Hypertension and Type 2 Diabetes in Viet Nam

Viet Nam is a low to middle-income country that is epidemiologically transitioning from acute care for communicable diseases to non-communicable chronic care13, 14.This epidemiological transition can be attributed to changes in the population, socio-demographic characteristics, and life expectancies13, 14. Hypertension has increased from 16.9% in 2001-2002 to 25.1% in 2008 and 33% in 200914. A recent meta-analysis found a pooled prevalence of hypertension of 21.9% based on research studies and 18.4% based on national surveys. This may be more accurate due to the larger sample size15.

Awareness and Treatment

The patient awareness of having hypertension is 46% to 48.4%, and only 29.6% undertook treatment16, 17.In rural districts, the level of awareness decreases to 17%, and only 6% undertook treatment18. Reasons for lack of awareness and treatment include the inadequate training of community health care workers, ineffective health dialogue, a lack of skills to communicate the diagnosis of hypertension, and poor education on hypertension among the general population18. Patient education and advocacy are recommended to increase awareness, treatment, and to encourage behavioral changes to improve the outcomes for hypertension19. A study in rural Northern Viet Nam found a 49.8% adherence to hypertension medication20.

Risk Factors

The risk factors for hypertension in Viet Nam include a sedentary lifestyle, obesity, metabolic syndrome, poor eating habits, family history, undiagnosed hypertension, and a nutrition transition19, 21, 22. Hypertension in Viet Nam has substantially increased in part due to the accelerated economic improvements, aging population, changes in diet, and urbanization14, 23.

Overweight and obesity has increased from 2.3% in 1993 to 15% in 201524. There is a low level of physical activity, a high consumption of salt, instant noodles, sugar-sweetened beverages, and a low consumption of fruit, vegetables and seafood24.

Research has demonstrated that there is a significant association between an increased time spent in green space in urban areas (, parks, gardens) and physical and mental health25. The beneficial effects of urban green spaces include improved mental health, reduced cardiovascular morbidity and mortality, obesity, and a higher risk of type 2 diabetes25. The underlying causal mechanisms that account for the health benefits of green spaces have been proposed as pathways linking greenspace to improved health including decreased air pollution, air temperature, and noise, increased physical activity, stress reduction, and social cohesion or support25.

Co-morbid Psychiatric and Substance Use Disorders and Tobacco

A study of depression among elderly diabetic patients found that 79.4% reported depressive symptoms26. The prevalence of serious depression was 28% for cancer patients27. Among chronic hepatitis B patients, 37.5% experienced symptoms of depression28. A study of industrial workers found that 38.6% reported symptoms of depression29, and a study of male casual laborers found that 25% reported depressive symptoms30. A study of the elderly in an urban area found that 66.9% reported depression31, and a study of the elderly in a rural setting showed that 26.4% were positive for depression32. A study of patients in Viet Nam, Cambodia, and Myanmar found that the prevalence for anxiety was 17% while depression was 39.1%33. Depression was greatest among patients with chronic obstructive pulmonary disease (62.1%), kidney disease (55.5%), Parkinson's disease (53.7%), and cardiovascular disease (52.6%). Anxiety was the greatest among the patients with cancer (7.8%). A related study of alcohol use in these three countries found that 9.3% of the population were problem drinkers, and that diagnoses of liver disease, gout, other musculoskeletal conditions, kidney disease, and dyslipidemia were positively associated with problem drinking34. Tobacco use prevalence was 20.7% for current tobacco smokers or smokeless tobacco users and 4.1% for daily tobacco use and problem drinking.

Alcohol consumption is on a sharp rise in Viet Nam with an increase in alcohol consumption per capita from 2003-2005 from 3.1 liters to 8.3 liters in 2015-201735. Alcohol use prevalence was 80.3% for males and 11.2% for females aged 24-69 years old, with 44% of the males engaged in heavy episodic drinking35. The WHO reported that 8.9% of males and 0.9% of females have an alcohol use disorder. In addition, 5.9% of males and 0.1% of females are alcohol dependent36.

Treatment of Hypertension in Viet Nam

The use of a pharmacological intervention where there is the use of medication to control blood pressure is typically used to treat hypertension in Viet Nam14. However, access to medication is problematic, significantly impacting treatment adherence15. The challenges to medication access include fragmentation and inconsistency when prescribing medication between different healthcare facility levels and short prescription time spans between follow-up visits to primary healthcare facilities15.Hypertension is poorly managed and treated in Viet Nam14, 15, 37.

Workforce

Research on hypertension indicates the insufficient training of community health care workers, a lack of knowledge, and the overall impact on the general population18. As a result, 70% of community health workers cannot ask the pertinent questions that need to be addressed to the patients with hypertension18.Furthermore, the barriers that the literature discusses include access to care, diagnosis, treatment, cost, education and management, a lack of knowledge about certain chronic diseases among the lower-tiered health care workers, and a lack of doctors who specialize in NCD's14, 38, 39, 40.

Integrated Healthcare in Viet Nam

There is a small body of research on integrated behavioral health in Viet Nam. The government has prioritized depression care in primary healthcare41.However, in practice, the responsive activities are limited to referrals and pharmacotherapy only. Access to evidence-based care for depression is still very limited41. Barriers to integration include the low level of knowledge of depression treatment among physicians, low resource availability in primary care, limited mental health training, and a primary care system that sets mental health apart from general services41. A collaborative care for depression program in primary care based on integrated behavioral health was found to be effective, feasible, and acceptable by providers and patients in improving depression outcomes42. A community-based depression management intervention that included psychoeducation and yoga in primary care was found to significantly improve depression43. The results of a supported self-management intervention for depression in primary care suggested that there was an improvement of depression symptoms44. The significant challenges found to implementation and sustainability included a lack of mental health providers, medical providers overburdened with medical cases, low levels of psychological mindedness among patients, and a lack of recognition of depression as a condition amenable to treatment41.

The Present Study

This review shows that behavioral factors such as poor nutrition, a lack of physical activity, tobacco smoking, alcohol abuse, untreated co-morbid psychiatric disorders, and poor medication adherence largely account for the increase of hypertension in Viet Nam. Screening for behavioral risk factors is poor, and integrated healthcare research is lacking. The current study is designed to address this gap by measuring: 1) the level of behavioral health care integration in hospital and community health centers as measured by the Practice Integration Profile45; 2) clinician ratings of the prevalence of common behavioral conditions and perceived need for a BHC in the clinic using a Provider Survey46, and 3) a patient self-report health risk assessment (HRA) for patients diagnosed with hypertension in Hanoi, Viet Nam. This study focused on three research questions: a) What is the level of behavioral health integration in primary care clinics in Viet Nam compared to the United States? b) What are the provider's perceived prevalence of behavioral problems and the need for an expert behavioral health consultant on the primary care team? and c) What are the results of a health risk assessment for patients?

Setting

This research was conducted by a doctoral student who deployed a 3-month study in Hanoi, Viet Nam, supported by the USAID Global Development Research (GDR) Scholar grant program in 2019 in partnership with Bach Mai Hospital in Hanoi. Bach Mai hospital was the only hospital in this study because the USAID GDR Scholar program was only focused on this hospital. However, Bach Mai is representative. It is one of the largest hospitals in Viet Nam, providing medical services for more than 900,000 out-patients and 100,000 in-patients each year. The departments identified within the hospital for the study include the Viet Nam National Heart Institute and Endocrinology department. The subjects included healthcare providers (, physicians and nurses), hospital leaders (., departmental heads), and patients diagnosed with hypertension and/or type 2 diabetes at the hospital. This study was approved by the Bach Mai Institute Review Board, and permission was granted to the Vietnamese and United States authors to use this research data for publication.

Subjects

The subjects included healthcare providers, hospital leaders, and the patients at Bach Mai Hospital. The providers were physicians and nurses providing care in the hospital. The leaders included the departmental heads from various departments in the hospital who were familiar with the full range of services offered in each departmental setting. The leaders were from the Viet Nam National Heart Institute and the Department of Endocrinology of Bach Mai Hospital. The patients were adults, both male and female, with diagnoses of hypertension and/or type 2 diabetes from these two departments.

Procedures

The PI's university approved the study's human subject protocols. Trained research assistants (RA) recruited the patients as they checked in for a routine medical appointment if an out-patient or by inquiring about their interest from those being seen as in-patients. The RA provided a brief description of the study, completed the consent forms, and then completed the demographic and Health Risk Assessment (HRA) forms. Each patient received a payment of $3 USD. The RA later collected the patient’s biometric data (blood pressure, blood sugar, and BMI) from their medical record. The RA also contacted staff to complete the PIP (clinic leader) or the Provider Survey (physicians and nurses, or other clinicians). The participants received an incentive payment of $10 USD.

Measures

All measures were translated to Vietnamese and back translated into English. The translations were then reviewed by the Vietnamese team and the USA team. The teams agreed that the items for all measures appeared to be face valid and applicable to the providers and patients in Viet Nam as appropriate. The Practice Integration Profile (PIP) is a 30-item, 6-point Likert scale validated measure of the degree of behavioral health integration in primary care45.The Provider Survey is a list of 23 behavioral health problems (., headache, depression) to be rated by the primary care clinicians. The clinician rates the prevalence of each symptom in practice and how often they would request a consultation with a behavioral health clinician46.The subscales for mental and behavioral health are reported based on the methodology developed by Wardell47. The study’s Health Risk Assessment is comprised of the My Own Health Report (MOHR)48. The MOHR includes seven domains: nutrition (4 items from Starting the Conversation)49, physical activity (2-items from The exercise vital sign50, risky alcohol use (1-item)51, smoking/tobacco use (3-items from the Tobacco use screener)52, anxiety and depression as measured by the PHQ-453, stress (1-item from the distress thermometer54, and sleep (3-items from the BRFSS52). The MOHR items were selected from among the validated measures by an expert consensus to screen for the most common symptom presentations in primary care48.

This study also included the following measures. The medication adherence visual analog scale (VAS) was validated against the prescription medication refills for chronic disease patients55.The Somatic Symptom Scale (SSS) is a validated 8-item version of the PHQ-15 designed to measure somatic symptom disorders56.The abbreviated PTSD Civilian Checklist is a validated 2-item version of the PTSD Checklist57. A Green Health exposure screen developed by the PI was included based on research that greater exposure to green places (., parks, gardens) is associated with improved cardio-metabolic and psychological health status58. The patient cardiometabolic health risk measures included systolic and diastolic blood pressure (SBP; DBP), HbA1c, waist circumference (WC), and BMI.

Data Analysis

Descriptive statistics were used to analyze the demographics, including the participants' income, education level, healthcare, and support. Chi-square and ANOVA were utilized to determine whether there were any significant differences between sites for the patient HRA physical health, mental health, and substance use subscales. The Provider Survey was analyzed utilizing Chi-Square tests with Monte Carlo simulations (n = 10,000 simulations) in cases where there were cell counts less than five59.Formal statistical testing cannot be completed for the PIP because most sites had only one observation. Pearson's correlation analysis was conducted for the patient-reported HRA items. Ordinary least squares Regression analyses were conducted to examine the relationship between HRA behavioral conditions and each of the biometric health risk factors(BMI, SBP, DBP, WC) while controlling for the patient demographic variables.

Level of Integrated Care

To determine the overview of the integrated care level in Viet Nam, the median of each of the six domains of the PIP survey was reported and compared to the United States. In all of the six domains measured, Bach Mai Hospital scored significantly lower than the median from the United States. The domains Services (36%), Need (30%), and Workflow (27%) were the highest, and Integration (16%), Engagement (13%), and Workspace (6%) were the lowest (see Figure 1). In addition, we compared the PIP median scores for each domain between Viet Nam and the comparable PIP data collected from Thailand60(Figure 2). The Viet Nam scores were all lower than the Thailand scores. One possible reason for this is that Thailand has many community health workers and psychiatric nursing staff working in their clinics, and Viet Nam does not.

Clinician ratings of the prevalence of behavioral conditions the need for a BHC

The provider survey (= 41) results further showed the prevalence of mental health and health behaviors in Viet Nam and the need for BHC. The results found that the top five conditions that they want behavioral health assistance with are: a) mental health disorders (50%), b) chronic insomnia (40%), c) medication non-compliance (40%), d) chronic and terminal illnesses (40%), and e) emotional symptoms (31%). The Provider Survey mean for the prevalence of mental health symptoms was 2.53 and it was 2.81 for health behavior symptoms. The mean reported that the need for a BHC was 2.70 for mental health symptoms and 2.86 for health behavior symptoms on a 4-point Likert scale, indicating a moderate need. The statistical analysis showed there to be no significant differences between the mental health and health behavior subscales (see Table 1).

Patient Demographics and Health Risk Assessment

This study also collected data from the patients to present a systematic insight into integrated behavioral health care in Viet Nam. The majority of participants were over 50 years old (85%), and most were married (76%). Nearly half of the population was retired, about one-third were fully employed, and 10% were homemakers. Most participants (65%) had graduated from high school, with only 21% having college experience. The average number of persons per household was evenly distributed. Most people had health insurance (97%), with only 3% being uninsured (see Table 2).

Table 3 shows the medical record biometrics and patient HRA descriptive results. The biometric data collected from the patient medical record showed elevated systolic and normal diastolic blood pressure for men and women and a mean BMI that falls into the obese category for men but normal weight for women. The results of the HRA for physical health items were mixed. Somatic symptoms and daytime sleepiness were in the low-risk range, but 60% of patients reported snoring. Physical activity was 176.7 minutes/week, above the target of 150 minutes/week.Weekly fast food fell into low risk, but fruit and vegetable consumption fell into high risk. Medication adherence was high (90%), and health literacy was poor. The green space ratings showed no risk for the time spent in green places, as well as the good reported access to and quality of the green spaces. The mental health measures showed no risk of depression/anxiety, a low risk of PTSD symptoms, and medium severity for stress. Binge drinking was 7% for men and 3% for women, smoking tobacco was 13% for men and 10% for women, and chewing tobacco was 3% for men and women.

Correlations among the Key Behavioral Conditions Variables

This study further explored the correlations among the key behavioral conditions variables of physical health, mental health, and substance use. The Pearson correlations showed there to be significant positive correlations between physical symptoms and all three mental health items (PHQ-4, PTSD, stress). Poor health literacy was associated with greater daytime sleepiness. Green space days were positively associated with sleep apnea, exercise, smokeless tobacco, and fast food and negatively associated with daytime sleepiness, fruit consumption, and health literacy. Green space quality was positively associated with physical activity. Binge drinking was positively associated with physical activity and tobacco smoking. Smokeless tobacco use was positively associated with fast food intake. Health literacy was positively associated with daytime sleepiness. There were significant positive correlations between most of the green space variables, between the mental health variables, and between smoking and smokeless tobacco (see Table 4).

Relationship Between HRA Behavioral Conditions and Biometric Health Risk Factors

The regression analysis of patient-reported demographic and HRA behavioral condition variables on biometric health risks (BMI, SBP, DBP, WC) showed that the significant predictors of age were BMI, having health insurance and SBP and DBP (negative), being retired, and BMI and WC, and being unemployed and DBP. The HRA variables showed that the significant predictors for sleep apnea were BMI and WC, daily vegetables and WC (negative), green space days and BMI, depression and WC, stress and BMI (negative), DBP and WC (negative), smoking and BMI (negative), smokeless tobacco and SBP (See Table 5).

Limitations

There are several limitations to this study. First, the PIP, Provider Survey, and most HRA screening measures have not been validated in Viet Nam. The PIP and HRA measures have been validated in the US, while the Provider Survey has not. There are no widely used measures of integration or provider ratings on prevalence and the need for behavioral health problems in Viet Nam, and only a few HRA screening measures have been used and validated. A review of the questionnaires with the stakeholders in Viet Nam indicated that all of the measures had good face validity. However, some items on the PIP contained terms that were not familiar to the providers. Second, this study only investigated one hospital with a small sample size, therefore the findings cannot represent other cities of Viet Nam. Another limitation is that this is a descriptive study with one sample of data collected per site. Therefore, this study cannot address changes among physicians and patients over time in a longitudinal study. Lastly, this study was a convenience sample and did not include randomization or a more rigorous research design.

Recommendations for future study include an evaluation of the translation quality and validity, and a look at the reliability of the study measures in each country. A detailed review of the study findings in each country with key stakeholders will be completed in order to identify additional strengths and areas of improvement in this project. A validation study of the PIP in Viet Nam will be completed by this research team. This study will include focus groups of leaders and clinicians to review the measures to identify clear translations versus unclear ones, and what is in need of revision or replacement.

Implications for Behavioral Health

The PIP leadership survey, clinician Provider Survey, patient self-reported Health Risk Assessment, and medical record biometrics combined provide a complete estimate of the need for integrated behavioral health care in Viet Nam based on the key stakeholders of the leadership, clinicians, and patients. These measures appear to be well-suited for applied research in resource-poor settings that require brief measures that produce actionable data. This study demonstrates the need for integrated behavioral health care in Viet Nam based on the generally low levels of integration.