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

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

Populations in the global south are disproportionately exposed to the stressors of development, disaster and armed conflict, all of which heighten cardiovascular disease (CVD) risk. We consider how war-related stressors exert a lasting influence upon population health, in particular the cardiovascular health of war survivors now entering older adulthood. Data come from the 2018 Vietnam Health and Aging Study conducted among 2,447 northern Vietnamese adults age 60 and older. We conduct survey-adjusted logistic regression analyses to examine the associations among respondents’ wartime exposure to combat and physical threat, malevolent environment conditions, and four CVD conditions (hypertension, dyslipidemia, heart disease, and stroke). We examine posttraumatic stress disorder (PTSD) as it mediates the association between wartime stress exposures and late life CVD, and gender as it moderates the relationship between wartime stressors and CVD. We find that exposure to wartime combat and violence, as well as malevolent living conditions, exhibit significant, positive associations with cardiovascular conditions. These associations are mediated by the severity of recent PTSD symptoms. For certain CVD conditions, particularly hypertension, the associations between wartime stressors and late life cardiovascular conditions diverge across gender with women experiencing a greater penalty for their exposure to war-related stressors than their male counterparts. We conclude that the stressors of war and resultant PTSD, widespread in this cohort of Vietnamese older adults who endured myriad forms of war exposure during their young adulthood, exhibit modest, yet significant associations with late-life cardiovascular conditions. Women, especially those exposed to wartime violence and combat, bear this CVD burden alongside men.

Adequate infection control plays a key role in preventing healthcare-associated infections (HAIs). This study aimed to explore staff perceptions of hospital infection control in a rural and an urban hospital in Vietnam. Individual interviews were conducted with hospital managers, and focus group discussions were conducted with doctors, nurses and cleaning workers separately. Content analysis was applied. An interview guide including discussion points on HAIs, hand hygiene and healthcare waste management was used. Generally, the staff were knowledgeable of hospital infection control, but they were not aware of the situation in their own hospital, and infection control practices in the hospitals remained poor. Reported difficulties in infection control included lack of resources, poor awareness and patient overload. A main theme emerged: &lsquo, Making data on HAIs available for health workers can improve their awareness and motivate them to put their existing knowledge into practice, thus decreasing the know-do gap in infection control&rsquo, This could be a feasible intervention to improve infection control practice in the hospitals with limited resources, high workload and patient overload.

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

Staff practice, driven by knowledge, plays a decisive role in hospital infection control. This study aimed to assess and compare knowledge and self-reported practices of infection control among various occupational groups in a rural and an urban hospital in Vietnam. Questionnaires consisting of items on knowledge and practices were collected from 339 hospital staff with varying occupations. For analysis, total knowledge or practice score ranged from 0–15. Mood’s median test was performed to compare median scores. Post-hoc analysis of ordinal logistic regression models was applied to test differences in scores among occupational groups. The majority of hospital staff had good or adequate knowledge (median score: rural = 11.8; urban = 12), but the score range was wide (1.4–14.5). Self-reported practices in the urban hospital were likely to be better than in the rural one (p = 0.003). Self-reported practices yet not completely satisfactory, indicating the need for continuing professional development in both settings. Overall, cleaners had lower scores than both physicians and nurses, highlighting the need for tailored education in this topic. Future infection control strategies within the hospitals might want to assess the difference between the staff’s self-reported practice and their actual real practice. These findings can be of value in many other similar settings.

The environmental spread of antibiotic-resistant bacteria has been recognised as a growing public health threat for which hospitals play a significant role. The aims of this study were to investigate the prevalence of antibiotic resistance and antibiotic resistance genes (ARGs) in Escherichia coli isolates from hospital wastewater in Vietnam. Wastewater samples before and after treatment were collected using continuous sampling every month over a year. Standard disk diffusion and E-test were used for antibiotic susceptibility testing. Extended-spectrum beta-lactamase (ESBL) production was tested using combined disk diffusion. ARGs were detected by polymerase chain reactions. Resistance to at least one antibiotic was detected in 83% of isolates; multidrug resistance was found in 32%. The highest resistance prevalence was found for co-trimoxazole (70%) and the lowest for imipenem (1%). Forty-three percent of isolates were ESBL-producing, with the blaTEM gene being more common than blaCTX-M. Co-harbouring of the blaCTX-M, blaTEM and qepA genes was found in 46% of isolates resistant to ciprofloxacin. The large presence of antibiotic-resistant E. coli isolates combined with ARGs in hospital wastewater, even post-treatment, poses a threat to public health. It highlights the need to develop effective processes for hospital wastewater treatment plants to eliminate antibiotic resistant bacteria and ARGs.

Stigma has been identified as a major barrier to HIV response. While much is known about stigma directed towards people living with HIV (PLHIV), less is known about stigma experienced by health workers who treat PLHIV. This study aims to explore the perceptions and experiences of health workers regarding how stigma influences their work with HIV-positive patients. The study employed a qualitative design involving individual semi-structured in-depth interviews with 14 health workers, purposively selected from hospitals and detention centres for people who use drugs and sex workers in Hanoi, Vietnam. Findings showed that the stigma experienced by health workers may be organised around several themes: (1) lack of social prestige associated with HIV work; (2) fear of infection expressed by family members; (3) feelings of being devalued within the healthcare field; and (4) work-related stress and burnout, especially for staff working in detention centres for drug users and female sex workers. Efforts are needed to improve the public image of HIV work, scale up stigma reduction, enhance stress management and create a safe and supportive working environment for health workers.

Background: Appropriate antibiotic use is vital to effectively contain antibiotic resistance and improve global health. Acute respiratory infections (ARIs) remain the leading cause of disease and death in children under five in low-income countries. Objective: To evaluate a multi-faceted intervention targeting health-care-providers’ (HCPs) knowledge, practical competences and practices regarding antibiotic use for ARIs. Methods: A multi-faceted educational intervention with a two-armed randomised controlled design targeting HCPs treating ARIs in children was conducted in Bavi district, a rural district in Northern Vietnam in 2010–2011. Thirty-two communes of the district were randomized into two arms, with 144 HCPs in the intervention arm and 160 in the control arm. The intervention, conducted over seven months, comprised: (i) education regarding appropriate-antibiotic use, (ii) case scenario discussion and (iii) poster distribution. Questionnaires to assess knowledge and dispensing/prescribing forms to assess practice were completed before-and after interventions. The main outcome measures were differences in improvement in knowledge and practice in the intervention and control group, respectively. Results: Knowledge improved in the intervention group for ARI aetiology by 28% (ΔDecrement control arm 10%), antibiotic use for mild ARIs by 15% (ΔDecrement control arm 13%) and for severe ARIs by 14% (ΔImprovement control arm 29%). Practical competence for a mild ARI case scenario improved in the intervention and control groups by 20% and 11%, respectively. Total knowledge score increased statistically in the intervention group (Δmean improvement 1.17); less so in the control group (Δmean improvement 0.48). Practice regarding antibiotics for mild ARIs improved by 28% in the intervention group (ΔDecrement control arm 3%). Conclusions: The intervention significantly improved HCPs’ knowledge of ARIs and practice of antibiotic use in treatment of ARIs. We suggest mixed method assessment and long-term follow-up of these interventions to enable better appreciation of the effects and effect sizes of our interventions.

In many low- and middle-income countries (LMICs), a poor link between antibiotic policies and practices exists. Numerous contextual factors may influence the degree of antibiotic access, appropriateness of antibiotic provision, and actual use in communities. Therefore, improving appropriateness of antibiotic use in different communities in LMICs probably requires interventions tailored to the setting of interest, accounting for cultural context. Here we present the ABACUS study (AntiBiotic ACcess and USe), which employs a unique approach and infrastructure, enabling quantitative validation, contextualization of determinants, and cross-continent comparisons of antibiotic access and use. The community infrastructure for this study is the INDEPTH-Network (International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries), which facilitates health and population research through an established health and demographic surveillance system. After an initial round of formative qualitative research with community members and antibiotic suppliers in three African and three Asian countries, household surveys will assess the appropriateness of antibiotic access, provision and use. Results from this sample will be validated against a systematically conducted inventory of suppliers. All potential antibiotic suppliers will be mapped and characterized. Subsequently, their supply of antibiotics to the community will be measured through customer exit interviews, which tend to be more reliable than bulk purchase or sales data. Discrepancies identified between reported and observed antibiotic practices will be investigated in further qualitative interviews. Amartya Sen’s Capability Approach will be employed to identify the conversion factors that determine whether or not, and the extent to which appropriate provision of antibiotics may lead to appropriate access and use of antibiotics. Currently, the study is ongoing and expected to conclude by 2019. ABACUS will provide important new insights into antibiotic practices in LMICs to inform social interventions aimed at promoting optimal antibiotic use, thereby preserving antibiotic effectiveness.

Choices for delivery care are made based on the available resources and influence health outcomes of women and their children. The aim of the paper is to study utilization and preference for delivery care and related factors in one urban and one rural area of northern Vietnam. Two cohorts of pregnant women were carried out in DodaLab and FilaBavi Health and Demographic Surveillance Sites (HDSS) in Hanoi, Vietnam from April 2008 to December 2009. Together, 2515 pregnant women were identified and followed until delivery through quarterly household interviews using structured questionnaires. Almost all women delivered at health care facilities. Most of the rural women gave birth at primary health care facilities (88.5%) while urban women primarily used secondary and tertiary hospitals (93.6%). Caesarean section (CS) was used for 38.5% of births in the urban area and 12.4% in the rural. Giving birth in hospitals and CS were more common among highly educated women, employed women, women living in households or communities with good economic conditions, and women expected to give birth to a son. Technology preference in delivery care was associated with better socioeconomic conditions and expecting a boy. Improving the quality and reputation of primary health care facilities, informing women about CS risks and monitoring indications of CS are important policy issues.

This paper contributes evidence documenting the continued decline in all-cause mortality and changes in the cause of death distribution over time in four developing country populations in Africa and Asia. We present levels and trends in age-specific mortality (all-cause and cause-specific) from four demographic surveillance sites: Agincourt (South Africa), Navrongo (Ghana) in Africa; Filabavi (Vietnam), Matlab (Bangladesh) in Asia. We model mortality using discrete time event history analysis. This study illustrates how data from INDEPTH Network centers can provide a comparative, longitudinal examination of mortality patterns and the epidemiological transition. Health care systems need to be reconfigured to deal simultaneously with continuing challenges of communicable disease and increasing incidence of non-communicable diseases that require long-term care. In populations with endemic HIV, long-term care of HIV patients on ART will add to the chronic care needs of the community.

SummaryBackgroundWhile a large amount of data about the epidemiology of asthma, COPD, chronic bronchitis and respiratory symptoms are available from developed countries, the information about these diseases in developing countries in south-east Asia are scarce.AimAssess the prevalence of respiratory diseases and symptoms and their relation with demographic data including smoking habits among adults in rural and urban Vietnam.MethodsA random sample of subjects aged 21–70 years were invited; 3008 subjects living in an inner city area of Hanoi and 4000 in a rural area of Bavi in northern Vietnam. An internationally used questionnaire was delivered by field workers to the study subjects. The questionnaire was completed by the subjects, or when necessary, by the field workers after reading the questions for the study participants.ResultsThe response rate was 92% in Bavi and 70% in Hanoi. Of men in Bavi 67.8% (Hanoi 49.7%; p

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

Objectives To describe the pattern of drug use among the children with respiratory illnesses and/or diarrhoea; and to analyze the association between various socio-economic factors and pattern of drug use. Methods A population-based survey of 4087 children under five was conducted within the framework of an epidemiological surveillance site in a rural district of Vietnam. Through interviewing mothers or caretakers, data on self-reported illness, use of drugs, and use of health services during 2 weeks prior to the survey and other background information were collected. Results Out of 4087 children, 1836 children had respiratory illness and/or diarrhoea during 2 weeks before the interview and drugs were used in the majority of cases. Antibiotics (72.2%) and analgesics/antipyretics (53.5%) were the drugs most commonly reported. Corticosteroids were used in 11.6% of all cases. Among children with diarrhoea, Oral Rehydration Solution (ORS) was used in 9.7%, while anti-diarrhoea drugs were used in 36.1% of all cases. There was a significant association between the family's socio-economic condition and use of corticosteroids, but to a lesser degree regarding other drugs. There was no significant association between pattern of drug use and type of health service consulted. Conclusions There are major problems about irrational drug use among children. The treatment guidelines for respiratory illness and diarrhoea are not followed. Urgent actions are needed and should target all actors in the field, mothers, doctors, pharmacy staff, and authorities in order to improve this situation. Copyright © 2009 John Wiley & Sons, Ltd.

Objectives: To investigate the prevalences of reproductive tract infections (RTI)/sexually transmitted infections (STI) among married women in a rural district of Vietnam, and analyse the influence of socioeconomic, sociodemographic, and other determinants possibly related to RTI/STI. Methods: A community-based cross-sectional study. Married women aged 18–49 years (n = 1012) were interviewed and underwent a gynaecological examination. Specimens were collected for laboratory diagnosis of chlamydia, gonorrhoea, trichomonas, bacterial vaginosis (BV), candidiasis, hepatitis B, HIV, and syphilis. Results: In total, 37% of the women were clinically diagnosed with an RTI/STI. Aetiologically confirmed RTI/STI was identified in 39% of the women (including 6% with STI). Endogenous infections were most prevalent (candidiasis 26%, BV 11%) followed by hepatitis B 8.3%, Chlamydia trachomatis 4.3%, Trichomonas vaginalis 1%, Neisseria gonorrhoeae 0.7%, genital warts 0.2%, and HIV and syphilis 0%. Fifty per cent of the STI cases were asymptomatic. Younger age and intrauterine devices were significantly associated with an increased risk of BV. Determinants of candidiasis were vaginal douching, high education level and low economic status, whereas a determinant of chlamydia was high economic status. Outmigration of the husband was associated with an increased risk of hepatitis B surface antigen seroposivity among women. Conclusions: RTI/STI were prevalent among married women in a rural population of Vietnam. Syndromic algorithms should be consistently supplemented by risk assessment in order to reduce under and overtreatment. Microscopic diagnosis could be applied in primary care settings to achieve more accurate diagnoses. The promotion of health education aimed at reducing RTI/STI prevalences is an important tool in STI/HIV control programmes. Vaccination to prevent hepatitis B for migrants should be considered.

Summary: Purpose: We conducted a survey to assess knowledge, attitudes, and practice toward epilepsy in a population-based study in a rural district of Vietnam. Methods: We utilized an established knowledge-attitudes-practice questionnaire. This was applied by trained surveyors in face-to-face interviews of 2005 randomly selected adult residents (19–71 years of age) of the BaVi district, 60 km west of Hanoi. Results: Of the respondents, 67.0% had heard about epilepsy, 52.1% had known someone with seizures, and 49.3% had witnessed seizures. In total, 36.3% would object to their children playing with someone with seizures and 82.0% to their children marrying someone with epilepsy. Only 32.6% thought that epilepsy patients should be employed in a job as other people, while 10% thought that epilepsy was a form of insanity. Familiarity with epilepsy, having heard of epilepsy, known someone with epilepsy, or having seen seizures was associated with less negative attitudes. About half of the respondents (50.4%) thought epilepsy was caused by a brain disease and 80.1% would suggest consultation of a medical doctor for epilepsy. Conclusions: Knowledge of epilepsy among Vietnamese people is still limited compared to some Western countries and the attitudes more negative. Our findings indicated more negative attitudes than in another recent survey from Vietnam. This may be due to differences in sociodemographic characteristics and educational level of the study populations. The discrepancies demonstrate the importance of selection of study population and the need for caution in generalizing from results of surveys.

The Vietnam Initiative for Zoonotic Infections (VIZIONS) includes community-based ‘high-risk sentinel cohort’ (HRSC) studies investigating individuals at risk of zoonotic infection due to occupational or residential exposure to animals. A total of 852 HRSC members were recruited between March 2013 and August 2014 from three provinces (Ha Noi, Dak Lak and Dong Thap). The most numerous group (72.8%) corresponded to individuals living on farms, followed by slaughterers (16.3%) and animal health workers (8.5%). Nasal/pharyngeal and rectal swabs were collected from HRSC members at recruitment and after notifying illness. Exposure to exotic animals (including wild pigs, porcupine, monkey, civet, bamboo rat and bat) was highest for the Dak Lak cohort (53.7%), followed by Ha Noi (13.7%) and Dong Thap (4.0%). A total of 26.8% of individuals reported consumption of raw blood over the previous year; 33.6% slaughterers reported no use of protective equipment at work. Over 686 person-years of observation, 213 episodes of suspect infectious disease were notified, equivalent of 0.35 reports per person-year. Responsive samples were collected from animals in the farm cohort. There was noticeable time and space clustering of disease episodes suggesting that the VIZIONS set up is also suitable for the formal epidemiological investigation of disease outbreaks.

In this study we concentrate on injuries and affected households' capacities to earn incomes. A longitudinal study was performed in Bavi district, Vietnam, with the specific objectives to investiga ...

In Vietnam, hypertension was estimated to cause a large number of deaths in hospitals. However, population-based knowledge about the magnitude of hypertension in Vietnam and its relationship with socioeconomic status, especially in the rural communities, still remains scarce. This paper, taking advantage of a study on noncommunicable disease (NCD) risk factors in Bavi district, Vietnam, using the WHO STEPs approach, estimates the prevalence of hypertension in the setting and examines its association with some socioeconomic factors. A representative sample comprising 2000 adults aged 25-64 years were selected randomly and surveyed in 2002. The JNC VII criteria for hypertension were used. Socioeconomic status of the study subjects was estimated by assessing their education, occupation and economic conditions. Descriptive techniques and multivariate logistic regression were used. The prevalence of hypertension was 14.1%. Of hypertensives, only 17.4% were aware of their hypertensive status. Men were hypertensive more often than women and age was positively associated with hypertension. The association between hypertension and socioeconomic status was complex and differed between men and women. Among men, those with lower educational and occupational status but who were richer were more likely to be hypertensive. More women with lower occupational and economic status were hypertensive.

SUMMARYA reassortant swine-origin A(H3N2) virus (A/swine/BinhDuong/03-9/2010) was detected through swine surveillance programmes in southern Vietnam in 2010. This virus contains haemagglutinin and neuraminidase genes from a human A(H3N2) virus circulating around 2004–2006, and the internal genes from triple-reassortant swine influenza A viruses (IAVs). To assess population susceptibility to this virus we measured haemagglutination inhibiting (HI) titres to A/swine/BinhDuong/03-9/2010 and to seasonal A/Perth/16/2009 for 947 sera collected from urban and rural Vietnamese people during 2011–2012. Seroprevalence (HI ⩾ 40) was high and similar for both viruses, with 62·6% [95% confidence interval (CI) 59·4–65·7] against A/Perth/16/2009 and 54·6% (95% CI 51·4–57·8%) against A/swine/BinhDuong/03-9/2010, and no significant differences between urban and rural participants. Children aged

The objective of this study was to assess the effects of a multicomponent intervention on private pharmacy practice. From 641 private pharmacies in Hanoi, 68 pharmacies were randomly selected and matched into 34 pairs. Each pair consisted of a control and an intervention pharmacy. Three interventions were applied sequentially: Regulatory enforcement, Education, and Peer influence. Four tracer conditions were selected: uncomplicated acute respiratory infection (ARI), sexually transmitted disease (STD), requesting the prescription-only drugs prednisolone, and a short course of cefalexin. Practice was assessed through the Simulated Client Method (SCM). The intervention pharmacies improved significantly compared to the control pharmacies (P

OBJECTIVES To assess the effectiveness of a multi-component intervention on knowledge and reported practice amongst staff working in private pharmacies in Hanoi regarding four conditions: urethral discharge [sexually transmitted diseases (STD)], acute respiratory infection (ARI), and non-prescription requests for antibiotics and steroids. METHOD Randomized controlled trial with staff working in 22 matched pair intervention and control private pharmacies who were administered a semistructured questionnaire on the four conditions before and 4 months after the interventions. The interventions focused on the four conditions and were in sequence (i) regulations enforcement; (ii) face-to-face education and (iii) peer influence. Outcome measures were knowledge and reported change in practice for correct management of tracer conditions. RESULTS The intervention/control-pairs (22 after drop-outs) were analysed pre- and post-intervention using the Wilcoxon signed rank test. STD: More drug sellers stated they would ask about the health of the partner (P = 0.03) and more said they would advise condom use (P = 0.01) and partner notification (P = 0.04). ARI: More drug sellers stated they would ask questions regarding fever (P = 0.01), fewer would give antibiotics (P = 0.02) and more would give traditional medicines (P = 0.03). Antibiotics request: Fewer said they would sell a few capsules of cefalexin without a prescription (P = 0.02). Steroid requests: No statistical difference was seen in the numbers who said they would sell steroids without a prescription as numbers declined in both intervention and control groups (P = 0.12). CONCLUSION The three interventions in series over 17 months were effective in changing the knowledge and reported practice of drug sellers in Hanoi.

Background : As the HIV/AIDS pandemic has evolved over recent decades, Africa has been the most affected region, even though a large proportion of HIV/AIDS deaths have not been documented at the individual level. Systematic application of verbal autopsy (VA) methods in defined populations provides an opportunity to assess the mortality burden of the pandemic from individual data. Objective : To present standardised comparisons of HIV/AIDS-related mortality at sites across Africa and Asia, including closely related causes of death such as pulmonary tuberculosis (PTB) and pneumonia. Design : Deaths related to HIV/AIDS were extracted from individual demographic and VA data from 22 INDEPTH sites across Africa and Asia. VA data were standardised to WHO 2012 standard causes of death assigned using the InterVA-4 model. Between-site comparisons of mortality rates were standardised using the INDEPTH 2013 standard population. Results : The dataset covered a total of 10,773 deaths attributed to HIV/AIDS, observed over 12,204,043 person-years. HIV/AIDS-related mortality fractions and mortality rates varied widely across Africa and Asia, with highest burdens in eastern and southern Africa, and lowest burdens in Asia. There was evidence of rapidly declining rates at the sites with the heaviest burdens. HIV/AIDS mortality was also strongly related to PTB mortality. On a country basis, there were strong similarities between HIV/AIDS mortality rates at INDEPTH sites and those derived from modelled estimates. Conclusions : Measuring HIV/AIDS-related mortality continues to be a challenging issue, all the more so as anti-retroviral treatment programmes alleviate mortality risks. The congruence between these results and other estimates adds plausibility to both approaches. These data, covering some of the highest mortality observed during the pandemic, will be an important baseline for understanding the future decline of HIV/AIDS. Keywords : HIV/AIDS; tuberculosis; Africa; Asia; Mortality; INDEPTH Network; Verbal Autopsy; InterVA (Published: 29 October 2014) Citation: Glob Health Action 2014, 7 : 25370 - http://dx.doi.org/10.3402/gha.v7.25370 SPECIAL ISSUE : This paper is part of the Special Issue: INDEPTH Network Cause-Specific Mortality . More papers from this issue can be found at http://www.globalhealthaction.net

Background : Because most deaths in Africa and Asia are not well documented, estimates of mortality are often made using scanty data. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering all deaths over time and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available. Objective : To build a large standardised mortality database from African and Asian sites, detailing the relevant methods, and use it to describe cause-specific mortality patterns. Design : Individual demographic and verbal autopsy (VA) data from 22 INDEPTH sites were collated into a standardised database. The INDEPTH 2013 population was used for standardisation. The WHO 2012 VA standard and the InterVA-4 model were used for assigning cause of death. Results : A total of 111,910 deaths occurring over 12,204,043 person-years (accumulated between 1992 and 2012) were registered across the 22 sites, and for 98,429 of these deaths (88.0%) verbal autopsies were successfully completed. There was considerable variation in all-cause mortality between sites, with most of the differences being accounted for by variations in infectious causes as a proportion of all deaths. Conclusions : This dataset documents individual deaths across Africa and Asia in a standardised way, and on an unprecedented scale. While INDEPTH sites are not constructed to constitute a representative sample, and VA may not be the ideal method of determining cause of death, nevertheless these findings represent detailed mortality patterns for parts of the world that are severely under-served in terms of measuring mortality. Further papers explore details of mortality patterns among children and specifically for NCDs, external causes, pregnancy-related mortality, malaria, and HIV/AIDS. Comparisons will also be made where possible with other findings on mortality in the same regions. Findings presented here and in accompanying papers support the need for continued work towards much wider implementation of universal civil registration of deaths by cause on a worldwide basis. Keywords : mortality; cause of death; Africa; Asia; verbal autopsy; INDEPTH Network (Published: 29 October 2014) Citation : Glob Health Action 2014, 7 : 25362 - http://dx.doi.org/10.3402/gha.v7.25362 SPECIAL ISSUE : This paper is part of the Special Issue: INDEPTH Network Cause-Specific Mortality . More papers from this issue can be found at http://www.globalhealthaction.net

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

Policy decisions regarding whether to incorporate new vaccines into routine public health practice in developing countries will depend in part on the costs of vaccine purchase and of vaccine delivery. In March, 1997, a large-scale effectiveness trial of a locally produced, orally administered bivalent vaccine against Vibrio cholerae 01 and 0139 began in Viet Nam. Empirical data obtained from the trial was used to determine the costs of the immunization campaign from the government perspective. The study population, including the children less than one year of age and pregnant women who were ineligible for immunization, was 353926. A total of 289041 persons received two doses of vaccine, and 13340 persons received one dose of vaccine. Two-dose vaccine coverage was 83.4%. The total cost of vaccine delivery during the immunization campaign was $66527. The cost of each dose of vaccine was $0.31. Therefore, the total cost of the immunization campaign was $0.44 per dose administered, and $0.91 per fully immunized person. Attempts to reduce the cost per dose of vaccine (e.g. the use of a monovalent vaccine against serogroup 01) are likely to have a large impact on the cost of future similar immunization campaigns.

Vietnam, a developing country, has had comparatively good health and human survival at low cost. The economic reform changed the health care system, and private pharmacies during the last 5 years have taken over a majority of the drug distribution. Problems include weaknesses in drug regulation and reported increases in antibiotic resistance. This case study, a purposive sample of two private pharmacies in Hanoi, explored management, including dispensing, inventory and financing, using the concept of triangulation. Observations and interviews of customers were complemented by stock inventory and interviews of the pharmacy staff. Drugs were classified according to the ATC code and the essential drug list of Vietnam. Pretested protocols were used. In all 1833 encounters were studied during the 2 weeks, out of which 286 were children. Less than 1% of customers came with prescriptions and 94.9% decided by themselves which drugs to buy. Antibiotics represented 17%, of which 90% were broad spectrum. Ampicillin dominated, both in children and adults. Some 50% of the antibiotics were given for 2.5 days or less. Less than 50% of the drugs were essential drugs (ED) on dispensing and even less on inventory. Antibiotics and vitamins were the most commonly sold drugs and, overall, brand names dominated. Little if any drug information was observed. Antibiotics were said to represent the most profitable drugs, according to the pharmacy staff. More than 20% of all products were combination drugs, including irrational and popular products with antibiotics and corticosteroids and combinations of aspirin, phenacetin and caffeine. This study shows an unexpectedly high proportion of customers, being "Tu Lam Bac Sy" (their own doctors), deciding themselves which drugs to buy. Although the "Doi moi" renovation has led to much improved drug availability, at least in urban setting, our case study highlights major problems in need of urgent actions. In particular the prevailing practices regarding antibiotics and combination drugs need to be seriously scrutinized and drug regulatory mechanisms should be enforced.

BACKGROUND: The irrational overuse of antibiotics should be minimized as it drives the development of antibiotic resistance, but changing these practices is challenging. A better understanding is needed of practices and economic incentives for antibiotic dispensing in order to design effective interventions to reduce inappropriate antibiotic use. Here we report on both quantitative and qualitative aspects of antibiotic sales in private pharmacies in northern Vietnam. METHOD: A cross-sectional study was conducted in which all drug sales were observed and recorded for three consecutive days at thirty private pharmacies, 15 urban and 15 rural, in the Hanoi region in 2010. The proportion of antibiotics to total drug sales was assessed and the revenue was calculated for rural and urban settings. Pharmacists and drug sellers were interviewed by a semi-structured questionnaire and in-depth interviews to understand the incentive structure of antibiotic dispensing. RESULTS: In total 2953 drug sale transactions (2083 urban and 870 rural) were observed. Antibiotics contributed 24% and 18% to the total revenue of pharmacies in urban and rural, respectively. Most antibiotics were sold without a prescription: 88% in urban and 91% in rural pharmacies. The most frequent reported reason for buying antibiotics was cough in the urban setting (32%) and fever in the rural area (22%). Consumers commonly requested antibiotics without having a prescription: 50% in urban and 28% in rural area. The qualitative data revealed that drug sellers and customer's knowledge of antibiotics and antibiotic resistance were low, particularly in rural area. CONCLUSION: Over the counter sales of antibiotic without a prescription remains a major problem in Vietnam. Suggested areas of improvement are enforcement of regulations and pricing policies and educational programs to increase the knowledge of drug sellers as well as to increase community awareness to reduce demand-side pressure for drug sellers to dispense antibiotics inappropriately.

Objectives To examine the association of low birthweight (LBW) and prematurity with clinically significant symptoms of antenatal common mental disorders (ACMDs) during the third trimester of pregnancy in a semi-rural area in Vietnam. Methods Prospective community-based cohort study. Severity of ACMD symptoms was assessed with the Edinburgh Depression Scale, low birthweight was defined as below 2500 g, and gestational age was estimated according to last menstrual period. Reproductive and socio-demographic risk factors were measured as potential confounders of the association between ACMD and the outcomes. We conducted bivariate analyses of association between ACMD and the perinatal outcomes, employing chi-square tests, crude odds ratios and 95% confidence intervals. Multiple logistic regression analysis was used to adjust for confounding. Findings We found a prevalence of clinically significant symptoms of ACMDs of 37.4%, which were significantly associated with preterm birth (adjusted OR 1.98, CI95% = 1.14–3.43) and low birthweight (adjusted OR 2.24, CI95% = 1.02–4.95). Among the examined risk factors for the outcome measures, only maternal age was found to be statistically significant for low birthweight and preterm birth. Conclusions This study confirms that clinically significant symptom levels of ACMD in Vietnam are associated with preterm birth and low birthweight. These findings highlight the importance of cost-effective public health interventions for ACMD in Vietnam and further exploration of its physiological link with preterm birth and low birthweight. Objectifs Examiner l'association entre le faible poids de naissance (FPN) et la prematurite avec des symptomes cliniquement significatifs de troubles mentaux prenataux courants (TMPC) au cours du troisieme trimestre de la grossesse dans une zone semi-rurale au Vietnam. Methodes Etude prospective de cohorte communautaire. La severite des symptomes de TMPC a ete evaluee avec l’echelle de la depression d'Edimbourg, le faible poids de naissance a ete defini comme inferieur a 2500 grammes et l’âge gestationnel a ete estime d'apres la derniere periode menstruelle. Les facteurs de risque de reproduction et sociodemographiques ont ete mesures comme variables confusionnelles potentielles de l'association entre les TMPC et les resultats. Nous avons effectue des analyses bivariees de l'association entre les TMPC et les resultats perinataux, en employant les tests de Χ2, des odds ratios bruts et des intervalles de confiance a 95%. Une analyse de regression logistique multiple a ete utilisee pour corriger selon les variables confusionnelles. Resultats Nous avons trouve une prevalence de symptomes de TMPC cliniquement significatifs de 37,4%, qui etaient significativement associes a la prematurite (OR ajuste: 1,98; IC95% = 1,14 a 3,43) et au faible poids de naissance (OR ajuste: 2,24; IC95% = 1,02–4,95). Parmi les facteurs de risque examines pour les mesures de resultats, seul l’âge de la mere a ete trouve statistiquement significatif pour le faible poids de naissance et la prematurite. Conclusions Cette etude confirme que des degres de symptomes cliniquement significatifs de TMPC au Vietnam sont associes a la prematurite et au faible poids de naissance. Ces resultats soulignent l'importance du rapport cout-efficacite des interventions de sante publique pour les TMPC au Vietnam et l'exploration plus poussee de leur lien physiologique avec les naissances prematurees et le faible poids de naissance. Objetivos Examinar la asociacion entre el bajo peso al nacer (BPN) y la prematuridad con sintomas clinicos significativos de de desordenes mentales comunes prenatales (DMCP) en mujeres en el tercer trimestre de embarazo de un area semirural en Vietnam. Metodos Estudio de cohortes, prospectivo y basado en la comunidad. La severidad de los sintomas DMCP se evaluo utilizando la Escala de Depresion de Edimburgo, el bajo peso al nacer se definio como menos de 2500 gramos, y la edad gestacional se calculo segun el ultimo periodo menstrual. Los factores de riesgos reproductivos y sociodemograficos se midieron como posibles factores de confusion de la asociacion entre DMCP y los resultados. Realizamos analisis bivariados de la asociacion entre DMCP y los resultados perinatales, utilizando pruebas de Χ2, razon de probabilidades e intervalos de confianza del 95%. El analisis de regresion multiple se utilizo para realizar el ajuste por los factores de confusion. Hallazgos Encontramos una prevalencia de sintomas clinicos significativos de DMCP del 37.4%, que estaban significativamente asociados con el nacimiento prematuro (OR ajustado 1.98, IC95% = 1.14–3.43) y bajo peso al nacer (OR ajustado 2.24, IC95% = 1.02–4.95). Entre los factores de riesgo examinados para los resultados, solo la edad de la madre era estadisticamente significativa para el bajo peso al nacer y el nacimiento prematuro. Conclusiones Este estudio confirma que unos niveles clinicamente significativos de sintomas de DMCP en Vietnam estan asociados con un nacimiento prematuro y un bajo peso al nacer. Estos hallazgos subrayan la importancia de las intervenciones de salud publica coste-efectivas para DMCP en Vietnam, asi como de explorar mas a fondo su relacion fisiologica con un nacimiento prematuro y bajo peso al nacer.

Hospital effluents represent an important source for the release of antibiotics and antibiotic resistant bacteria into the environment. This study aims to determine concentrations of various antibiotics in wastewater before and after wastewater treatment in a rural hospital (60 km from the center of Hanoi) and in an urban hospital (in the center of Hanoi) in Vietnam, and it aims to explore the relationship between antibiotic concentrations in wastewater before wastewater treatment and quantities of antibiotics used in the rural hospital, over a period of one year in 2013. Water samples were collected using continuous sampling for 24 h in the last week of every month. The data on quantities of antibiotics delivered to all inpatient wards were collected from the Pharmacy department in the rural hospital. Solid-phase extraction and high performance liquid chromatography-tandem mass spectrometry were used for chemical analysis. Significant concentrations of antibiotics were present in the wastewater both before and after wastewater treatment of both the rural and the urban hospital. Ciprofloxacin was detected at the highest concentrations in the rural hospital’s wastewater (before treatment: mean = 42.8 µg/L; after treatment: mean = 21.5 µg/L). Metronidazole was detected at the highest concentrations in the urban hospital’s wastewater (before treatment: mean = 36.5 µg/L; after treatment: mean = 14.8 µg/L). A significant correlation between antibiotic concentrations in wastewater before treatment and quantities of antibiotics used in the rural hospital was found for ciprofloxacin (r = 0.78; p = 0.01) and metronidazole (r = 0.99; p < 0.001).

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

Background The proportion of people in Vietnam who are 60 years and over has increased rapidly. The emigration of young people and impact of other socioeconomic changes leave more elderly on their own and with less family support. This study assesses the willingness to use and pay for different models of care for community-dwelling elderly in rural Vietnam. Methods In 2007, people aged 60 and older and their family representatives, living in 2,240 households, were randomly selected from the FilaBavi Demographic Surveillance Site. They were interviewed using structured questionnaires to assess dependence in activities of daily living (ADLs), willingness to use and to pay for day care centres, mobile care teams, and nursing centres. Respondent socioeconomic characteristics were extracted from the FilaBavi repeated census. Percentages of those willing to use models and the average amount (with 95% confidence intervals) they are willing to pay were estimated. Multivariate analyses were performed to measure the relationship of willingness to use services with ADL index and socioeconomic factors. Four focus group discussions were conducted to explore people's perspectives on the use of services. The first discussion group was with the elderly. The second discussion group was with their household members. Two other discussion groups included community association representatives, one at the communal level and another at the village level. Results Use of mobile team care is the most requested service. The fewest respondents intend to use a nursing centre. Households expect to use services for their elderly to a greater extent than do the elderly themselves. Willingness to use services decreases when potential fees increase. The proportion of respondents who require that services be free-of-charge is two to three times higher than the proportion willing to pay full cost. Households are willing to pay more than the elderly for day care and nursing centres. The elderly are more willing to pay for mobile teams than are their households. Age group, sex, literacy, marital status, living arrangement, living area, working status, poverty, household wealth and dependence in ADLs are factors related to willingness to use services. Conclusions Community-centric elderly care will be used and partly paid for by individuals if it is provided by the government or associations. Capacity building for health professional networks and informal caregivers is essential for developing formal care models. Additional support is needed for the most vulnerable elderly to access services.

There is a lack of knowledge on mortality and causes of death among human immunodeficiency virus (HIV)-infected patients after initiation of antiretroviral therapy (ART) in Vietnam. We investigated the mortality rate, risk factors, causes of death, and impact of enhanced adherence support on survival among 640 Vietnamese treatment-naïve HIV-infected patients receiving ART in a cluster randomized controlled trial.Patients in the intervention group received enhanced adherence from peer-supporters. Data were collected through medical records and a verbal autopsy questionnaire. We used Kaplan-Meier analysis to describe the survival trends and the Cox proportional hazard model to identify predictors of acquired immune deficiency syndrome (AIDS)-related deaths.After a median follow-up of 15.2 months, there were 60 deaths, 73% of which occurred within 6 months. The mortality rate was 7.4/100 person-y and survival probability was 91% after 1 y. There was no significant difference in mortality rate between the intervention and the control groups. At baseline, the predictive factors for AIDS-related death were age35 y, clinical stage 3 or 4, body mass index (BMI)18 kg/m(2), CD4 count100/μl, haemoglobin level100 g/l, and plasma viral load100,000 copies/ml. Tuberculosis (TB) was the most common cause of death (40%).Early deaths occurred after ART, and delay of ART caused a significant decrease in CD4 count and a high mortality. Adherence support had no impact on survival at the early stage of ART. Early ART initiation and intensive follow-up of patients during the first 6 months of ART are therefore necessary to reduce AIDS-related mortality.

Few prospective studies regarding antibiotic use for mild acute respiratory infections (ARI) have been conducted in community settings. This paper aimed to assess knowledge of children's caregivers and actual antibiotic use for children under five and to identify factors associated with antibiotic treatment for mild ARIs. Caregivers in 828 households in Bavi, Vietnam, were interviewed using a structured questionnaire assessing both knowledge and practice. Subsequently, 823 children were followed for 28 days to collect information regarding symptoms and drug use. For management of ARIs, only 13% of caregivers demonstrated correct overall knowledge in accordance with standard guidelines. The symptoms of the most recent illness were consistent with mild ARI in 79% of cases, and antibiotics were used in 71% of these. During the 28-day period, 62% of children had been given antibiotics and 63% of antibiotic courses were used for mild ARIs. One-half of the mild ARI episodes and 63% of the children with mild ARIs were treated with antibiotics. Most of the unnecessary antibiotic treatment was recommended by healthcare providers (82%). Most of the children had been administered antibiotics for common colds, although most caregivers believed that antibiotics were not required. Antibiotics were unnecessarily recommended at health facilities in the area.