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The study uses the data collected by IntraHealth led Capacity Project Assessment of Human Resources Needs for Management and Coordination of HIV/AIDS Prevention, Treatment, Care and Supp[r]
(1)Managers perceptions of job satisfaction in HIV prevention and’ control in Vietnam: A qualitative study
Pham Nguyen Ha1,2, Myroslava Protsiv1, Mattias Larsson1, Ho Thi Hien3, Daniel H de Vries4, Anna Thorson1
1Division of International Health (IHCAR),
Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden 2Department of Public Health, Hanoi Medical University, Hanoi, Vietnam 3 Department of Biostatistics and IT, Hanoi School of Public Health, Hanoi, Vietnam
4 Centre for Global Health and Inequality, Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, the Netherlands Abstract
Background: Recent development of the HIV epidemic in Viet Nam has led to a growing need for treatment, care and support to people living with HIV This puts greater demands on HIV prevention and control in the country, primarily on managers as well as employees in the sector The study aimed to explore managers’ perceptions of job satisfaction and to gain understanding of the factors influencing job satisfaction of employees within the contexts of HIV prevention and control in Viet Nam.
Methods: A qualitative exploratory study used data collected by IntraHealth International’s USAID-funded Capacity Project from a human resources for health assessment in the Vietnamese HIV/AIDS sector Data was obtained from seven focus group discussions involving 80 participants and 15 semi-structured individual interviews at different levels of the governmental agencies responsible for HIV in five cities and provinces in Viet Nam The combination of the inductive and theory-driven approach of content analysis was applied
Open coding was used to inductively classify data into themes and data examined for regularities and variations in relationships between and within themes.
Results: Job satisfaction of employees within HIV prevention and control was found to be affected by poor compensation, uneven distribution of career development opportunities, lack of positive feedback and rewards, and poor supervisory competencies Also new factors which were not included in the original theoretical framework were found to be specific to employment within the HIV sector These included stigma and fears of contracting HIV and TB The stigma both enacted towards people living with HIV and experienced by employees due to association with their HIV positive patients had negative impacts on their job satisfaction. The stigma was found to contribute to added stress and high perceptions of risk of being infected by HIV
Conclusions: Along with addressing known problems causing dissatisfaction in employees of health sector in Viet Nam, there is a need for stigma-reduction intervention aimed at employees in HIV areas involving both their families and their colleagues Efforts of agencies and health facilities should be targeted at managing work-related stress, and improving work safety.
Keywords: HIV, AIDS, job satisfaction, motivation, health workers, Viet Nam, stigma Background
One of the crucial requirements for a functioning health system is the availability of a qualified and motivated workforce Shortage of human resources has been often cited as a major barrier for implementing scale-up for HIV and AIDS services in low- and middle-income countries [1] [2] [3] Years of under-investment in human resource development, combined with restrictive employment policies and fragmented, time consuming and ineffective human resource management systems, have resulted in health staff being underpaid and unskilled to deliver new health services (such as antiretroviral therapy) They are consequently demoralized, and unable to meet demands for even basic health services [4]
(2)During the period 2007-2008, international sources accounted for 90% and the Government sources almost 10% of total AIDS spending The sustainability of the response is a significant issue as Viet Nam approaches middle income country status and donor funding is likely to decrease Therefore, a human resource strategy to retain qualified staff and provide capacity building opportunities for staff at all levels, especially provincial level is important task for the Government
Studying job satisfaction of health staff is important because it can reveal factors causing satisfaction and dissatisfaction, thus make recommendations to improve the staff work motivation There have already been a variety of studies on health workers’ job satisfaction in different settings which showed similar finding Some factors increasing job satisfaction were: continuous education and career advancement opportunities [7], professional conscience and ethos [8], supportive supervision and fair performance appraisal [9] Other factors decreasing job satisfaction were: low income, heavy workload, and lack of recognition [10], job stress, role conflict and ambiguity, lacks of organizational and professional commitments [11]
Besides these common factors among health workers, the studies on impacts of work with HIV patients showed some specific effects such as more stress and burnout [12], fear of transmission [13], concerns about becoming stigmatized [14] However, the work to help HIV patients have stable health status, overcome the desperation and find the fresh hope in life, also bring the employees feeling of humanitarian accomplishments [12] and pride about their work [14]
This study aimed to explore factors causing job satisfaction of managers in particular and employees in general within the HIV prevention and control in Vietnam, identify measures to enhancing the positive factors and limiting the negative factors, thus improving their work motivation
Theoretical framework
There have been several theories on job satisfaction The Maslow’s 5-level hierarchy of needs [15] suggested that job satisfaction depends on fulfilment of individuals’ needs, first basic needs and then higher needs of belongingness, love, esteem and self-actualization
The job dimensions proposed originally by Hackman and Oldham [16] are mediated by critical psychological states and result in variations in degrees of motivation, performance, absenteeism and overall job satisfaction
The Motivation-Hygiene theory by Herzberg [17], suggests that job satisfaction and dissatisfaction are not extreme points of one dimension, but rather two separate concepts Satisfaction factors are understood as intrinsic motivation, whereas hygiene factors are related to basic needs satisfaction
Kudo et al [18] focused on seven facets such as: work as a specialist, workplace safety, and relationships with colleagues, supervisors, work-life balance, communication and salary
According to Spector [19], job satisfaction is seen as an attitudinal concept that results from employee cognitive processes of assessing his various aspects of the job The theory sees the employee’s job satisfaction as a multifaceted concept that consists of nine facets as pay, promotion, supervision, fringe benefits, contingent rewards, operating conditions, co-workers, and the nature of the job in question and levels of communication open to the employee
In our study, we used the Job Satisfaction Survey (JSS) developed by Spector [20] as the theoretical framework As the original JSS was designed for surveys, we used its nine facets of job satisfaction as categories and applied them to a theory-driven analysis [21]
(Figure is about here)
(3)Study setting
The present study was part of the IntraHealth led Capacity Project Assessment of Human Resources Needs for Management and Coordination of HIV/AIDS Prevention, Treatment, Care and Support Programs in Vietnam [22] funded by USAID, in collaboration with Vietnam Administration of HIV/AIDS Control (VAAC)
The Capacity Project in Vietnam was conducted interfacing with different levels of the governmental agencies for HIV prevention and control in two provinces of Quang Ninh, Khanh Hoa, and three cities of Ha Noi, Ho Chi Minh and Can Tho These selected provinces and cities represent the North, Central and South parts of Vietnam and have relatively high HIV prevalence rates and large number of donor-funded projects
Data collection
Seven focus group discussions, with a total of 80 participants and 15 semi-structured individual interviews were conducted during February- March 2009
The study participants were selected from the top and middle managers who have direct roles in managing and coordinating AIDS programs within the National Committee for AIDS, Drugs, and Prostitution Prevention and Control at three different levels: central, province and district The participants included those from Vietnam Administration of HIV/AIDS Control (VAAC), Provincial AIDS Centres (PAC), local authorities, the police, social workers, representatives of civil organizations, and other partners who share responsibility for implementing the HIV/AIDS prevention and control in Vietnam The groups were diverse in terms of participants’ different experiences of direct contact with PLWH in everyday practice For example, health workers in hospitals would have contacts with PLWH routinely while representatives of central institutions would have hardly any contact with PLWH in their work Consequently, it was decided gather these diverse groups under the term “employees in HIV prevention and control” Because the number of issues to cover was numerous and complex, each focus group discussion had two meetings in two days, each lasted for approximately 2.5 hours
(4)Two professional facilitators and two secretaries were engaged in data collection in interviews held at all sites The interviews and group discussions were tape recorded and, in addition, written notes were taken by the secretaries After each discussion and interview, the secretary and the facilitator listened to the tapes and expanded and/or corrected the notes Thereafter, the notes were translated into English
Data analysis
Collected data was coded and analyzed in NVivo software [23] for data coding, creating nodes and organizing them in node-trees
The study applied Spector’s theory of job satisfaction [19] to the theory-driven content analysis [21] This means that data was coded according to a prior established list of nine categories Simultaneously, we applied data-driven coding in order not to avoid the possibility of missing some important context-related factors that could not be accounted for in the original theory It was achieved practically by detecting meaningful parts in the text, labelling them and coding these according to the content of the information it contains Hence, the approach to data coding combined deductive and inductive techniques as described by Miles and Huberman [24] and Fereday and Muir-Cochrane [25]
Trustworthiness
We used the analyses criteria of Dahlgren et al [26] to ensure study trustworthiness Credibility was established thorough the inter-coder check, which meant comparing the coding in Vietnamese performed by the first author and coding into English by the second author Preliminary results were also checked in a similar fashion Transferability was achieved by detailed descriptions about study setting, participant selection, data collection and data analysis Dependability was gained through the description of data analysis and the application of theory-driven coding The study findings are illustrated with quotations from interviews and focus groups to help illustrate the main points being made
Triangulation
Triangulation was performed by applying different data collection methods, considering findings in relation to documents and reports on similar issues and taking into consideration the possible different investigators’ perspectives in the research team
Using data collected via both interview and focus group discussions helped ensure triangulation of data collection methods Triangulation of findings was achieved through comparing the findings with technical reports like the Vietnam’s fourth country progress report on following up on the declaration of commitment on HIV/AIDS [27], health financing in Viet Nam [28], and human resources for health in Vietnam [29]
The collaboration of researchers engaged with the current study with different backgrounds ensured to a certain extent triangulation of researchers’ perspectives
Ethical considerations
Informed consent by oral agreements was received from all respondents before interviews and focus groups before data collection proceeded
Results
In the process of analysis, the different aspects of “job” as described by participants were grouped into the categories corresponding to the facets of job satisfaction, while the categories altogether constituted an overall assessment of employees’ job satisfaction
We generated six themes related to job satisfaction of employees of HIV prevention and control as presented in Table
(Table is about here)
Table Themes and their relations to categories and subcategories
Themes Categories Sub-categories
Unsatisfactory
compensation Pay Limited opportunities for additional income generation;Unsatisfactory salaries; Fringe benefits Uneven distribution of benefits
Work hazards Risk of being infected with HIV or TB Lack of positive
feedback, reward and appreciation
Supervision Lack of positive feedback from supervisors;
Contingent rewards Rewards tied to annual appraisal: weak and poorly implemented; Communication Outdated and inefficient ways of communication; Uneven distribution
of career advancement opportunities across levels and provinces
Career opportunities Uneven distribution of job opportunities;
Fringe benefits Uneven distribution of training opportunities; Lack of management
(5)supervisors Communication Outdated and inefficient ways of communication; Contingent rewards Rewards tied to annual appraisal: weak and poorly implemented; Fear of contracting
HIV and avoidance of direct contact with
PLWH
Stigma Negative attitudes towards key populations at risk in the society; Stigmatization of HIV+ patients by employees;
Stigmatization of employees by association with their HIV+ patients; Working hazards Perceived risk of being infected through contact with HIV+ patients;
Work-related stress; Increasing work load Stigma
One of the most important factors contributing to the staff dissatisfaction was stigma
The employees share popular attitudes towards the HIV key populations of high risk and therefore resist having direct contact with HIV patients at work wherever possible
“The biggest constraint from HIV/AIDS control and prevention is that staff may not want to have direct contacts with HIV affected people /…/ you see, most of the people living with HIV now have some relations with social evils Therefore the others still feel quite reluctant to contact directly/ /”
Interview participant, Hanoi
The other factor as high perception of risk of HIV infection emerges while discussing characteristics of the work within HIV prevention and control
“For those who work on the area of HIV, there are very typical constraints and problems, e.g the risks of infections, working with patients who have ulcerated bodies, and very low incentives.”
Interview participant, Hanoi
Due to the concentrated pattern of the HIV epidemic in Viet Nam, HIV patients are mostly coming from key populations like IDUs and SWs These groups are highly stigmatized in the society and the behaviours have officially earlier been referred to as “social evils”
“In Quang Ninh province, the HIV prevalence rate due to drug injection is very high Hence, many people still see HIV as a social evil This perception is very hard to change.”
Interview participant, Quang Ninh
The common attitude to PLWH is that they are harmful to the society and that they have deserved their condition for practicing unacceptable behaviours and therefore it’s not worthwhile to treat them
“HIV patients always engage in activities that damage the order of the societies, so there are series of prejudices which consider that it is not a normal disease and that people deserve to get that disease, and it is not worth curing them.”
Focus group participant, Ho Chi Minh City
Moreover, PLWH tends to be avoided as well as the health facilities that they are using
“I have observed such cases: in the clinic of the district 4, there is X-ray, TB, and venereal sections, and we offer x-ray for HIV patients One patient showed up in X-ray section, saw “HIV” and left immediately We asked why, she said: “If the neighbours see me in that area, they may think I am same as HIV people I will go to other place to have X-ray.”
Focus group participant, Ho Chi Minh City
The employees are associated with the patients they are treating; hence there is a great deal of prejudice from their colleagues in the other domains of the health sector
One participant: Due to the prejudice toward patients, there is also prejudice towards the health workers who care for HIV patients I even said to the Board of Directors did it mean we are treating patients so we should be put in the same group with them
Other participant: I agree with you Doctors who are assigned treating HIV are also considered as lower graded than doctors in other departments”
Focus group participants 07 and 02, Ho Chi Minh City
Yet another issue is attitudes of the family members of the people employed within HIV sector, which are often negative and they try to convince the workers to quit their dangerous job
“Some people are not keen on working with HIV affected people, because their families, i.e their husbands or children, want them to leave that job, and it may not be their own decision.“
Interview participant, Hanoi
(6)Work hazards
The risk of getting infected with HIV or TB while performing work tasks was discussed as one of the concerns of health staff However, the discussion about these work hazards concentrated mostly on the fact that in view of the dangerous nature of the job, the health employees directly exposed deserve better compensation
“Our staff does counselling and make contact with HIV affected people, but they don’t have any allowance. In prison No 1, prisoners designated HIV+ are numerous Many of our staff also gets infected with tuberculosis We have proposed that doctors and nurses who work directly with these prisoners should be given some incentives.”
Focus group participant, Hanoi
The participants talked about monetary incentives with respect to high risk, whereas the issue of work safety was not brought up
On the other hand, currently there is no clear understanding of policies about occupational accidents involving the health staff They report to be highly concerned about whether getting infected with HIV at work would be compensated
“They are most afraid of being infected by the disease At the moment, there have been no regulations on the benefits for the staff that are infected by HIV They don’t know whether they will receive compensation for occupational accidents.”
Interview participant Quang Ninh
The risk-perception of being infected with HIV at work is still high for some of the employees, especially in those that probably have had less contact with HIV patients and less experience, for example among young professionals
“Because they are afraid of the danger that the job may bring, especially for the young people, they may be the most frightened But if working for a long time, they may feel they like the work and become attached to it. The difficult thing is to make people love this job It is not only the issue of money”
Interview participant, Khanh Hoa Or employees in rural areas:
“The reason why people leave HIV/AIDS is their lack of knowledge, or fear of being infected with HIV, or the fear of contracting tuberculosis from AIDS patients Nowadays, especially in the countryside, people are still scared and try to be away from patients.”
Focus group participant, District health centre in Ho Chi Minh City
By contrast other employees realize that the risk of HIV infection is exaggerated The risk of getting TB, on the other hand, is seen as a more serious threat
The participants communicated that their work can be very stressful Moreover, the level of stress becomes higher due to the worries about HIV infection and TB and dealing with “special patients” that are stigmatized in the society
“The general situation of preventive health care is that it is very difficult to recruit staff There are not any doctors who are willing to move to preventive care because the work is very stressful, very time consuming and salaries and benefits are low /…/ moreover, in HIV/AIDS they have to deal with special patients Carrying out ARV treatment for patients at the last stage of AIDS whose health has decreased to a major extent is very stressful There are also many patients with TB, and with TB and AIDS together And they also face stigma”.
Focus group participant, Ho Chi Minh City
Hence, the work-related stress for staff within HIV prevention and control is reported rather high due to the stress resulting from worries about the risk of exposure to HIV and TB through contact with patients and the caring for PLWH that are viewed as “special patients” because of stigma in the society
There were concerns expressed about the increasing workload within the HIV sector due to growing number of newly infected cases and therefore an increasing demand for HIV treatment, care and support
“We lack staff and cannot recruit doctors and nurses Newly recruited staff stayed with us for a few days then moved to other departments, or to other hospitals where working conditions are better, less infection and less stressful./…/ the workload increases but support structures remain the same.”
Focus group participant, Ho Chi Minh City
The increasing workload puts higher demands on the staff, which results in a high staff turnover, and vice versa the high turnover rate increases the overloading of remaining staff
“I know the need for staff but still haven’t done anything./ / I have just recently totalled up the number of infected patients, newly infected patients and I know that ARV treatment will have to expand to cover about 1,000 or 1,100 patients next year Still, the number of staff is unchanged Staff is complaining a lot about this.”
Interview participant, Ho Chi Minh City
(7)“A lot of the dispensers are overworked, contributing to the high staff turnover Workload management is a problem, and it is hard to keep staff well motivated in the bigger hospitals than in the smaller clinics.”
Interview with an expert in pharmaceuticals
A feeling of being overloaded at work is a factor known to influence one’s attitude towards job However in our findings, the dissatisfaction of the employees with growing overload could be further increased by the feeling that no effort is done from the management side to improve the situation
Pay
The study participants reported that employees in the HIV area are generally dissatisfied with the levels of salary which they receive The level of pay is very low and can therefore not meet the needs of the staff to make sufficient income to support both themselves and their families This could be a reason for many leaving their healthcare jobs As a focus group participant at the central level noted:
“They left because the salary was not enough for living I can still sit here because I can rely on my husband My own salary is not enough to buy medicine for us“
Focus group participant, VAAC
Managers were convinced that current levels of pay are not able to attract new personnel to the HIV prevention and control sectors
“Let’s face it; I am a specialist with 20 years of experience in HIV and AIDS My total income is VND 3.9 million, which is the highest in the Centre So how can we attract people? I this job as I believe this is my karma If I worked outside, in an NGO, I would earn a dozen of million dong a month easily The new graduates, who would dare to follow us?”
Interview participant, Can Tho
The current level of salaries of employees in the HIV prevention sector is perceived as insufficient to satisfy basic living needs Therefore, the staff is forced to look for alternative ways of making their income
The additional income generating opportunities, which are common in the rest of the health sector like organizing private practices, are however not possible for employees in the HIV prevention and control because normal patients are reluctant to go to see the doctors who are working in that healthcare domain
“/…/doctors working on HIV/AIDS cannot have clients if they work part-time in the private sector So how can they support their family? Thus, it’s very hard to carry on the profession.”
Focus group participant, Quang Ninh
Also services provided to HIV-patients are considered to be potentially unprofitable to include them in the range of services provided by private health facilities
“Because it is difficult to privatize health care services for HIV prevention, since the low, or non-profitable, nature of these services cannot attract the private sector Thus, the staff working on HIV doesn’t have many opportunities to improve their income.”
Interview participant, Hanoi
The inability to have private practice and get payments from the patients does not only restrict the employees’ chances to make income, but also brings frustration Limited opportunities for income generation further complicate the healthcare employees’ situation about adequate compensation and therefore cause dissatisfaction with pay and this appeared to be the major factor that contributes to overall job dissatisfaction
Career opportunities
Taking into account that the availability of jobs was brought up by the participants from the two big cities, while there were nothing mentioned on the matter from other sites, which means that there are less opportunities at lower levels of the health sector such as in districts and communes, as well as in rural areas, compared to urban settings
The following quotations illustrate the uneven distribution of job opportunities across the various levels of the health sector in Viet Nam
"At the commune level, where people have low skills, there is no opportunity for career advancement At the district level, there is some chance of getting promoted e.g to a provincial hospital At the province level, however, there are more opportunities for advancement And at the central level, there are lots of opportunities for training, involvement in donor programs, etc However, the opportunities are pretty much in the big cities, whereas there’s little opportunity for advancement for those in rural areas."
Interview with an expert, Policy Unit of Ministry of Health
Consequently, the employees involved in HIV prevention and control in big cities have more job opportunities and career options, while those in the urban areas that lack of such opportunities might be expected to feel less satisfied
Supervision
(8)included decentralization of decision-making and management The managers received the authority to supervise people without having prior training in supervision and many areas related to management The limited capacity of supervisors impacts upon employees’ job satisfaction
“/…/the main concern now is the capacity of supervisors I am trained so the work is less difficult, but my subordinates not have experience in supervision because they lack training Even medical universities not train on this They assess based on their feeling so it is not as good as the ones who have gone through training.”
Interview participant, Quang Ninh
In addition to managers’ lack of supervision capacity, other staff members have limited understandings of supervision Junior staff tend to be afraid of strict supervisory measures that they refer to as “inspection” and try to resist it, while the supervisors have to rely on their own judgments about how the supervision should be done “People don’t understand what is meant by supervision They view it as inspection, and get very nervous about it – try to hide things from supervisors.”
Focus group discussion with study facilitators
The participants communicated lack of positive feedback from supervisors Examples of this lack of positive feedback are represented by the following two quotations:
“If our performance in this is good, nothing will happen, but in the case of performance not being so good, it will be reflected in our evaluation.”
Participant of focus group, Ho Chi Minh City
“Yes It will be taken into account if we fail and nobody will comment if we it well”.
Participant of focus group, Ho Chi Minh City
The lack of positive feedback from supervisors was related by the participants to the current ineffective system of monitoring of working tasks, which fails to record and recognize employees’ good performance and achievements This unsystematic way of monitoring performance is perceived as unfair and reaction to this by interviewees may be related to dissatisfaction
Fringe benefits
Due to the low level of wages, fringe benefits are an essential part of employees’ income, which supplements the earning of the payroll employees Receiving lower or no benefits is considered a major cause for dissatisfaction in the staff Nevertheless, the distribution of the benefits is unequal between staff categories Some professions, not necessarily the ones with the highest wages, are receiving small or no benefits at all
The distribution is uneven and varies according to the level of health facility
“Allowance for workers at communes and wards are around VND 120,000 which is just enough to fill up the gasoline tank really, thus it is hard to require them to concentrate only on work I myself feel so sad thinking about this There is no insurance system for them as they are not full-time but social workers The staff working for provinces or districts in contrast has official payroll positions”.
Focus group participant, Can Tho Treatment versus prevention:
“Health workers engaged in HIV work in hospitals receive an allowance of 50% [sectoral hazardous allowance], low but something, while preventive health workers receive nothing Preventive care is declared to be the priority of health care, but in the case of preventive care, remuneration is considered as a minor problem (laughed).”
Interview participant, Can Tho And payroll versus project:
“Project staff is at a disadvantage compared to government staff working in the same OPC who also receive a hazardous allowance equivalent to 30-45% of salary This allowance for direct caregivers is 45percent of salary while project staff receives only their fixed salary.”
Interview participant, Ho Chi Minh City
Training opportunities are among the top reasons for staff satisfaction There are plenty of training opportunities within HIV prevention and control; however they are mostly only available for middle-level staff at provincial and central levels The study participants recognize the importance of training for staff:
“They have more opportunities Working on HIV means working in a rapidly changing environment. Working here for a short period of time, your capacity will be much improved /…/ there is a lot of opportunities for learning, both in the country and overseas.”
Focus group participant, VAAC
The training opportunities, however, are also unevenly distributed just as the other fringe benefits
(9)Interview Participant, Hanoi
Contingent rewards
Under the section of contingent rewards the annual “emulation” was discussed as the example of reward and recognition for the staff On the basis of annual staff appraisals, staff is often awarded with honourable titles along with monetary rewards
The current rewarding system was criticized for poor encouragement measures that cause dissatisfaction among healthcare employees
“Regarding the shortcoming in division of work, the ones who are productive are usually assigned more work; whilst the ones who are useless are assigned less But the salary payments are the same The assessment of work for promotion and awards is also unfair because the one who does a lot of work may make more mistakes so he is ranked average while another who does less work makes fewer mistakes and thus is ranked excellent.”
Focus group participant, district health centre in Ho Chi Minh City
Being awarded with an emulation title was considered important for several reasons First of all it is very honourable to receive emulation title like “The best staff member”
“For example, if they work well on treatment for HIV patients, the city may give them a reward, possibly in cash There are also many honourable titles to be awarded, for example, fighter for emulation, or excellent cooperatives in emulation, etc.”
Interview participant, Hanoi
Emulation titles also can be viewed as quite positive experience for the employee, which comes along with monetary reward as well as a demonstration of recognition from society
“I myself am keen on this work because it is relevant to my expertise and interest Many people work because of their love and responsibility to the work In addition, your work is also compensated and respected by the others.”
Interview participant, Khanh Hoa
The second reason why the emulation award is perceived important is that it gives a possibility to be recognized by the management, which later might lead to promotion
Overall, it was concluded that employees value rewards in terms of monetary benefits as well as recognition from society Nonetheless, the system of monitoring staff performance, which serves as a basis for distributing awards, was assessed by employees as unfair For job satisfaction, it means that rewards and recognition are positively influencing attitude about one’s job; however, the inconsistent implementation of delivering annual awards on the other hand is a reason for employees to be dissatisfied
Operating procedures
Among the most important personnel policies, the one on hazard allowance and recruitment policy were discussed The policy on hazard allowance, which grants to the medical staff that has risks associated with exposure to HIV through direct contact with blood, benefit in size of 30 percent to 50 percent of the salary, was criticized for being inconsistent and for excluding some categories of staff
“/…/But when I visited prisons and orphanage centres, I found that the staff working there did not have any allowance So I think that the policy should be consistently applied to all staff whose work is related to HIV healthcare In reality, I have seen that some people who not directly work on HIV are still entitled to that allowance So it is very important to ensure that staff having direct contacts with HIV-affected people benefit from good policies.”
Interview participant, Hanoi
If the applied policy is excluding some part of the staff within one organization, it may be seen as unfair from the point of view of the excluded staff, while managers can take decisions to restore fairness by dividing available benefits
Nature of work
The staff liked to perform their work tasks because of the humanitarian nature of work
“Most people working on HIV/AIDS are dedicated to the social development and human values, so they are happy to carry out these activities/…/”
Focus group participant, Ho Chi Minh City And their sympathy and willingness to help:
“After some time of working here, I also have found something interesting I also feel sympathetic towards the patients, if you think they are your relatives, you will have more sympathy.”
Focus group participant, District Health centre in Ho Chi Minh City
Doing this job was related to higher morale and awareness of doing well among the staff
(10)work and the earning of respect from others
“We love our job, and we devote our efforts to work to gain effective outputs Some external organizations have offered me a job with good salary which is good for my family, but that job cannot contribute as much as the current one Here my work will have broader influence/…/.”
Focus group participant, VAAC
Communication
The current modes of communication in the organization were discussed in terms of being outdated, insufficient and time-consuming, but still widely applied
Managers recognized that due to the growing workload they are unable to visit numerous meetings, which is affecting their subordinates as they reported missing information
Question: Leaders may have different ways of working Your boss doesn’t go regularly to meetings, possibly due to his desire of empowerment or due to his extremely busy agenda?
“He is too busy If he was less busy, he just would have to reserve minutes for a dialogue, and it would be very quick Dialogues before giving any task would be helpful, and there would not be any need of revision or modification for several times during the implementation But the boss is too busy.”
Participant of focus group, VAAC
The capacity of using IT for communication is still limited and uptake of these new technologies is a slow process
“If there is anything that requires my contribution, it can be sent to me using the internet and I can then give my comments However, may be because the ability in organization, administration is still limited in many units, so many tasks cannot be done using the internet.”
Interview participant, Ho Chi Minh City
Overall, the employees perceive themselves as poorly informed, which could be seen as one of the causes for dissatisfaction
Discussion
We indentified the following themes that cause HIV healthcare employees’ job dissatisfaction These were poor compensation, unevenly distributed career and training opportunities, lack of positive feedback and rewards, and lack of competencies in staff management and supervision in managers We also detected two additional themes which are specific for the work in HIV prevention and control: Fear of contracting HIV and TB; and avoidance of direct contact with PLWH, which suggested that employees were influenced by stigma in their work, both of the perceived and enacted kinds The presence of these themes related to fear of contracting HIV and TB and stigma might suggest that the work within HIV prevention and control may be different from how employees experience their employment in the rest of the health sector
Therefore, in this Discussion part, we want to focus on some specific factors which affect the job satisfaction of employees within HIV area
Low pay
Low salary is the main factor which affect the work motivation of the employees This factor has been mentioned in many different studies on motivation of health staff in many countries as well as in Vietnam In this study we found that the differences of salaries between the government staff and contracted staff in donor funded project lead to inconvenient comparisons Working as government staff gives the feeling of stable jobs but salaries are lower than the ones as contracted by the projects The Vietnam’s UNGASS 2010 [5] has pointed out that “ HIV treatment and care services rely on a large number of contract health workers The majority of these positions are funded by projects” which shows a concern on the sustainability of the future national response to HIV Due to the needs of speeding up the implementation, the donor projects try to attract qualified staff with competitive salaries and pay the allowances for government staff working in these projects These trends are difficult to change and are considered as short term solutions However, long term and sustainable solutions in regards to human resources and their salaries need to be identified
NEGATIVE ATTITUDES TOWARDS KEY POPULATION AT RISKS IN THE SOCIETY
The stigma on HIV patients especially the IDUs have been addressed in many previous studies This leads to the decrease of the work motivation of the employees within HIV area Actually, the IDUs cum HIV patients are often the ones who commit crimes in order to get money for purchasing drugs Therefore, increased drug rehabilitation for IDUs with different methods, enhanced implementation of methadone substitution, creating more jobs for them, will lead to improving the society’s stability feeling This will also improve the motivation of the employees working in HIV area
The study of perspectives of HIV-related stigma in a community in Vietnam [30], described exactly the same perceptions of the PLWH Therefore, we concluded that those attitudes are very common in the Vietnamese context and are shared by many people, including staff in HIV prevention and control
(11)previous studies in other countries as well as in Vietnam The stigma affects negatively on the employees and their families members This affects the employee’s motivation and their work pride The employees work more effectively only when they proud of their works
Stigmatization of HIV-patients by employees
In this study, we found that stigma towards the risk-groups is manifested as resistance of staff to have direct contact with HIV-patients These staff are influenced by the common negative attitudes to the IDUs and SWs because they are “not immune to the prejudice in society”[14]
Concerning the reasons behind this reluctance, fear of transmission of HIV is likely a contributing factor, which was further supported by empirical evidence from quantitative [31] [32] and qualitative research [33]
In our study, we found that resistance to having direct contact with HIV patients, especially in younger employees, was possibly due to lack of experience
Further, stigma and avoidance is found to result in sub-standard care or even refusal of health services This might not affect the staff directly, but the example of an indirect effect could be a feeling of guilt because the HIV patients were neglected and rejected by their colleagues trying to avoid contact with HIV patients
Stigmatization of employees by association with their HIV+ patients
In the current study we found that staff of HIV prevention and control were exposed to stigma due to association with PLWH from their colleagues and to some extent from society Taking into account the social role of a doctor in Vietnamese culture, which is regarded as a very respectful and honourable profession, we could make a hypothesis that stigmatization of the staff by association with PLWH can have a very negative impact on the staff ’s view on their job and profession
Another finding is the negative view of staff family members on the jobs in HIV prevention and control Similar findings were cited in the literature review [14]
Risk of contracting HIV and TB
This study identified the employees’ concerns on risks of contracting HIV or TB These concerns might be overestimated However, our study showed that risks are serious in certain settings such as in prisons or in the centres 05, 06 for rehabilitation of drug users and female sex workers where substantial numbers of HIV patients live in a crowded and close settings According to Vietnam’s UNGASS report 2010 [5] that “05/06 Centres often lack both facility-based services and continuum-of-care to link drug users to community-based HIV treatment, care and support services” and that “ART is not available in any prisons and only a few are providing TB treatment” The study participants have mentioned the serious risks of contracting TB in the prisons and these centres These risks become more serious when there is new type and antibiotic resistant TB available in Vietnam
The study participants perceived the risk of contracting HIV as a considerable threat and, hence, any work with HIV patients is dangerous Some participants mentioned HIV as a serious occupational hazard, while others recognized risk of exposure to TB as a more potent threat Fears of HIV were resulting in stress and higher perception of occupational risk These fears were showed in the extensive literature review by Horsman and Sheeran [14] and Barbour [34]
Going back to our finding about HIV work hazards, we wonder whether in our findings the perception of the job as being dangerous and of high risk of contracting HIV and TB was found rather high due to compromised work safety measures Li et al [31] argues that with better access to preventive measures such as better availability of gloves, sufficient health insurance and access to training about work safety, employees would perceive themselves as better protected and more comfortable with their work
Training opportunities
Training opportunities are the most appreciated positive factors on the staff motivation Due to the substantial international financial resources and technical assistance, there are many training opportunities for the staff working in HIV With the knowledge and skills gained from these training, the staff have more chances to apply for the new jobs with higher salaries in donor projects However, most of the training courses are short term and focus more on project implementation skills Therefore, the long term training on HIV and AIDS at medical universities is necessary to have a sustainable human resource with comprehensive knowledge on HIV prevention and control
Humanitarian and morale significances of the HIV work
Most of the Vietnamese people practice ancestor worships and strongly affected by Buddhism philosophy that doing humanitarian activities will bring the happiness to them and their families Being influenced by this belief, many employees within HIV area feel that they are doing humanitarian and morale works with HIV patients This work brings their job satisfaction and leads to the sympathy in the society towards PLWH, reducing the stigma and discrimination This also enhance the staff work motivation
(12)working tasks because of the humanitarian nature of work, sympathy, their eagerness to help as well as they found their encouragement in the meaningful tasks This finding is supported by other studies on positive feelings of health workers related to HIV care is likely related to an ability to help and provide non-judgmental care to stigmatized people [14, 35] The study findings also suggest that recognition from patients as well as the support and positive feedback from supervisors is extremely important to reduce burnout and attrition of the staff
Conclusions
Job satisfaction of employees within HIV prevention and control in Viet Nam is influenced by both commonly known factors within health sector, which were initially included into the JSS and some specific factors for HIV such as stigma and fear of contracting HIV and TB
The known factors are: unsatisfactory compensation; uneven distribution of career development opportunities; lack of positive feedback, reward and appreciation as well as lack of management competency in supervisors The impact of stigma toward PLWH from employees’ families, colleagues and society, on employee’s job satisfaction, was confirmed in our study In practice, stigma reduction should therefore be targeted at staff members, their families and colleagues Results of the study also suggest the need to improve working conditions within HIV prevention and control in order to reduce the fears of infections and work-related stress
(Figure is about here)
Methodological Considerations
In our study we explored managers’ perceptions of employee’s jobs satisfaction, which could be viewed as a proxy-measure of job satisfaction of their subordinates However, we should recognise that managers themselves are employees within HIV prevention and control
The theory-driven method of data coding has the risk of trying to “fit” the data into categories However, we believe that this was overcome to some extent by combining theory-driven coding with data driven coding approaches and by establishing a strategy of recognizing facets of job satisfaction in the data In a process of data analysis, we faced challenges related to the work with translated material There was a great risk for misunderstanding and misinterpreting data We tried to address these issues by comparing the data coding with Vietnamese coding, and also compared preliminary findings in this language and double checked for more accurate translation of the quotations used for the reporting of the findings
List of abbreviations
AIDS Acquired immunodeficiency syndrome
HIV Human immunodeficiency virus
IDU Injecting drug user
JSS Job satisfaction survey
MSM Men who have sex with men
PAC Provincial AIDS centre
PLWH People living with HIV
(13)TB Tuberculosis
VAAC Viet Nam Administration of HIV/AIDS control
Competing interests
The author(s) declare that they have no competing interests
Authors' contributions
PNH and AT designed the study PNH conducted data collection, coding, data analysis and drafted the manuscript MP conducted data analysis and drafted the manuscript AT and ML revised the paper critically for substantial intellectual content DV and HTH participated in study design and coding All authors commented critically on the drafts and approved the final manuscript
Acknowledgements
The study uses the data collected by IntraHealth led Capacity Project Assessment of Human Resources Needs for Management and Coordination of HIV/AIDS Prevention, Treatment, Care and Support Programs in Viet Nam (The Capacity Project, 2010) by USAID in collaboration with Viet Nam Administration of HIV/AIDS Control (VAAC)
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(14)Capacity Project Chapel Hill, NC: IntraHealth International
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30 Gaudine, A., et al., Perspectives of HIV-related stigma in a community in Vietnam: a qualitative study Int J Nurs Stud, 2010 47(1): p 38-48
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A NEEDS ASSESSMENT OF PLHA SELF-HELP AND SUPPORTED GROUPS (SSGS) IN VIETNAM
Nguyen Nguyen Nhu Trang, Nguyen Duy Tung Tran Lan Anh, Luong Thi Tinh
Ngo Tri Tue , Ngo Thi Thu Thuy, Dong Duc Thanh Center of Promotion for Quality of Life, Ho Chi Minh City, Vietnam
Health Policy Initiative Vietnam, Abt Associates Inc., Hanoi, Vietnam Center for Community Health and Development, Hanoi, Vietnam
Vietnam 2008 UNGASS Report
HIV/AIDS Policy in Vietnam: A Civil Society Perspective. Public Health Watch-Open Society Institute New York : November 2007 1 Background
Self-help and supported groups for people living with HIV/AIDS have developed rapidly in Vietnam in terms of quantity, capacity and scope and areas of work As reported in the UNGASS 2008 report, the years 2006 – 2007 have seen a strong improvement in involvement and participation of civil society organizations in all HIV/AIDS-related aspects including prevention, treatment, care and support, behavioral change communication, counseling and testing, reducing stigma and discrimination, promoting harm reduction, economic support, and improving quality of life of PLHA To date, very few self-help and supported groups have been legally established; which is a major barrier that prevents these groups from expanding their activities into policy advocacy and policy development and accessing direct international funding
(15)with men (MSM)), supported groups and clubs (collectively hereafter termed self-help and supported groups [SSGs]) During April and May 2009, HPI Vietnam and two of its local partners – Centre for Community Health and Development (COHED) and Vietnam Network of PLHA (VNP+) – conducted a mapping and capacity building needs assessment of the SSGs in the PEPFAR focus cities/provinces of Vietnam
2 Objectives of the assessment
1)To explore and analyze SSGs’ capacity, needs and gaps in organizational development; and
2)To recommend a capacity building plan in coordination with other stakeholders of capacity building support
3 Study units and assessment methods 3.1 Study units
* Self-help groups: are groups that were created by its own members These groups are managed by themselves, through a selected management team, and thus have autonomy and decision making power over the group’s operation and development
* Supported groups: are groups that were established by the City/Provincial AIDS Committee (PAC), or I/VNGOs These groups are commonly managed by these organizations and not have independent decision making power
122 active SSGs were identified in the PEPFAR focus cities/provinces among the working list of 178 of those groups compiled by HPI with support from VNP+ Province-based members of the VNP+ helped make contact with leaders of these groups to arrange interviews
* Leaders of active SSGs
SSGs that have been making progress towards registration or were successfully registered were identified for in-depth interviews to learn about their experiences in obtaining their operation permits
Leaders of the active groups were identified by the assessment team during the structured interviews and in consultation with the local health/AIDS authorities and VNP+ members in their respective provinces
* Capacity building partners
Agencies, e.g UNAIDS, Pact, Care Vietnam, Institute for Social and Development Studies (ISDS) that host Vietnam Civil Society Partnership Platform on AIDS (VCSPA) and Center for Community Enhancement and Management (CECEM) were identified for their active contribution to providing capacity building to SSGs
* Agencies involved in legal registration
Agencies such as the Ministry of Home Affairs (MOHA) and the Vietnam Union of Scientific and Technology Associations (VUSTA) are the concerned agencies facilitating legal registration to form associations and organizations by the Decree 88 and Decree 81 The Provincial AIDS Committees/Centers or HIV/AIDS Associations, Provincial Red Cross and other similar entities can also form groups as their associated members
3.2 Assessment methods
The assessment applied both quantitative and qualitative methods as follows: * Mapping of SSGs and Clubs in the PEPFAR-focus cities/provinces * Desk review on available legal documents for registration of SSGs
* Structured interviews with leaders of the mapped SSGs using a semi-structured questionnaire * In-depth individual interviews with an interview guide:
* Leaders of the selected SSGs and Clubs and HIV/AIDS activists * A representative from each of the registration concerned agencies * A representative from each of the capacity building agencies
Most in-depth interviews were audio-recorded unless not permitted by the respondents In such cases, the assessment team took notes Each interview was approximately 45-60 minutes long
4 Results
1 Profiles of the participating groups: (1) Mean group life (to the time point of assessment): 38 months (n=upload.123doc.net); (2) On average each SSG has management members; and (3) 32% management members with university or higher degree
2 Organizational development-related skills: Figures 1-3 show the skills in which SSGs reported having been trained, those skills which they had actually applied in their work, and those skills in which they felt they needed improvement Nearly half of SSGs had received group management and facilitation skills but still reported need for further training This is because: (1)Trainings are not appropriate to groups’ current work; (2) No refresher trainings;(3) Ongoing assistance to apply the covered skills is not available; and (4) Overlap of trainings results in over-training or under-training for some group members (SSG management members)
(16)Figure 2: Project management related skills trained, applied and still needed to work better
Figure 3: Other technical skills trained, applied and still needed to work betterMost important skills needed
According to the survey, these were the three most necessary skills for groups’ development:
Self-help groups (n=65) Support groups (n=55)
Group management and facilitation: 33.8% Proposal design: 18.5%
Communication skills: 15.4%
Care for PLHA: 29.1%
Group management and facilitation: 21.8% Communication skills: 20% SSGs’ Legal registration needs:
* 70 groups (57%) desire legal registration – some not want the sponsorship/supervision from a government or quasi-government agency that is required
(17)* 32 SSGs reported needing support with registration process 5 Discussion
With regard to legal registration, there has been a considerable level of interest among both self-help and supported groups in exploring registration options However, there is a lack of information and guidance on which options are feasible given the group’s current capacity In response to this need, HPI and UNAIDS have developed and are widely disseminating a handbook summarizing the requirements for legal registration under all currently available options
The participating groups expressed a high degree of need for group management skills and skills related to sustainable development of the organization e.g project design Priority skills areas are fairly similar between the two groups
• Priority skills for self-help groups: * Group management and facilitation * Project design
* Communication skills
• Priority skills for supported groups: * Care for PLHA
* Group management and facilitation * Communication skills
Coordination of capacity building efforts among organizations is deemed necessary Overlap of training programs was reported and some group members working as peer educators were either over-trained or under-trained
6 Recommendations
* To provide all groups with information on the existing registration policies and advice or consultation on registration options to groups who expressed interest and commitment to registration Additionally, such groups would need to receive support in organizational (and program) strategic planning
* Capacity building should be focused on the set of skills that are considered most necessary by the groups, as summarized above
* Coordinate with agencies working with the same SSGs to harmonize or agree upon an improved coordinated capacity building plan overall and/or at the provincial level
(18)Improving Data Quality to Maximize Using in Program Planning and Managing, Experience from Pact Vietnam
Thi Chu Phuc, MD, MPH, Pact Vietnam Nathan Wilkinson, MSc, Pact Vietnam Abstract
Monitoring and evaluation (M&E) activities crucial to program success M&E data are used at all levels in planning, implementing, and evaluating HIV prevention and control Data quality is important in promoting not only quality services but also effective program management With PEPFAR funding from USAID, Pact analyzed potential data quality problems and preventative measures within the HIV/AIDS programs it supports in Viet Nam, and then implemented comprehensive remedies for narrowing gaps in data quality A range of measures were deployed systematically to all levels of reporting systems for all Pact partners: developing or refining standardized, appropriate data collection tools and operations for programs; providing frequent, intensive on-site supportive supervision; developing Indicator Protocols (IPs); implementing periodic data audits to assess data collection, management and reporting systems; and establishing a database to coordinate, track and manage information gathered across partners These efforts improved data quality and facilitated effective program planning and management Stakeholders recognize the need for further actions to ensure data quality and facilitate data use for evidence-based decision making
I Background
HIV infections in Viet Nam have been steadily increasing since the first case of HIV was detected in 1990 In 2012 over 280,000 people are projected to be living with HIV (Ministry of Health, 2009) The Vietnamese Government and international organizations have devoted great efforts to combating this epidemic While international assistance for the HIV/AIDS prevention and control in Viet Nam has significantly increased, the management and implementation of HIV/AIDS programs in Viet Nam is still a concern, especially regarding the effectiveness of foreign assistance and investments.2 The accuracy and the relevance of program data are vital to quality services and effective program management.4, 5, 7 To support the efforts of the Viet Nam Administration for AIDS Control (VAAC) and international partners in strengthening the Monitoring and Evaluation System in Viet Nam, many M&E and data quality issues need to be solved.8 Following a review of constraints on HIV/AIDS data quality for M&E in Viet Nam, this paper presents the measures implemented and results achieved by Pact and 25 Pact partners in improving the quality of reported data and maximizing data use for program management PEPFAR funding for this work was provided by USAID Recommendations are proposed for future actions to strengthen the Monitoring and Evaluation System
The HIV M&E Technical Working Group’s 2009 situation analysis of the national M&E system pointed out many weaknesses in the M&E system in Viet Nam There was a lack of a standard and coherent monitoring and evaluation system for HIV/AIDS programs across the implementing agencies, particularly with regard to tools and indicators for measuring quality of services and effectiveness of HIV/AIDS projects A survey revealed that, in many instances, M&E activities are built into a project just to make the project document look “complete”; at least 50% of HIV/AIDS projects were not evaluated Evaluation work is commonly used in formally closing projects, rather than identifying shortcomings to improve implementation.2 Capacity of program staff in management and supervision of program implementation is also limited, due to lack of experience and understanding regarding evaluation methods for HIV/AIDS programs Project monitoring is carried out mainly through traditional methods: big folders of documents, without a good information storage system, management or statistical work Although projects devote large amounts of money and human resources to implementation of project activities, the budget for M&E is negligible
Even if managers were to develop the skills and habits to use data, evidence-based decision making is impeded by poor-quality data that is missing, out of date or drawn from inconsistent sources Double counting of individuals is a common problem due to the range of services they receive via different providers Organizations often have not implemented systems for tracking the services they deliver, because of fragmentation of the referral system and lack of cooperation among service providers Surveillance data from data triangulation groups were found to be out of date, small-scale and not nationally representative, being unavailable for many areas outside PEPFAR focus provinces.2
(19)difficult to increase and sustain the quality of data for monitoring program effectiveness Ensuring confidentiality of client data can be a challenge due to poor storage of data or policies and procedures implemented by the facility The focus is mainly on the services provided and production of reports, with little regard to controlling the quality of data for completeness, accuracy or timeliness Quality of supervision is weak due to lack of manuals and tools
II Major content: Measures implemented by Pact and Pact partners
To deploy comprehensive measures systematically across all levels of reporting systems, Pact grantees were first requested to review their data collection, reporting and tracking systems with attention to USAID and Pact requirements Forms and data collection tools were revised to ensure accuracy of data collected, Standard Operating Procedure checklists were developed for monitoring a minimum package of caregiver, peer educator and supervisor activities, and a list of core indicators was identified for broader, intercomparable program monitoring and learning purposes Organizations implementing behavior change communication (BCC) activities adopted specialized program monitoring forms with core output indicators A standardized information management system for home-based healthcare programs, based on Excel datasheets, was designed to efficiently counting indicators, especially those disaggregated by HIV status, gender and age This feeds into a Pact database for coordinating, tracking and managing information gathered across partners and program areas during country operational planning, reprogramming, and related processes
Pact also addressed gaps by building M&E capacity across all partners, though two yearly training modules: one on monitoring, evaluation and reporting skills, and the other focused mainly on developing data quality management systems to maximize utility of the data generated Participants received frequent, intensive on-site supportive supervision by Pact staff
A final measure implemented to ensure data quality is periodic data audits, either internally or by an external data quality audit team) Data audits verify the quality of the data reported at service sites for validity, completeness, reliability, timeliness, accuracy and integrity, as well as assess the system that produces the data The project or internal team follows up every six months or year to see if recommended improvements have been implemented
III Results
M&E systems were found to be considerably strengthened, with improved quality of reported data and facilitated program planning The standardized guidelines and data collection tools helped users avoid mistakes, freeing time for data aggregation and better program management Many partners stated that their old forms were confusing, making it difficult to keep track of patients and aggregate data The development of a systematized client management system makes it feasible to assess the quality of care at each visit Partners also reported that the Excel sheet is working very well to count PEPFAR indicators and follow up on clients served under their projects, for example when beneficiaries die or contact is lost
Capacity building through training modules and on-the-job support helped to improve data collection and monitoring of outreach and home-based healthcare activities Supervision trips found that program data is recorded in a consistent fashion Consistent data collection and monitoring enables managers to identify strengths and weaknesses and appropriately revise program activities: For example, data was used to access and provide services to new hotspots, and add services to some projects The data also are used to monitor the progress of coverage by prevention programs as well as performance of peer and outreach educators
Integrated and supportive supervision is implemented frequently, as recommended Reports from some partners showed that project staff, outreach group leaders and local HIV/AIDS bureau program staff supervised at least 50% of all activities planned Documents submitted with reports were found to have fewer mistakes and better-quality data
Data audits that Pact conducted of some partners revealed consistent data recorded in registers and summarized at various levels Data quality at the sites audited was acceptable in terms of accuracy, completeness, timeliness and integrity
Increasing coordination meetings between partners reduced overlap of services, facilitated access to services and improved resource allocation Collaborations helped minimize double counting of clients served Most partners have proceded to analyze their data, for example by creating graphs and charts, and in the case of some partners using SPSS Some partners used data to estimate the number and distribution of higher-risk populations for effective allocation of prevention resources
(20)Strengthening M&E systems improves data quality, which in turn supports evidence-based planning and program management It is important to develop appropriate, streamlined, standardized forms and definitions Peer educators and caregivers rquire detailed instructions on use of the forms and logbooks, and these should contain real examples for easier understanding and retention
M&E capacity building can be implemented through different means: refresher trainings, on-the-job training and supportive supervision Capacity building for peer educators and caregivers should be emphasized and conducted regularly on topics such as communication skills, accessing clients and especially their own self-esteem
Data quality is likely to correlate positively with a sense of data ownership among program staff, peer educators and caregivers, which can improve their engagement to catch potential data issues Mistakes in data collection and aggregation should not be blamed on individuals, but encouraged through a culture of common ownership and combined effort
Various forms of supervision should be carried out for peer educators and caregivers: direct and remote observation, review of daily work diaries and crosschecking with beneficiaries and other community members Data quality assurance should be integrated into routine supervision using a standardized methodology Formal data quality auditing should be conducted on a periodic basis for selected indicators More effort must be devoted to encourage effective use of data in decision-making processes
Weaknesses in data quality for monitoring and evaluation need to be overcome with support from leaders of Government, international organizations and local non-government organizations Following are recommendations to continue improving data quality and usage:
Develop comprehensive M&E systems from the beginning of program formulation: clearly designing
organizational M&E structures, developing effective tools and indicators for measuring the results of HIV/AIDS projects, and developing comprehensive methods/strategies to make data available and control for quality
Equip management and M&E staff working in agencies and localities with essential skills, such as the
requirements of M&E activities, knowledge and training to perform M&E, and use of information technology to support M&E activities
Continue efforts to reduce existing weaknesses: more data on quality of services need to be established,
impact and outcomes evaluations should be conducted, and databases should be developed for connecting programs (especially outreach, voluntary counseling and testing, antiretroviral and methadone treatment, outpatient clinics and home-base healthcare) Information sharing between government agencies and donor organizations in planning, management and monitoring of HIV/AIDS prevention and control programs should be strengthened to provide necessary data and information for the Government’s long-term planning and management of HIV/AIDS programs
Encourage partners and managers to use reported data, surveillance data and evaluation information in
planning, managing and developing programs References:
1 “Annual report of VAAC on HIV/AIDS prevention and control programs”, VAAC, 2006, 2007, 2009 “Coordination, management & utilization of foreign assistance for HIV/AIDS prevention in Vietnam”, Center for Community Health Research & Development, Ha Noi, 2006
3 “National M&E framework for HIV prevention and control program”, The MOH; Hanoi, 2007
4 Online Forum on Data Quality Assurance for Reproductive Health Information System and Monitoring & Evaluation, 2009
5 “A guide for project monitoring and evaluation – managing for impact in rural development” International Fund for Agricultural Development Rome, Italy (see www.ifad.org/evaluation/)- IFAD (2002)
6 Lora Sabin, et all, Evaluation of President’s Emergency Plan for AIDS Relief (PEPFAR) - Funded Community, Outreach HIV Prevention Programs in Vietnam: Report on Findings, 2009
7 “Handbook on M&E for Results United Nations Development Program”, New York, USA (see www.undp.org/eo/rbm/index.htm) - UNDP (2002)
(21)Sexual Risk Behaviours among Male Migrant Freelance Labourers in Urban Vietnam: Prevalence and Correlates
Nguyen Van Huy1, 2, Michael P Dunne2, Joseph Debattista3, Nguyen Tran Hien1,4 & Dao Thi Minh An1
1Faculty of Public Health, Hanoi Medical University, Vietnam 2School of Public Health, Faculty of Health,
Queensland University of Technology, Australia 3Brisbane Sexual Health & HIV Service, MetroNorth Health Service District, Australia 4National Institute of Hygiene and Epidemiology, Vietnam ABSTRACT
Like many other developing countries, Vietnam is experiencing an increasing wave of rural-urban migration This process of migration, whether voluntary or not, may result in the spread of HIV infection both to those who migrate and to members of the communities that receive migrants This study examined self-reported risk behaviours among 450 male migrant freelance labourers in urban Hanoi, Vietnam, in 2009-2010 Risk of acquiring or transmitting HIV and other Sexually Transmitted Infections (STI) was high among these men One third of the sample reported having intercourse with commercial sex workers and one quarter had casual sex partners. Approximately one in every 12 men reported homosexual or bisexual behaviour The men on average had 3 partners within the preceeding year In general, condom use was inconsistent These men have limited HIV knowledge and only moderate motivation and perceived behavioural skills for protective behaviour The study provides strong evidence for preventive further interventions To be effective, a comprehensive public health approach tailored to the specific needs and vulnerabilities of these men should be applied It is important to include such factors as the pervasive peer influence to ‘live dangerously’, persistent myths about low risk from sex with people who look healthy or with casual partners not classified as ‘sex workers’ and the low group norms for HIV prevention motivation.
Key words: Vietnam; Migrant Labourer, HIV/AIDS; IMB Model; Sexual Behaviour; Sexual Risk Behaviour
INTRODUCTION
Most previous studies of HIV risk behavior in Vietnam have focused on traditional “core transmitter” groups (Agence France-Presse, 2001; N T Hien, 2002; N.T Hien, Long, & Huan, 2004; Tuan et al., 2007; Vietnam Commission for Population Family and Children, 2003) However, this concentration on high risk groups may leave others under-protected or unprepared for prevention For male migrant workers, the separation from family, breakdown of social networks, lack of social controls and support and anonymity of living in a city make them especially vulnerable to HIV infection These men may have multiple sexual encounters with different, changing partners, and usually without condom protection (Jochelson, Mothibeli, & Leger, 1991), and consequently have higher rates of HIV as compared with non-migrant men (Lurie, Williams, Zuma, Mwamburi, et al., 2003)
Although there is growing interest of research in migrant labourers (Duong, Anh, Hong, Trung, & Bach, 2005), little is known about patterns and determinants of risky or safer sexual behaviours for HIV (N V Huy, Dunne, Debattista, Hien, & An, 2010)
(22)The main goal of this study was to examine prevalence of HIV risk behaviour and factors associated with risky - or safer - sexual behaviour among male migrant freelance labourers in urban Vietnam To understand factors associated with such a behaviour, we adopted the IMB model with an additional components –consisting of alcohol use, migration index, social connectedness, depression, and access to AIDS information as a basis to examine these associations Our study hypothesized that social structure, information and motivation would be associated with protected sex self-efficacy and this self-efficacy would be associated with the level of safer sex behaviour among male migrant labourers
The current study has been informed by two qualitative sub-studies The first of these illuminated migrants’ life experiences in urban space, including stressors related to physical, financial and social factors among migrant labouring men and the strategies they use to cope with them (N.V Huy, Dunne, Debattista, & An, 2010) The second sub-study explored how social contexts shape HIV risk behaviours (N V Huy, et al., 2010) The current quantitative survey study was carried out as part of a larger, multi-disciplinary project attempting to understand determinants of HIV risks among male migrant freelance labourers in Vietnam
METHOD
Research Site The site for this study is in urban and suburban Hanoi in northern Vietnam Hanoi is one of the two large cities in Vietnam and one of the most frequent choices for rural-urban migrants , including those who become unregistered labourers
Sample Size and Participants Based on a definition freelance labourers by Duong et al (2005) and Simpson and Weiner (1989) participants were males aged 18-59 who work for private owners or self-earn without a labour contract. A sample of 450 was identified given the following formula of (Lwanga & Lemeshow, 1998) for sample surveys of simple random sampling.
(Z2
1-α/2 )P(1-P)N
n =
-D2 (N-1) + (Z2
1-α/2 )P(1-P)
Where α refers to a statistically significant level at 05; (1-α) is a confidence level (95%); Z yields 1.96, a value derived from the Z-table corresponding to α of 05; P is defined as an estimated population proportion with protected sex (36.2% based on our pilot survey); d is an absolute precision at 04; N is the population size with 5000 as estimated for male freelance workers in Hanoi based on the data of ANU (2003) and Duong et al (2005); n, a minimum sample size according to the formula, is 450
A sampling frame was made by social mapping venues of migrant labourers in districts of Hanoi We aimed to identify as many venues of male migrant labourers within the city as possible A group of researchers were formed and trained on mapping Each member was assigned a number of districts where he or she was expected to visit Afterwards he or she identified venues at which migrant labourers congregated In each district field workers searched for men in casual employments Typically this is in streets, markets, construction sites, bus stations, small business shops, or by such other social services as schools, hospitals, and factories In each venue key informants such as migrant labourers themselves, local people living close to the venue, local leaders, experienced researchers from prior studies on mobile populations, peer educators and outreach officers were consulted for mapping the next venues At the same time, field workers were asked to estimate the number of male migrant labourers as a basis for approaching respondents in the main survey Finally a list of all the venues and the estimated number of respondents was created
Survey Procedures This study began with 16 explorative qualitative interviews to identify key variables to be included in the modified IMB model The draft research instrument was evaluated with a sample of 55 participants The pilot showed that the instrument was technically feasible for the main survey (Cronbach’s α>.70 for most subscales) and an average number of 770 participants were estimated from 13 potential districts within the city Experience from prior research indicated that 10% of the sample would refuse interviews and about 30-35% changed locations; therefore in this study we approached the entire population to conduct structured interviews
(23)Measures
Social Structure Access to AIDS information was formed from 12 items (α = 55) The ratio of the number of migratory cities to years of total migration was employed as an index of mobility (Li, Fang, Lin, Mao, Wang, Yang, et al., 2004) Alcohol use was a composite of the number of standard drinks and frequency of use over the past weeks (α = 60) Social connectedness was assessed with items of (Hawthorne, 2006) (α = 74) To measure Depression, a short version “Boston form” of CEDS was used as it is made up of concrete experiences that participants with less formal education could interpret in the context of
their daily lives, it has been proven reliable and valid though with less items in prior research, as well
as validated in the a labor migrants, most of whom are males with life experiences (Joseph, Joseph, Laura, Thomas, & Sara, 2006) With ten 4-point items the scale of depression experience has an α
of .88 (Andresen, Carter, Malmgren, & Patrick, 1994; Cole, Rabin, Smith, & Kaufman, 2004; Kohout, Berkman, Evans, & Cornoni-Huntley, 1993; Santor & Coyne, 1997) The above five indicators serve as
a latent construct of social structure (α = 60)
Information AIDS preventive information was assessed with ten true/false/don’t know items (Bryan, Fisher, & Benziger, 2001; Misovich, Fisher, & Fisher, 1997) Scoring the information scale was accomplished by dichotomizing each item into a value of (correct) and (incorrect or don’t know) and then summing the item values to form a composite score with higher scores on this scale reflecting increased knowledge about AIDS prevention (α = 60) The scale is split into two subscales One subscale includes items (α = 57) measuring theoretical knowledge or relevant to the sexual transmission of HIV (e.g., “Using condoms when you have sex can reduce the chance of getting HIV”); the sum of correct responses is the sexual transmission information score The other subscale comprises items (α = 62) that address HIV prevention heuristics (e.g., “Once you trust your partner you don’t need to use condoms with them”) The sum of correct responses is the heuristic information score These two scores serve as indicators of the latent construct of AIDS prevention information
Motivation was measured by twenty one 5-point items assessing respondents’ attitudes towards condom use [e.g., “How good or bad would it be if you talked about condom use (to keep from getting HIV/AIDS) with your sex partner(s) before having sex with them during the next month?”]; subjective norms or generalized perceptions of social support for their practice of condom use (e.g., “Most people who are important to you think you should talk about condom use with your partner(s) before having sex with them during the next month?”; and intentions to perform each condom behaviour (e.g., “If you have sex during the next month, you intend to talk about condom use with your partner(s) before having sex with them?”) (Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975; Misovich, Fisher, & Fisher, 1998) Respondents rate their performance of twenty one condom use statements on a 5-point semantic scale (bad-good) from (negative evaluation) to (positive evaluation) A composite score was obtained by summing responses to items with higher composite scores indicating higher levels of motivation toward condom use (α = 90)
Behavioural Skills Behavioural skills toward safer sex were assessed with seven items dealing with perceived self-efficacy to perform behaviors related to condom use The answers are on a 5-point semantic scale ranging from very hard (1) to very easy (5) (e.g., “How hard would it be for you to consistently use condoms with a partner every time you have sex with?”) (Bryan, et al., 2000; Misovich, et al., 1998) A composite score was obtained by summing responses to items with higher scores reflecting higher levels of behavioural skills for condom use (α = 86)
Protected Sex Behavior was assessed with three subscales measuring discussion of safer sex, condom accessibility, and condom use (Misovich, et al., 1998), employed in a variety of safer versus riskier sexual practices Safer sex discussion was measured with two items that if the respondent has discussed safer sex (condom use) with sexual partner(s) and if he has tried to persuade a sexual partner to practice safer sex using a condom (α = 73), which were summed to create an indicator of safer sex discussion Condom accessibility was assessed with two items asking respondents how often they have purchased condoms and the extent to which they have kept easily available (α = 86), which were summed to create an indicator of condom accessibility Condom use during sexual intercourse was assessed with four items asking respondents about their frequency of condom use during intercourse (α = 83), which were summed to produce an indicator of condom use The above three subscales were summed to form a composite score of safer sex behaviour (α = 90)
Analysis Strategy The Pearson’s Product Moment correlation coefficient was used to determine whether pairs of factors are significantly associated with each other We used a conventional p value of 05 for these analyses Descriptive statistics (frequency, percentage, mean, SD, and range) were adopted to identify prevalence and levels of risky sexual behaviour
FINDINGS
(24)the sample were ethnic Kinh, 84% were married, 73.8% followed one type of religion (Buddhism, catholic, and ancestor worship) Mobility was fairly high as most (63%) were born in rural areas Almost 70% resided in urban centres before traveling to Hanoi In the whole sample, 87% were migrants; the average number of cities for paid work was 2.4; and the average number of years in cities for paid works was 16.4 The mean age was 39 years and most had low levels of education (mean years completed=8.19) The majority (almost 60%) were farmers when in their hometowns and the most common occupation in urban areas were motorbike driver (~65%), followed by manual laborer and construction worker, each contributing more than 10% of the total The average monthly income was 2.6 million VND (equivalent to U.S.$140) Despite a fairly low level of alcohol consumption per drinking occasion, nearly all men consumed alcohol sometimes (over 90%) Level of access to HIV information was limited (M=3; range=0-9)
Table Selected Socio-Demographic Characteristics
Variable (N=450) n (%)
Mean ± SD
Age (year, range=18-59) 39.23±10.29
Marital status Unmarried Married Separation/divorced/widowed/cohabitation 46(10.2) 378(84.0) 26(5.8) Race Kinh
Minors 444(98.7)6(1.3)
Religion Buddhism Catholic/Christian Ancestor worship None 116(25.8) 9(2.0) 207(46.0) upload.123doc net(26.2)
Education level (class completed, range=0-15) 8.19±2.52
Place of birth Urban
Rural 167(37)283(63)
Place of residence before Hanoi Urban
Rural 314(69.8)136(30.2)
Number of cities traveled for paid works 2.41±2.68
Number of years in cities for paid works 16.36±14.10
Mobility 392(87%)
Living with whom in urban area Alone
Peers and friends
Sex partners (wife, lovers, casual partners, sex workers & others) Family and relatives
46(10.2) 147(32.7) 202(44.9) 55(12.2) Main occupation during urban stay
Manual laborer
Construction worker and subcontractor Porter Motorbike driver Small trader Others 55(12.2) 49(13.1) 29(6.4) 291(64.7) 19(4.2) 7(1.6) Main occupation during hometown
Farmer Construction worker Office staff and factory worker
Militant Motorbike driver Student Unemployed 263(58.5) 36(8.0) 40(8.9) 7(1.6) 55(12.2) 19(4.2) 30(6.6)
Average income (million Vietnam dong, $USD1=VND18,000; range=.09-12) 2.60±1.30
Alcohol Use
Level of consumption (0-28.50) Percentage
5.66±4.83 416(92.22)
(25)Depression
Level of depression (0-27) Percentage
6.65±5.16 113(25.11)
Access to AIDS Information (0-9) 3.01±1.32
As can be seen in Table 2, there were deficits in HIV prevention behaviour More than 70% incorrectly believed that condoms only need to be used with prostitutes More than 50% incorrectly believed that once you trust your partner, you no longer need to use condoms with them, and many believed there is a cure for AIDS Around 60% incorrectly believed that oral sex is just as risky as vaginal intercourse for transmitting the virus, and as many men believed that you can tell by looking at someone if they have HIV, and there is currently a vaccine that prevents AIDS On a more positive note, over 98% knew that using condoms when you have sex can reduce the chance of getting HIV and more than 86% did not believe that it is safe to use the same condom more than once
Table Percentage and Level of Correct Responses to Knowledge of HIV/AIDS
Variable (N=450) n (%) # of Correct Responses
# of items n(%) Using condoms when you have sex can reduce the chance of getting HIV (true) 443(98.4) 4(.9)
It is safe to use the same condom more than once (false) 389(86.4) 23(5.1)
Oral sex is just as risky as vaginal intercourse for transmitting HIV (false) 190(42.2) 44(9.8)
Condoms only need to be used with prostitutes (false) 127(28.2) 62(13.8)
Once you trust your partner, you don’t need to use condoms with them (false) 129(48.6) 101(22.4)
It is safe to have sex without a condom if it’s with your wife (false) 50(11.1) 85(18.9)
As long as both partners wash themselves after sex, it is not necessary to use
condoms (false) 270(60.1) 79(17.5)
You can tell by looking at someone if they have HIV (false) 191(42.4) 30(6.7)
There is a vaccine that prevents AIDS (false) 171(38.0) 15(3.3)
There is a cure for AIDS (false) 207(46.0) 10 7(1.6)
Table displays general patterns of risk sexual behaviours for HIV Most participants (92.2%) reported that they were were heterosexual, 5.6% were bi-sexual, and 2.2% were homosexual The number of reported lifetime sexual partners ranged from to 77 with a mean of 10 (SD=7.5) Number of partners in the past year ranged from to 20 with a mean of 3.2 Around 95% of the participants had sexual encounters with regular partners, one third with sex workers, and almost 25% with casual partners Safer sex discussion with sex partners before having sex was fairly limited, with just over 50% of the participants saying that they talked about condom use Access to condoms was also relatively limited – those reporting buying condoms and keeping a condom available were in the minority Condom use among participants was inconsistent and with the proportions being just under one third with regular partners and commercial sex workers and very low (17.6%) with casual partners
Table Prevalence and Levels of Sexual Risk Behaviours for HIV
Variable n (%)
Mean ± SD
Sexual orientation (N=450) Sex only with men Sex only with women Sex with both men and women
10(2.2) 415(92.2)
25(5.6)
Age at first sex (N=435) (range=15-52) 22.46±3.69
Types of sexual partners (N=450)
Regular partners (participants don’t pay for sex) Commercial sex workers (participants pay for sex) Casual sex partners (participants don’t pay for sex)
427(94.9) 147(32.7) 109(24.2) Multiple sex relations (N=450)
# of different partners (lifetime) (range=0-77)
# of different partners (past year) (range=0-20) 10.13.17±2.10±7.54
Safer sex discussion with sex partners before having sex (past year) (N=435) Talking about condom use with sex partners before having sex
Level of persuading condom use with sex partners before having sex (range=0-2)§ 255(58.6).78±.70 Condom accessibility (past year) (N=450)
Level of buying a condom (range=0-4)§
Level of keeping a condom available (range=0-4)§ 1.55±1.101.81±1.29 Condom use
Last sex with regular partners (N=426) Last sex with commercial workers (N=149)
Last sex with casual partners (N=110)
(26)Level of past year condom use with regular partners (N=427) (range=0-4)§ Level of past year condom use with commercial workers (N=152) (range=0-4)§
Level of past year condom use with casual partners (N=112) (range=0-4)§ Level of past year condom use with all sex partners (N=435) (range=0-4)§
3.32±1.10 2.47±1.42
1.83±1.04
Protected sex behaviour (range=0-26) (n=450) 14.70±6.24
Range from to with higher scores indicating higher levels of the practice
The means, standard deviations and intercorrelations between key factors in the modified IMB model with an additional factor – social structure - are shown in Table HIV knowledge was limited (M=4.40; range=1-10), whilst motivation, perceived behavioural skills, and preventive behaviour were moderate With regard to intercorrelations among constructs, the majority of the scale scores were moderately to closely related to one another (r’s=.30-.60; p<.05)
Table Correlates of Key Factors with Protected Sex Behaviour
Variable (N=450) Mean ± SD
Social Structure (range=34.5-105.3)¥ 83.40±11.86 _
HIV Knowledge (range=1-10)¥ 4.40±1.83 21*** _
HIV Motivation (range=28-105)¥ 82.16±13.31 50*** .11* _
Behavioural Skills (range=7-35)¥ 25.79±5.20 57*** 15** 60*** _
Safer Sex Behaviour (range=0-26)¥ 14.70±6.24 34*** .12* 24*** 16** _
Ranges with higher scores indicate higher levels of the scale
DISCUSSION
Like many other developing countries, Vietnam is hosting an increasing number of migrants from rural to urban areas Other research in Asia and Africa has shown that people who migrate for work are at increased risk for HIV (Decosas & Adrien, 1997; M N
Lurie, Williams, Zuma, Mwamburi, et al., 2003) They often have higher infection rates
than those who not move (M N Lurie, Williams, Zuma, Mwamburi, et al., 2003) In
this study, as most respondents (87%) were migrants, we examined the effect of mobility on sexual risk behaviour in relation to a wide spectrumof possible influences
The findings reveal a general pattern of sexual risk among the Vietnamese migrant labouring population, The perrcentage of migrants in the present study who reported having intercourse with commercial sex workers (32.7%) was similar to reports among the Chinese migrants (31%) (Li, Fang, Lin, Mao, Wang, Liu, et al., 2004), and was substantially higher than commencial sexual activity among indigenous rural Chinese (7.8%) in other studies (Liu et al., 1998) The number of lifetime and past year sexual partners, the percentage and level of condom use discussion and persuasion to take precautions with sexual partners also indicate high levels of risk sexual behaviour among migrant labourers These results are consistent with data from other countries in both Asia and Africa (M Lurie, Harrison, Wilkinson, & Aldool Karim, 1997; M N Lurie, Williams, Zuma, Mkaya-Mwamburi, et al., 2003)
The current study has shown that many factors, including those constructs adopted from the IMB model, are associated with risk sexual behaviours in this population In particular, sexual risk was associated with limited knowledge of HIV and low motivation and perceived low behavioural skills toward safer sexual behaviour When the bivariate correlation between these factors is assessed in isolation, the contributions of all of the IMB model constructs with behaviour were significant This finding is consistent with other studies conducted in developed and developing countries (Bryan et al., 2001; Cornman et al., 2007; Fisher, J., & Fisher, W A., 1998) This is one of the first studies in Vietnam demonstrating the applicability of these theoretical constructs in behavioural decision making related to sex However, it is important to consider the limitations of the standard IMB model Bryan, et al (2000) and Odutolu (2005) have argued that a main limitation of the IMB model was that its constructs were largely individual-level based, suggesting a need for building models that more explicitly take into account the larger social context In this study we introduced a broader range of social variables to examine how they are associated with each construct of the IMB model and with sexual behaviour The associations of social structure with all the IMB constructs and with the risk sexual behaviour were significant
It is recommended that future preventive interventions should address all aspects of migrants’ vulnerability to infection, not only their needs for information As argued by Li, Fang, Lin, Mao, Wang, Liu, et al (2004), an HIV prevention program is unlikely to be effective for people who are disconnected from formalized education, employment, and health care, and other social services
(27)assessment Second, we are subject to the usual limitations of self-report bias in measures of sexual behaviour Also, our study has not simultaneously assessed the contributions of all of the IMB model constructs and social structure with behaviour using structural equation modeling – SEM, consequently the fit of the IMB model with an additional construct – social structure has yet to be analysed Further research, ideally with an intervention or a longitudinal design is needed to determine causal relationship among the model constructs as well as the effect of the intervention on male migrant freelance labourers’ behaviour To be effective, more prevention programs and a comprehensive public health approach to the specific needs and
vulnerabilities of these men should be applied There is a great need to improve access to condoms
for these men especially given the high numbers of casual and commercial partners, and also to have messages tailored for the substantial proportion of non-heterosexual men among these migrant labourers (about 8%)
Understanding and application of this IMB theoretical model for best practice may facilitate more effective HIV/AIDS prevention intervention programs in Vietnam and countries that have similar contexts
ACKNOWLEDGEMENTS
This study was supported by a combined grant by the Institute of Health and Biomedical Innovation from the Queensland University of Technology, and the Australian Government's Overseas Aid Program (AusAID) Dr Jeffrey D Fisher, Professor of Psychology, Director, Center for Health, Intervention, and Prevention, University of Connecticut, USA, was greatly acknowledged for his provision of the related invaluable materials The authors also thank the field teams for their tireless efforts to assist this study The authors gratefully acknowledge the participation of all male migrants labourers in the survey interviews in Hanoi city, Vietnam
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(29)Tuan, N T., Fylkesnes, K., Thang, B D., Hien, N T., Long, N T., Kinh, N V., et al (2007) Human immunodeficiency virus (HIV) infection patterns and risk behaviours in different population groups and provinces in Viet Nam Bulletin of the World Health Organization, 85(1), 35-41
UNAIDS (2002) Report on the global HIV/AIDS epidemic Geneva, Switzerland: Author
(30)A Picture of HIV Drug Resistance in Vietnam and the Region Todd M Pollack, MD
HIV-AIDS arose in Asia in the early to mid 1980s and Asia is now home to the second highest number of people living with HIV (PLHIV) Since 2003, the roll-out of antiretroviral therapy (ART) in the region and across the globe has occurred at a rapid pace At the end of 2009, 5.2 million people living in low- and middle-income countries were receiving ART Vietnam and its neighboring countries have experienced a nine-fold increase in the number of people receiving treatment in the last five years The success of ART has led to significant reductions in morbidity and mortality among people living with HIV/AIDS Despite these successes, less than 40% of people who need HIV treatment are receiving ART in the region As the roll-out of ART continues to accelerate, close attention must be placed on the emergence of drug resistance in the region
Early predictions that rapid roll-out of ART would lead to the widespread emergence of HIV drug resistance (HIVDR) have proven untrue Nonetheless, due to the limited number of regimens available in resource-limited countries, minimizing HIVDR remains particularly important In particular, there is increasing concern about the development of drug resistance as treatment coverage rates increase in the region A recent mathematical model of the HIV epidemic in a Southeast Asian setting predicted that after 10 years of universal treatment access, up to 20% of treatment-naïve individuals with HIV may have drug-resistant strains
This review will focus on published data regarding HIV drug resistance in Southeast Asia and in Vietnam, Cambodia, and Laos in particular Specific topics will include: (1) Transmission of HIV drug resistance, (2) HIV drug resistance associated with the prevention of mother-to-child HIV transmission, (3) Characterization of genotypic resistance mutations following failure of ART, and (4) Implications of drug resistance on health policy in the region
Biography:
Dr Pollack is Medical Officer with Harvard Medical School AIDS Initiative in Vietnam (HAIVN) He is a Clinical Instructor of Medicine at Harvard Medical School and holds a joint faculty position in the Division of General Medicine and Primary Care and in the Division of Infectious Diseases at the Beth Israel Deaconess Medical Center in Boston
Tools for HIV Estimation and Projection UNAIDS
HIV/AIDS has been a serious problem in many countries In order to slow down HIV epidemic in a country, it is important that the country need to know whether their epidemic is growing If so, how fast is the epidemic, where it is, and in what groups? What will most effectively slow or stop this growth? And what are the future treatment needs? Modeling tools for HIV estimation and projection are used to answer these questions
There are many modeling tools that have been developed and used to estimate and project HIV/AIDS and its impacts The common modeling tools that have been applied in many countries include the UNAIDS Workbook, UNAIDS Estimation and Projection Package (EPP), Spectrum, and Asian Epidemic Model (AEM) These models have range from very simple to very complex model They have different amount of inputs and outputs
To determine which tool to be used in a country, it is depended on the availability of data When little data is available, the most common used tool is UNAIDS Workbook It has been widely used in Asia due to data limitations in many countries The Workbook model was designed to be a simple model and requires only the size of subpopulations at risk and their HIV prevalence Because it is simple, the model can only produce a single year estimate of number of people living with HIV/AIDS
For countries with moderate data available, the most common tools used are EPP and Spectrum EPP is a curve fit model that requires size of subpopulations and series of HIV prevalence among those subpopulations EPP can project the HIV prevalence and HIV incidence for each subpopulation This prevalence curve or incidence curve from EPP is used as an input for Spectrum to generate some impact figures Spectrum is not an epidemic model It is an impact model Spectrum needs input that is an HIV epidemic curve from other models such as EPP model It also requires demographic data, disease progression, and treatment information as inputs Outputs of Spectrum include number of people living with HIV, new infections, deaths, needs for treatment, and children infections
(31)In conclusion, modeling tools are useful for estimating and projecting number of HIV/AIDS However, countries need to know their data availability and understand the advantage and limitations of each modeling tools before applying them
COMMUNITY AND HOME-BASED CARE IN VIET NAM: KEY FINDINGS AND
RECOMMENDATIONS FROM A REVIEW OF PACT-SUPPORTED COMMUNITY- AND HOME-BASED CARE PROGRAMS
I Background
Since 2004, Pact has supported community- and home-based care (CHBC) programs for people living with HIV/AIDS in Viet Nam, with PEPFAR funding via USAID Implemented by international and local organizations with management, financial and technical assistance from Pact, these CHBC programs provide direct care and support services to adults and children living with HIV/AIDS and help link them to health and social services They also help build skills for self-care among people living with HIV (PLHIV), and provide support and training to their family caregivers Indirectly, many other stakeholders benefit from the training and community mobilization activities supported by CHBC programs, including HIV/AIDS service providers, local government authorities and other community members
II Major content
In 2010, Pact completed a review of nine of these CHBC programs, including seven CHBC programs that are operated by community-based groups and two CHBC programs that are operated as part of clinic-based, comprehensive HIV/AIDS care and treatment programs The primary objectives of the review were to:
* Document the program model and core activities of partners
* Assess the achievements of each partner, including quality, access and sustainability of CHBC services * Determine the strengths, weaknesses and gaps in services offered by each partner, with a focus on case management and referral systems
* Document client needs and outcomes, with a focus on program responsiveness to clients’ evolving needs over time
* Document lessons learned and emerging innovations, which will help inform future directions for CHBC across the Pact portfolio
The review is a small-scale study, intended to provide a snapshot of program functioning and client experiences with CHBC The review team used a range of qualitative methods (in-depth case reviews, in-depth interviews, observations, focus group discussion) to collect information from a variety of stakeholders, including adult clients, family members of adult and OVC clients, CHBC service providers, CHBC program managers and key stakeholders (including representatives from HIV/AIDS outpatient clinics and local authorities, such as DOLISA, the Women’s Union and the People’s Committee)
III Results
The review found that CHBC programs have reached many PLHIV and OVC who need care and support, including PLHIV who are socially isolated and may be disconnected from care and treatment systems as well as from social support systems (e.g PLHIV returning to communities from prison or rehabilitation centers)
CHBC workers provide important healthcare services, including home management of simple symptoms, and coach PLHIV and their family members in antiretroviral adherence and self-care CHBC workers often act as “bridges” to healthcare systems, helping PLHIV register for ongoing medical care such as antiretroviral treatment at HIV/AIDS outpatient clinics and referring PLHIV and HIV-affected children to clinics for treatment of complex health problems However, the review also found that CHBC workers’ assessments of client health needs are currently completed in a verbal, informal way, without job aids or reference materials (including referral lists and screening/referral algorithms)
Stakeholders – including PLHIV, family members, CHBC workers and representatives from local authorities – reported significant improvements in the health of CHBC clients, which they attribute to the care provided – or referred to – by CHBC workers Some CHBC programs serve PLHIV who enrolled in the late stages of HIV/AIDS (e.g PLHIV who were released from rehabilitation centers when they became seriously ill) For these clients, CHBC workers provide essential end-of-life palliative care to PLHIV and families
(32)problems
All CHBC programs offer small packets of staple foods to PLHIV, prioritizing clients who are very poor and/or appear to be malnourished These food packets mostly help offset other caregiving costs and support food security at the household level Some CHBC workers offer very general nutritional advice, with a few programs providing practical coaching to families on practical, sustainable strategies using food to support ARVs and help manage the symptoms of opportunistic infections
CHBC programs have integrated some prevention services into routine care and support CHBC workers consistently counsel PLHIV and their partners on preventing sexual transmission of HIV, as well as distributing condoms and coaching on correct condom use Some programs offer specialized counseling and support for discordant couples and prevention of HIV transmission through caregiving As part of routine health checks, CHBC verbally screen and refer clients for STI/RTI diagnosis and treatment, but as noted before, without job aids or screening/referral tools All CHBC programs promote condom use to prevent HIV transmission and provide counseling and referral for pregnant women, but other sexual and reproductive health services are poorly integrated Only one program offers pre-conception counseling and proactively refers couples to mother-to-child transmission services to help them plan safe and healthy pregnancies Only a few programs counsel female clients to seek routine annual gynecological exams Risk-reduction counseling for injecting drug users is not provided systematically by any program, and referrals to harm reduction programs (needle/syringe exchange) and methadone programs are inconsistent, due in part to the poor coverage of these programs
Throughout the review, all stakeholders reiterated that meaningful employment and income generation activities (IGA) are among the top priorities of PLHIV: There are currently very few IGA programs in Viet Nam and this need has largely been unmet A few CHBC programs offer small-scale IGA, including group loan projects and vocational training, that only benefit a few clients and are not all well-designed or well-managed To date, CHBC programs have not systematically referred clients to IGA programs where they exist
Most CHBC programs in this review not offer specialized services to support the holistic development of HIV-affected orphans and vulnerable children (OVC) Programs offer small stipends to help families with school-related expenses and support social events for children With a few exceptions, CHBC workers not routinely monitor the physical development of OVC; programs provide packets of basic foods to families with OVC but only a few provide specialized nutritional supplementation for children and infants No programs have trained CHBC workers to monitor children’s social or cognitive development; nor are they trained to provide psychosocial support to children and teens Most CHBC programs not have child protection policies and are not consistently monitoring and referring for neglect or abuse
HIV/AIDS-related stigma and discrimination (S/D) remains a considerable barrier to care and support for PLHIV and OVC Stigma and discrimination appears to be fairly common in healthcare facilities that not specialize in HIV/AIDS care and treatment, such as emergency rooms, surgical wards or OB/GYN departments Fear of stigma and discrimination remains a major disincentive to enrolling in HIV/AIDS-related care programs, including CHBC In addition, OVC still routinely experience discriminatory treatment in schools, including isolation from other children by teachers and bullying and teasing from fellow students
IV Lessons learnt
Each model of CHBC has its own advantages and barriers in providing services for PLIHV The review found that the clinic-based CHBC programs provided care and support services, with effective referral links between CHBC services and clinic-based services, and strong supervision and support to CHBC workers by social workers and case managers based at clinics However, these two programs had limited reach, prioritizing clients who are taking ARV and/or who are in ill health These programs might be missing opportunities for providing regular CHBC to other PLHIV and OVC who are in good health but could benefit from psychosocial support, referral to other services such as income generation activities, and coaching for self-care and early detection/care-seeking for health problems
(33)relationships between CHBC programs and healthcare facilities, referrals are based on personal knowledge and relationships of individual CHBC workers, and there is no organizational support to ensure consistent referral and follow-up or to address barriers to referral Job aids or reference materials (including referral lists and screening/referral algorithms) would help CHBC to more systematically screen, manage and refer for opportunistic infections and antiretroviral side effects Another area where CHBC can be expanded is in routine screening for serious psychological problems such as depression and anxiety, and referral to specialized mental health services when they are locally available, including at OPCs (many of which are currently developing mental health services) Program leaders or other program staff should be trained in specialized counseling skills and empowered to “back up” CHBC workers whose clients need time-intensive or specialized counseling
Determinants of health-related quality of life in adults with HIV/AIDS in Vietnam
Tran Xuan Bach1, Nguyen Thanh Long2, Nguyen Thu Anh1, Nguyen Huong Thao3
1Hanoi Medical University, Institute for Preventive Medicine and Public Health, Department of Health Economics (Email: info@123doc.org)
2Ministry of Health, Administration of HIV/AIDS Control 3Strategic Consultancy Company, Hanoi, Vietnam. Abstract
Background: Health-Related Quality of Life (HRQL) is a good indicator to monitor and evaluate healthcare services for adults with HIV/AIDS This study described HRQL of adults with HIV and its determinants, and compared it with HRQL for the general population Methods: A cross-sectional study with a national multistage sampling of households with and without HIV-positive people was conducted in 2008 Six provinces were purposively selected to represent areas of the country and progressions of HIV epidemics Households were sampled with probability-proportional-to-size, following the selection of rural and urban districts A total of 820 HIV-positive and HIV-negative adults (mean age: 32.5; 38.7% female) was interviewed Among 400 HIV-positive people, 52.3% had history of injecting drug, and 56.3% were at AIDS stage and receiving antiretroviral treatment (ART) HRQL was measured using the EQ-5D Multiple regression models were purposefully constructed to examine the determinants of HRQL Results: The EQ-5D index and VAS score in less advanced HIV people (0.90, 69.3) and AIDS patients (0.88, 65.2) were significantly lower than those of the general population (0.96, 81.6) (p<0.001) The frequency of reported problems across EQ-5D dimensions in the HIV population (2.4% to 30.9%) was significantly higher than in the general population (0.7% to 12.1%) Compared to ART patients, those at earlier HIV stages reported having problems at similar proportions across HRQL dimensions, except pain/discomfort, where ART patients had significantly higher proportion Injecting drug users taking ART perceived lower HRQL score than non-injecting drug users Multiple regression determined that joblessness (p<0.01) and inaccessibility to health services (p<0.05) were associated with lower HRQL In addition, involvements in self-help groups significantly improved HRQL among HIV-positive participants (p<0.05) Conclusion: The findings highlight the need to improve the health service referral system and enhance psychological and social supports for patients in early stages of HIV infection in Vietnam
INTRODUCTION
With substantial supports from global health initiatives, antiretroviral treatment (ART) services have been rapidly scaled up in Vietnam However, the effectiveness of ART might be confined given the majority of treated patients were IDUs Drug use was related to a rapid HIV disease progression, delayed access to ART, and more importantly, adherence difficulties once ART had been started Therefore, to develop health care policies and services for adults with HIV/AIDS in Vietnam, evaluation of health outcomes and their predictors are essential
(34)over time, and related to treatment adherence and viral load Measuring HRQL, therefore, has the potential to assess the impact of health interventions, identify the need for health services improvements, and monitor changes in health status of HIV+ patients over time
There has been a growing body of evidence in various aspects of HRQL in HIV populations [1, 2] Nevertheless, very few of them conducted in developing countries where large HIV populations exist [1] The purposes of this study were to measure and compare HRQL of HIV+ adults with that of the general population, and to explore the determinants of HRQL in HIV populations
METHODS
Study settings and sampling
A cross-sectional household-based survey was conducted during October 2008 to April 2009 Six provinces involved in the study represented the differences in ecological regions and progressions of HIV epidemics A sample frame of HIV population was constructed including lists of the total HIV+ cases in all districts HIV-affected households were sampled with probability-proportional-to-size, following the random selection of rural and urban districts in target provinces The study populations consisted of HIV+ individuals 18 years and older, and a comparison group of HIV- adults in general population HIV-affected households were referred by peer-HIV educators These included both peer-HIV+ people at an advanced stage of peer-HIV infection and receiving ART when CD4 counts < 200 cells/µL and/or WHO stage AIDS (56.3 %), and those not yet required ART (43.7 %) There were not HIV+ individuals in need of but not taking ART in this sample For each HIV-affected household involved, there was one conveniently selected adult in a surrounding household with similar living standard and family size
Instruments
Respondents were interviewed face-to-face using structured questionnaires Health-related quality of life was measured using the EuroQOL 5-dimensions questionnaire (5D), and a visual analog scale (VAS) The EQ-5D consisted of a weighted sum of domains: Mobility, Self-care, Usual activities, Pain/Discomfort and Anxiety/Depression, whichprovided a simple descriptive profile and a single index value for health status [3] Each dimension had levels: no problems, some problems and severe problems that enabled the EQ-5D to define 243 health states Each state was then assigned a preference weight using tariffs of general populations based on the time trade-off or the visual analogue scale valuation techniques Although the EQ-5D single index reflects full health and death as and 0, in some severe health states, it results in negative values, which indicate that the health states are considered to be worse than death This study applied the UK tariff which has a possible score range of [ −0.59 to 1.00] [3] Besides, the VAS recorded respondent’s self-rated health on a vertical, 20-cm visual analogue scale resembling a thermometer where the endpoints (0, 100) were labelled “Best imaginable health state” and “Worst imaginable health state” [3] The Vietnamese version of EQ-5D instruments was provided by EuroQOL Group
Data analysis
Population weights were constructed based on the selection probabilities and the sampling weights of each stratum Descriptive statistics were used to describe the health status, socio-demographic and HIV-related characteristics of respondents
Multivariate linear regression was used to identify independent factors associated with overall single index of HRQOL and VAS in statistical models Candidates for multivariate analysis included those variables that met one of the following three criteria: (1) biological association with the outcome of interest; (2) previously shown to be associated with the HIV-specific quality of life among Vietnamese population; and (3) significant difference between groups when screened by univariate analysis The significance level was set at p < 0.05 Logistic regression analysis was performed to determine the association of reported problems in each dimension of health-related quality of life while controlling for the effect of confounders
Internal consistency reliability of HRQL measurement, an average inter-item correlation of the dimensions, was estimated using Cronbach’s alpha Spearman’s rank correlation was estimated to test for correlation between EQ-5D Index score and VAS score Cross-sectional construct validity was evaluated by testing ‘a priori’ hypothesis that the measurement was capable to distinguish HRQL of HIV+ individuals at different disease progression and their HRQL was lower than that of the general population
RESULTS
Characteristics of the study participants
(35)people were living with their spouse or partners while it was 82.7% in the comparison group (p<0.001) In addition, HIV+ population was younger and had lower level of education than the comparison group (Table 1)
Table Socio-demographic profile of respondents
Characteristics Total (N=820) HIV+ (N=400) Non HIV (N=420) p - value Age (years)
Mean (95% CI) 30.0 (37.2 - 38.9) 30.8 (30.1 - 31.8) 44.9 (43.7 - 46.2) <0.001*
Sex n % n % n %
Male 503 61.3 251 62.8 252 60.0 0.419**
Female 317 38.7 149 37.3 168 40.0
Ethnics
Kinh people 757 92.3 369 87.9 388 92.4 0.603**
Others 63 7.7 31 7.4 32 7.6
Marital status
Living alone 295 37.1 224 58.3 71 17.2 <0.001**
Living with spouse/ partner 501 62.9 160 41.7 341 82.8
Level of education
Secondary school and lower 487 59.4 278 69.5 209 49.8 <0.001**
High school and upper 333 40.6 122 30.5 211 50.2
Occupation
Having a job 636 78.7 285 73.1 351 84.0 <0.001**
Retired 50 6.2 0.3 49 11.7
Unable to work 33 4.1 21 5.4 12 2.9
Jobless 89 11.0 83 21.3 1.4
* Student t-test ** Chi-square test
Stages of HIV infection and social supports structure
Of the HIV+ population, 56.3% were taking ART, and 43.8% were asymptomatic and/ or had not yet met the criteria for treatment Mean length of living with HIV was years (95% CI = [4.7; 5.3]), and ART patients having longer time (5.3 years) than those at earlier HIV stage (4.7 years) (p<0.05) Among HIV+ individuals, 52.3% reported historically injecting drug
The percentage of HIV+ respondents receiving social support services, such as loan, tuition fee for children, health care, food, medicine, was significantly higher in those with ART (89.2%) than among others (76.0%) (Chi2=12.3, p<0.01) Peer-group involvement was reported to be similar 44% in the PLHIV taking or not yet taking ART
Health-related quality of life
Table Comparison of health-related quality of life between HIV+ population and general population HIV+ population General population
(N=420) p-value Taking ART
(N=225)
Not yet required ART (N=175)
EQ-5 Dimensions n (%) n (%) n (%)
Mobility
No problems 205 (91.1) 165 (94.3) 411 (97.9) <0.01*
Some problems 19 (8.4) 10 (5.7) (2.1)
Severe problems (0.4) (0) (0)
Self-care
No problems 217 (96.4) 173 (98.9) 417 (99.3) 0.07*
Some problems (3.1) (1.1) (0.7)
Severe problems (0.4) (0) (0)
Usual activities
No problems 208 (92.4) 166 (94.9) 410 (97.6) 0.026*
Some problems 15 (6.7) (5.1) (2.1)
Severe problems (0.9) (0) (0.2)
Pain/discomfort
No problems 182 (80.9) 156 (89.1) 395 (94) <0.001*
Some problems 39 (17.3) 19 (10.9) 23 (5.5)
Severe problems (1.8) (0) (0.5)
(36)No problems 151 (67.1) 119 (68) 369 (87.9) <0.001*
Some problems 62 (27.6) 45 (25.7) 42 (10)
Severe problems 12 (5.3) 11 (6.3) (2.1)
EQ-5D Index score
Median (IQR) 1.00 (0.85 - 1.00) 1.00 (0.85 - 1.00) 1.00 (1.00 - 1.00) <0.001*** Mean (95% CI) 0.88 (0.85 - 0.91) 0.90 (0.88 - 0.93) 0.96 (0.94 - 0.97) <0.001**
VAS score
Mean (95% CI) 65.2 (63.3 - 67.1) 69.3 (66.9 - 71.8) 81.6 (80.3 - 82.9) <0.001**
Median (IQR) 70 (50 - 75) 70 (60 - 80) 80 (75 - 90) <0.001***
* 3x3 Khi-square test for the difference in percentages of reported problems **Adjusted Wald test
***Kruskal-Wallis equality-of-populations rank test
Adjusting for age and gender, the EQ-5D index and VAS score in early HIV stage people (0.90, 69.3) and ART patients (0.88, 65.2) were significantly lower than those of the general population (0.96, 81.6) (p<0.001) The frequency of reported problems across EQ-5D dimensions in the HIV population (2.4% to 30.9%) was significantly higher than in the general population (0.7% to 12.1%) in every dimension Compared to ART patients, those at earlier HIV stages reported having problems at similar proportions across HRQL dimensions (Table 2), except pain/discomfort, where ART patients had significantly higher proportion (Fisher exact test, p = 0.027)
Table 3: Health-related quality of life of HIV+ adults with and without history of injecting drug
Groups N EQ-5D Index score VAS score
Mean 95% CI p-value Mean 95% CI p-value
Taking ART 225
non IDU 107 0.88 0.84 0.91 0.67* 66.9 63.4 69.4 0.01*
IDU
uplo ad.1 23do
c.net 0.89 0.85 0.92 63.6 61.3 65.9
Not yet on ART 175
non IDU 84 0.90 0.86 0.93 0.14* 71.0 68.1 73.9 0.85*
IDU 91 0.91 0.88 0.93 67.8 64.9 70.7
Overall 400
non IDU 191 0.88 0.86 0.91 0.61** 68.7 66.5 70.9 0.04**
IDU 209 0.89 0.87 0.92 65.4 63.4 67.5
* Analysis of covariance to compare means adjusted for age and sex
* Analysis of covariance to compare means adjusted for age, sex and disease progression
Table compared HRQL between HIV+ individuals with and without history of injecting drug At early HIV stage, both EQ-5D index score and VAS score were not different between the groups However, during ART, IDUs reported significantly lower VAS score than non-IDUs (p=0.010)
Predictors of HRQOL among HIV+ population
Multivariate analysis was carried out to examine the influence of socio-demographic variables, HIV-related factors and social supports structure on HRQL in adults with HIV Linear regression results determined that joblessness (p<0.001), having difficulties in accessing to health services (p<0.001) were significant independent predictors for lower scores in both EQ-5D index and VAS Moreover, injecting drug behaviours and disease progression were also associated with lower VAS score in HIV+ population (Table 4)
Table 4: Determinants of HRQOL score in HIV+ populations
Predictors EQ-5D Index score VAS score
Coef 95% CI p value Coef 95% CI p value
Predisposing factors
Jobless vs Working -0.11 -0.16 -0.07 <0.001 -9.90 -13.44 -6.36 <0.001
Female vs Male -0.01 -0.05 0.03 0.79 0.67 -2.51 3.85 0.68
Single vs married/ live with partners -0.03 -0.07 0.01 0.17 -1.93 -5.07 1.20 0.23 Secondary school and below vs
(37)Age (years) 0.00 -0.01 0.00 0.08 -0.12 -0.36 0.13 0.34 HIV-related factors
Years of living with HIV/AIDS -0.02 -0.04 0.00 0.11 0.72 -1.16 2.60 0.45 Taking ART vs not yet required
ART -0.02 -0.06 0.02 0.36 -4.19 -7.27 -1.11 0.01
Historically injecting drug vs Non 0.01 -0.03 0.05 0.52 -3.33 -6.40 -0.26 0.03 Social support structure
Have social supports vs Non 0.01 -0.06 0.09 0.70 2.16 -3.85 8.17 0.48 Involve in self-help groups vs Non 0.05 -0.10 0.00 0.07 2.48 -1.96 6.92 0.27
Difficulties in health care access:
No vs Yes 0.14 0.07 0.21 <0.001 6.42 0.35 12.49 0.04 Barriers in education for children:
No vs Yes 0.13 0.03 0.22 0.01 0.56 -7.76 8.87 0.90
Table indicated the odd ratios of having problems in various HRQL dimensions Similarly to HRQL index and VAS score, joblessness and having barriers to health care services were strongly associated with almost all HRQL domains Besides, disease-related progression was also found to influence HRQL dimensions For every more year living with HIV, the risk of having problems in self-care, usual activities, and anxiety/ depression increased by 122%, 107% and 29% respectively In addition, the HIV+ patients taking ART were about times more likely to have poorer physical health as compared to those had not yet met the criteria for ART Furthermore, those without self-help group involvements were times more likely to have problems in usual activities than others (Table 5)
Table 5: Predictors of having problems in each dimension of HRQL in HIV population
Predictors Mobility Self-care Usual
activities
Pain/ discomfort
Anxiety/ depression OR p value OR p value OR p value OR p value OR p value Predisposing factors
Jobless vs Working 4.82 <0.001 13.38 <0.01 2.88 0.01 2.99 <0.001 2.48 <0.001
Female vs Male 0.61 0.29 1.05 0.95 1.03 0.94 1.30 0.38 1.32 0.23
Living alone vs married/
live with partners 0.79 0.60 1.57 0.52 0.93 0.88 1.37 0.29 1.43 0.12 Secondary school and
below vs higher 1.96 0.17 0.45 0.24 1.49 0.42 1.52 0.20 1.17 0.53
Age (years) 1.02 0.48 0.99 0.77 1.00 0.99 1.02 0.34 1.02 0.32
HIV-related factors Years of living with
HIV/AIDS 1.49 0.10 2.22 0.09 2.07 0.01 1.07 0.70 1.29 0.06
Taking ART vs not yet
required ART 1.57 0.26 3.06 0.16 1.41 0.42 1.93 0.03 1.02 0.93
Historically injecting drug
vs Non-injecting 1.34 0.46 1.27 0.72 0.69 0.37 1.21 0.49 0.70 0.10 Social support structure
Have social supports vs
Not 1.65 0.65 1.89 0.62 1.61 0.67 2.63 0.21 0.51 0.13
Involve in self-help groups
vs Not 1.87 0.37 0.29 0.33 6.30 0.03 1.75 0.20 1.33 0.42
Difficulties in health care access:
No vs Yes 0.20 0.02 - - 0.19 0.02 0.31 0.02 0.16 <0.001 Barriers in education for
children:
No vs Yes 0.27 0.13 - - 0.81 0.85 0.29 0.05 0.19 0.01
- : variable dropped
Validity of EQ-5D instruments
(38)respectively EQ-5D instrument demonstrated a good cross-sectional construct validity which distinguished patients at different HIV progression (Table 2)
DISCUSSION
This study, for the first time, measured HRQL in a nationally representative sample of adults living with HIV, and compared it with HRQL of the general population in Vietnam We identified substantial impacts of HIV/AIDS on physical and psychological well-being in adults living with HIV Particularly, compared with the general population, the results indicated a considerable negative influence of HIV infection on psychological functioning
Several studies have found that physical functioning was worse in AIDS patients than those who had less advanced HIV disease [4-6] Our findings were consistent with these prior works In addition, we found that ART patients who had history of injecting drugs perceived lower HRQL score than non-IDU Besides, although problems in physical functioning were much higher at advanced HIV stage, we observed reported psychological problems at similar proportions across different HIV stages This highlighted the demand for early psychosocial support interventions and health care services for adults with HIV/AIDS, particularly IDUs, in Vietnam
Although ART has been rapidly scaled up in the country, it is necessary to make this service accessible to all those requiring treatment, which in turn improves quality of life of patients as well as treatment outcomes In our study, barriers of access to health care services were identified as significant predictors of decreases in HRQL This was in line with previous studies in Vietnamese settings where perceived stigma and access to HIV-related information influenced health seeking behaviours HIV testing have been popularly introduced in the country through friendly HIV voluntary testing and counselling (VCT) services In fact, scaling up ART services has the potential to encourage an earlier detection of HIV cases as the accessibility to ARV encourages testing for HIV infection For the efficiency of HIV care and treatment programs, it is crucial to improve the quality of VCT services with particular focus on post-counselling and referrals
The limitation of our study included the recruitment of respondents which was referred by peer-HIV-educators Because of that, we were not able to reach people who had not disclosed their HIV status, and those who were being at in-patient clinics Several clinics-based surveys showed a lower HRQL score among patients initiating treatment and/ or having severe opportunistic infections However, given the fact that advanced HIV patients require life-long ART like other chronic illness, after treatment for opportunistic infections, most of them will be taking drugs at home
The validity of EQ-5D instruments was shown to be able to measure population health in Vietnam This study provides a norm of HRQL in general population in Vietnam that would be useful for identifying health-related problems in specific population such as HIV/AIDS Nevertheless, EQ-5D items showed a relatively high ceiling effect Application of EQ-5D for measuring changes in health status and in longitudinal assessment, therefore, should be considered
Consequently, as the first household survey on the HRQL in HIV+ population in Vietnam, this study provided comparable and representative evidences for developing health care services and conducting economic evaluations of HIV care and treatment alternative strategies in Vietnam as well as large-populations in low-income settings
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