemployment rate were derived from the 2001 population Census. Three-level random-intercepts logistic and Poisson regression models were performed to estimate the standardized odds ratio (SOR), prevalence risk ratio (SRR), ratio of SORs/SRRs, and (95% confidence interval (CI)). Interaction between area- and individual-level SEP variables was also tested. The odds of having MetS and the count of its constituents increased over time. This increase did not vary according to baseline area-level SEP (ratios of SORs/SRRs ≈ 1; p ≥ 0.42). However, at baseline, after adjustment for individual SEP and health behaviours, median household income (inversely) and unemployment rate (positively) were significantly associated with MetS prevalence (SOR (95%CI) = 0.76 (0.63-0.90), and 1.48 (1.26-1.74), respectively), and the count of its constituents (SRR (95%CI) = 0.96 (0.93-0.99), and 1.06 (1.04-1.09), respectively). The inverse association with area-level education was statistically significant only in participants with less than post high school education (SOR (95%CI) = 0.58 (0.45-0.73), and SRR (95%CI) = 0.91 (0.88-0.94)). Area-level SEP does not predict an elevated trajectory to developing MetS or an elevated count of its constituents. However, at baseline, area-level SEP was inversely associated with prevalence of MetS and the count of its constituents, with the association of area-level education being modified by individual-level education. Population-level interventions for communities defined by area-level socioeconomic disadvantage are needed to reduce cardiometabolic risks.

Area-level socioeconomic characteristics and incidence of metabolic syndrome: a prospective cohort study.

BACKGROUND: The evidence linking socioeconomic environments and metabolic syndrome (MetS) has primarily been based on cross-sectional studies. This study prospectively examined the relationships between area-level socioeconomic position (SEP) and the incidence of MetS. METHODS: A prospective cohort study design was employed involving 1,877 men and women aged 18+ living in metropolitan Adelaide, Australia, all free of MetS at baseline. Area-level SEP measures, derived from Census data, included proportion of residents completing a university education, and median household weekly income. MetS, defined according to International Diabetes Federation, was ascertained after an average of 3.6 years follow up. Associations between each area-level SEP measure and incident MetS were examined by Poisson regression Generalised Estimating Equations models. Interaction between area- and individual-level SEP variables was also tested. RESULTS: A total of 156 men (18.7%) and 153 women (13.1%) developed MetS. Each percentage increase in the proportion of residents with a university education corresponded to a 2% lower risk of developing MetS (age and sex-adjusted incidence risk ratio (RR)=0.98; 95% confidence interval (CI) =0.97-0.99). This association persisted after adjustment for individual-level income, education, and health behaviours. There was no significant association between area-level income and incident MetS overall. For the high income participants, however, a one standard deviation increase in median household weekly income was associated with a 29% higher risk of developing MetS (Adjusted RR=1.29; 95%CI=1.04-1.60). CONCLUSIONS: While area-level education was independently and inversely associated with the risk of developing MetS, the association between area-level income and the MetS incidence was modified by individual-level income.

Evidence and decision making: tobacco control policy and legislation in Vietnam.

The Ministry of Health (MOH) in Vietnam is currently drafting the Tobacco Harm Prevention Law. The government requested the MOH to provide evidence on the strategies proposed in the draft law as part of its submission to the National Assembly. This study examines the availability and strength of evidence and its relationship to policy stakeholders' positions towards policy instruments proposed in the law. Several qualitative methods were employed including documentary analysis, key informant interviews, focus group discussion and a key stakeholders' survey. Contradictory findings were identified over the role of evidence. While there is high demand for local evidence, the availability and strength of evidence are not always aligned with stakeholders' positions with respect to different strategies. Stakeholders' positions are shaped by competing interests on the basis of their perceptions of the socioeconomic implications and health consequences of tobacco control. Claims of limited availability of evidence are often used to justify the maintenance of the status quo, a position that is seen to protect the state-owned tobacco industry and state revenue. Local evidence of the impact of tobacco on population health is argued to be 'one-sided' and evidence of selected interventions discounted. Compelling and comprehensive local evidence, including those addressing economic concerns, is acutely needed in order to proceed with the current legislation process. For evidence to play a critical role, it needs to engage those ministries responsible for the tobacco industry itself and the economic development.

Translating knowledge into policy: provision and use of evidence in the Tobacco Harm Prevention Law in Vietnam.

Vietnam is currently considering a Tobacco Harm Prevention Law and the Ministry of Health has been asked to provide supporting evidence. This analysis explores factors influencing uptake of evidence in that legislation process. The political environment reflects the government's ambivalence over how to balance health and socioeconomic issues of tobacco control in a state-owned industry. Although the growing presence of transnational tobacco companies is alarming, the role of Framework Convention on Tobacco Control in prompting government compliance with set milestones is encouraging. Evidence of effectiveness of interventions for health needs now to be complemented with socioeconomic evaluation, and strengthening of the ties between advocates and decision makers.

The development of Tobacco Harm Prevention Law in Vietnam: stakeholder tensions over tobacco control legislation in a state owned industry.

BACKGROUND: Building on its National Tobacco Control Policy initiated in 2000, Vietnam is currently considering introducing a comprehensive law to strengthen the implementation of tobacco control policy. This study analyses the positions of key stakeholders in the development of tobacco control legislation in the context of a largely state-owned industry, and discusses their implications for the policy process. METHODS: Several qualitative methods were employed for the study including: literature review and documentary analysis; key informant interview; focus groups discussion; and key stakeholders survey. FINDINGS: The Ministry of Health, Ministry of Trade and Industry, and Ministry of Finance are key players in the tobacco control policy and legislation, representing competing bureaucratic interests over health, macro-economy and revenue. High-ranking officials, including the Communist Party and National Assembly members, take a rather relaxed position reflecting the low political stakes placed on tobacco issues. The state-owned tobacco industry is regarded as an important contributor to the government revenue and gross domestic product, and the relative weight on health and socioeconomic issues placed by stakeholders determine their positions on tobacco control. Overall, short-term economic interests have more immediate influence in setting policy directions, with the consequences of health gains perceived as relegated to a distant future. This was reflected in the position of tobacco control advocates, including MOH, that presented with reluctance in insisting on some tobacco control strategies revealing a mixture attitude of concessions to the socioeconomic uncertainties and a sense of bargaining to win the strategies that are more likely to be accepted. CONCLUSION: The state-ownership of tobacco industry poses a major paradox within the government that benefits from manufacturing of tobacco products and is also responsible for controlling tobacco consumption. The perceptions of negative implications on government revenue and the macro-economy, coupled with the reluctance to challenge these issues from health perspective too directly, means that tobacco control has yet to secure itself a place on the priority policy agenda. The overall policy environment will shift in favour of tobacco control only if the economic framing can be challenged.

The use of reproductive healthcare at commune health stations in a changing health system in Vietnam.

BACKGROUND: With health sector reform in Vietnam moving towards greater pluralism, commune health stations (CHSs) have been subject to growing competition from private health services and increasing numbers of patients bypassing CHSs for higher-level health facilities. This study describes the pattern of reproductive health (RH) and family planning (FP) service utilization among women at CHSs and other health facilities, and explores socio-demographic determinants of RH service utilization at the CHS level. METHODS: This study was based on a cross-sectional survey conducted in Thua Thien Hue and Vinh Long provinces, using a multi-stage cluster sampling technique. Questionnaire-based interviews with 978 ever-married women at reproductive age provided data on socio-demographic characteristics, current use of FP methods, history of RH service use, and the health facility attended for their most recent services. Multiple logistic regression analyses were used to identify socio-demographic determinants of their use of CHS RH services. RESULTS: Eighty nine percent of ever-married women reported current use of birth control with 49% choosing intra-uterine device (IUD). Eighty nine percent of pregnant women attended facility-based antenatal care (ANC) with 62% having at least 3 check-ups during their latest pregnancy. Ninety one percent of mothers had their last delivery in a health facility. Seventy-one percent of respondents used CHS for IUD insertion, 55% for antenatal check-ups, and 77% gynecological examination. District and provincial/central hospitals dominated the provision of delivery service, used by 57% of mothers for their latest delivery. The percentage of women opting for private ANC services was reported at 35%, though the use of private delivery services was low (11%). Women who were farmers, earning a lower income, having more than 2 children, and living in a rural area were more likely than others to use ANC, delivery, and/or gynecological check-up services at the CHS. CONCLUSIONS: Women choice of providers for FP and RH services that help them plan and protect their pregnancies is driven by socio-economic factors. While the CHS retains significant utilization rates, it is under challenge by preferences for hospital-based delivery and the growing use of private ANC services.

Population-level approaches to universal health coverage in resource-poor settings: lessons from tobacco control policy in Vietnam.

Population-based health promotion and disease prevention approaches are essential elements in achieving universal health coverage; yet they frequently do not appear on national policy agendas. This paper suggests that resource-poor countries should take greater advantage of such approaches to reach all segments of the population to positively affect health outcomes and equity, especially considering the epidemic of chronic non-communicable diseases and associated modifiable risk factors. Tobacco control policy development and implementation in Vietnam provides a case study to discuss opportunities and challenges associated with such strategies.

Quality of reproductive health services at commune health stations in Viet Nam: implications for national reproductive health care strategy.

This paper presents a qualitative study conducted in 2009 of provider and patient perceptions of primary level reproductive health services provided by commune health stations (CHSs), and the implications for Viet Nam's 2011-2020 National Strategy for Reproductive Health Care. In the three provinces of Thai Nguyen, Thua Thien Hue, and Vinh Long, we interviewed the heads of CHSs, held focus group discussions with midwives and women patients, and observed facilities. Half the 30 CHSs visited were in poor physical condition; the rest were newly renovated. However, the model of service delivery was largely unchanged from ten years before. Many appeared to fall short in meeting patient expectations in terms of modern medical equipment and technology, range of drug supplies, and levels of staff expertise. As a result, many women were turning to private doctors and public hospitals, at least in urban areas, or seeking medication from pharmacies. To make CHS clinics sustainable, promotion of access to reproductive health services should be undertaken concurrently with quality improvement. A responsive payment scheme must also be developed to generate revenues. Efforts should be made to reduce the unnecessary use of more costly services from private clinics and higher level public facilities.

Mandatory helmet legislation and the print media in Viet Nam.

With motorcycle ownership high and rising in Viet Nam, and motorcycle riders vulnerable to both fatal and non-fatal injury, the re-introduction of mandatory helmet legislation in 2007 has been a priority for the Vietnamese government. The paper uses a qualitative analysis of web-based versions of the eight most popular newspapers in Viet Nam to track reporting over four phases of the implementation of the legislation, identifying codes and constructing the dominant themes of the media coverage. The study documents the justification and promotion of the legislation, and the mechanisms for preparing for its implementation at a national and local level, developing solutions and encouraging the replication of successful strategies. It records opposition and obstacles to helmet use, and concerns raised around the quality of helmets purchased. In return, the press notes the response of the market in innovative solutions to these problems. With the successful implementation of the legislation, the functions of the print media in promulgating and promoting the legislation, together with the reporting of ongoing resistance to the process, serve to enable a dialogue between the State and population around expressed concerns. In highlighting quality control of helmets as a key issue, the media have identified a potential ongoing role in monitoring the state's initiative in reducing the road toll from traumatic brain injury in motorcyclists.