situation of using clinical services and effectiveness of health care model for elderly people rely on medical facilities in binh duong

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MINISTRY OF EDUCATION AND TRAINING
HEALTH

-

MINISTRY OF

INSTITUTE OF HYGIENCE AND EPIDEMIOLOGY
----------------------------

TRAN VAN HUONG

SITUATION USING THE EXAMINATION TREATMENT SERVICE AND

EFFECTIVENESS OF HEALTH CARE MODEL FOR ELDERLY IN
BINH DUONG MEDICAL FACILITIES
Specialization: Social Hygiene and Health Organizations
Code: 62 72 01 64

MEDICAL DOCTOR THESIS ABSTRACT

HA NOI - 2012


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The work was completed at:
INSTITUE OF HYGIENE AND EPIDEMIOLOGY

Supervisor:

1. Ass. Prof. Dr. Pham Van Thao
2. Dr. Nguyen Thị Thuy Duong

Review 1:
Review 2:
Review 3:

The thesis will be presented before Institute Thesis Expertise Board, taken
place in the National Institute of Hygiene and Epidemiology
At:.....................on................/................./ 2012

Thesis can be found at:
- National Library
- Library National Institute of Hygiene and Epidemiology


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HI
HP
CBM
HC
PHC
FI
HPr
Co
HS
CBE
PCA
BP

HH
IE
CL
EL
MP
MHCM
WHO
BS
CP
SS
PCI
HS
NC
PC
UNICEF
VEA
VNCA
PH
BI
AI

LIST OF ABBREVIATIONS
Health Insurance
Hospital
Community Based Monitoring
Health care
Primary health care
Efficiency index
Health program
Collaborators

Health Services
Community-based Executive
Polyclinic area
Blood pressure
Households
Intervention Effect
Clinical
Elderly
Medical personnel
Model of health care management
The World Health Organization
The Bureau of Statistics
Census population
Secondary school
Per capita income
Health Station
National Committee
People's Committee
United Nations Children's Fund
Vietnam Elderly Association
Vietnam National Committee on Ageing
Public Health
Before intervention
After intervention


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BACKGROUND
Due to the aging process, resistance and self-adjustment of the elderly

(EL) reduced, plus the absorption of nutrients, poor energy reserves...were
these conditions that made the disease easy to generate, develop more severe.
Of EL diseases was acute exacerbation of chronic diseases, diseases of the
vast and silent making it difficult to diagnose and detect, less ability to
recover.....So, if undetected, no care and treatment positive and timely
manner can easily lead to diminished health status and mortality.
Limit the aging process and illness for EL, to extend healthy life, useful
life was the desire of thousands of people. This depended on a very important
part of prevention, health care (HC), improved resistance to the EL. Binh
Duong province in the South East region, was one of the dynamic local
economy, attracting foreign investment, the rate of urbanization, increasing
people's living conditions improved, the EL on a increase. However, in Binh
Duong so far, no studies on the status of health care needs, access to and use of
medical services by the elderly and response capabilities of medical facilities.
From the above fact, we conducted the subject to get the following objectives:
1. Describe needs, access to and use of medical services for elderly people
in Binh Duong province and ability to meet of commune health centers, 2010.
2. Assessing the effectiveness of health care model for elderly
people rely on facility health in Binh Duong province (2010-2011).
* The new contribution of the thesis:
- Described the situation demands, access to and use of clinical
services (CL) of EL in Binh Duong province. Also, evaluated the ability of
health station (HS) to meet the demand for the CL needs of the people,
including EL.
- Construction and initial evaluated the effectiveness of model " EL
health care based on facility health". After 1 year of implementing this model
in Khanh Binh commune, Tan Uyen District: CL management system for EL
to be consolidated and strengthened, EL had CL timely, periodic blood
pressure measured in commune ....Periodical examination result showed that
the EL proportion of currently infected and the incidence of severe disease

reduced than before the intervention and compared to controls. 5 operating
indicators of community-based of CL management activities and blood
pressure monitoring management were significantly higher than that in
commune control, intervention effective (IE) was from 90.5% - 787.8 %.
* Layout of the thesis: The thesis consisted of 129 pages, 4 chapters of
Introduction: 2 pages; Chapter 1 - Overview: 39 pages; Chapter 2 - Subjects and
Methods: 20 pages; Chapter 3 - The Results: 36 pages; Chapter 4 - Discussion: 29
pages; Conclusion: 2 pages; Recommendations: 1 page; 37 tables, 9 charts, 124
references, of which 107 Vietnamese documents and 17 English documents.


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Chapter 1: OVERVIEW
1.1. The situation of the elderly
1.1.1. The concept of the elderly
World Congress on EL in Vienna (Austria) 1982 regulated: citizens
60 years old or older were classified as EL. In Vietnam, the National
Assembly promulgated Ordinance EL (4/2000) and the Elderly Law
(11/2009), that ruled man from 60 years of age (irrespective of gender) was
the EL.
1.1.2. Situation of elderly people in the world
Worldwide, the proportion of EL from 8.2% in 1950 has increased 10% in
2000. 2025 will be estimated over 1 billion EL, accounting for 14% of the total
world population. And in 2045, the first time in human history, population density
in children (0-14 years) and EL will be equal, or approximately 20.4%.
1.1.3. Situation of elderly people in Vietnam
According to the results of Population Census and household 2009,
the Vietnamese EL rate was 8.9%, increased 1.5 million from the previous
10 years. As such, we are standing at the threshold of the aging population.

EL in our country unevenly distributed among regions and in rural areas EL
accounted for 77.8% of EL in the country. For every 100 old men and there
were over 140 elderly women, in particular, the higher age, the more
elderly women than men and who were more than 80 years old, the number
of elderly women over 2 times the old men.
1.2. Situation use medical services for the elderly and the ability to
meet of the commune health stations.
1.2.1. EL's health care needs were enormous, but conditions had limited support.
EL health care was prevention of premature aging, prevention and
treatment of diseases caused by old age generated by many different
measures to maintain physical strength, spirit and life of EL. CL needs were
urgent requirements of the NCT to improve health, reduce chronic diseases,
disability and death when entering old age. EL CL needs not only depended
on the subjective but also depended largely on the quality, cost and severity
of illness, distance and ability to access to the medical facilities of each EL.
1.2.2. Access to health care services of the elderly
In society, people have right to access to any health care services do so
for the most favorable. However, for EL access to health care services have
specific characteristics needed to be taken seriously: the distance and time, cost,
service quality, culture, traditions ... In addition, access to health care services
of EL was influenced by a deep belief that EL has established throughout his
life.
1.2.3. Use of health care services in the elderly


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Use of health care services was the ability to get to health facilities
with each other when people get sick. This did not only depend on the
subjective but also depended largely on the quality, price, severe of illness,

distance and accessibility of the people.
1.2.4. Ability to meet of the commune health facilities about clinical
services for the elderly
Ability to meet was the general condition, the available resources of
the health facilities that made health services to meet health care needs of
the people. Ability to meet the medical facility for health care needs
included the following contents: Health personnel (medical staff, medical
officer) based on both quantity and quality; Conditions ensure health
services: facilities...; Medical Equipment: drugs, chemicals....; Health
budgets: State budget, local budgets, sources of socialization....
Operating community-based health care (OCBHC-Community Based
Monitoring-CBM): a system was built by the Health Ministry in 1998 with
the aim of improving the management skills, planning health activities of
communal health stations, monitoring process objective support.
With many different types of health services, but communal health stations
mainly implementing national health programs (HPr) and the work of
preventive medicine, clinical ordinary activities for the people ...
1.3. Elderly health care models
1.3.1. Policy on Ageing
Being aware of the meaning and importance in EL health care as well as to
promote the role of the good traditions of our people "old prime lens life", in recent
years, the Government has issued many policies and regulations on physical
treatment regime, health care for EL(health insurance card, clinical free..).
1.3.2. Health care models for the elderly
Worldwide, there are many different models in EL health care as CL model
at home in the U.S., France, Russia ... In some other countries, state institutions
reduced 50% percent of medical expenses for EL as in Mongolia; free periodic
screening for low-income EL in North Korea. In the Philippines, Indonesia held
EL health care activities in community through the training some of the most
basic knowledge about health care for the EL volunteers in the community ...

Some EL health care models in the current period in Vietnam:
- Family Doctor model;
- Models of consulting and EL health care;
- Model of EL health care in the community;
- Models of EL health care at commune health facilities;
- Model of EL health care in the hospital;
- Models of nursing home care for EL;
- Model of private health care for EL;


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In general, the pattern was not uniform and not comprehensive, there
were many factors that hinder the resources to maintain broad and
sustainable development in communities.
Chapter 2: SUBJECTS AND METHOD
2.1. Object, place and time study
2.1.1. Subjects and study materials
- The elderly, households with EL in the study area.
- Communal health stations: materials, medical staff, the operations ...
- The legal documents, the report on EL health care.
2.1.2. Study location: The study was conducted in four communes wards of four
district/town in Binh Duong province, including An Phu - Thuan An district
(commune control), Khanh Binh - Tan Uyen district (commune intervention),
Phu Hoa - Di An district and Tan Dong Hiep - Thu Dau Mot Town.
2.1.3. Research Time: From May 4/2010 to 6/2011, including two stages:
- Cross-sectional descriptive survey, theoretical modeling: April –June/2010
- Developed and evaluated model effectiveness: July / 2010 June/2011.
2.2. Research Methods
2.2.1. Study design: cross-sectional descriptive study and research

community interventions would be based on quantitative research data.
2.2.2. Sample size and sampling techniques
* Sample size was the elderly were calculated by the formula:
p1 (1 - p1) + p2 (1 - p2)
2
n1 = n2 = Z (α, β)
(p1 - p2)2
n1, n2: as of EL in commune intervention and commune control.
Z: coefficient of reliability.
α, β: was the probability of a mistake type 1 and type 2, chose α =0.05,
β=0.2
p1, p2: rate of EL was sick for 2 weeks before the survey, before and
after intervention; p1 = 0.35 (according to a study by Tran Ngoc Tu - 2008)
p2 = 0.25 (percentage desired). Calculated out: n 1 = n2 = 328 EL, the vote
provision was 15%, so: n1 = n2 = 378, in fact, in commune intervention
survey was 382 people, in commune control was 383 people. Descriptive
studies before intervention was conducted in four communes/ wards: 382
people x 4 communes/wards =1528 people, actually 1530 people.
* Sampling Technique: Using a combination of technology targeted
sampling (selecting 4 districts/towns: Di An, Tan Uyen, Thuan An and Thu
Dau Mot), random sampling unit (choose a commune/wards in each
district /town have chosen) and random system (selected EL). Intervention


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commune in four communes/wards has been randomly chosen, selected a
commune of the 3 remaining communes as commune control.
2.2.3. The study indicators
- For the EL including: gender, population structure, per capita

income, nutrition, personal activities, mental, symptoms/illness, health
insurance, the frequency of illness, the demand for clinical and disease
prevention, nutrition needs and demand for caring spirit...access to health
facilities, health services use.
- For households including family structure, vehicle, life, spirit care
and care for EL.
- For the communal health stations including: human resources,
facilities, medical equipment, medical activities of EL. Ability to meet
medical services for EL of communal health stations.
- The indicators intervention models including:
+ 10 indicators for organizational management EL CL.
+ 5 indices of community-based executive.
2.2.4. The data collection techniques
- Interview by questionnaire.
- Medical examination for EL to determine disease status.
- The intervention community compared before and after and
comparison with control: Intervention model "health care based on medical
facilities", including the following contents:
+ To build EL health management network;
+ Develop indicators OCBHC to evaluate intervention model result;
+ Manage CL periodically for EL in the commune;
+ Manage EL blood pressure monitoring in rural areas;
+ Communication, health counseling and some other health care activities.
2.2.5. Resources took part in
- Investigators: Health staff of 4 communal health stations/wards studied.
- Medical examination for EL: Health staff of Nam Anh General
Clinic, districts and communes health centers.
- Supervisor: PhD, district health centers leaders, staff from National
Hygiene and Epidemiology Institute.
2.2.6. Moral in research

- Information collected was only for research purposes.
- With the consent of the government, local health and research subjects.
- The Board of Moral Health of Binh Duong Department of Health
and Hygiene and Epidemiology Institute accepted.
2.2.7. Limitations of the research
- New topics studied only in 4 communes / wards of four
districts/towns in Binh Duong province should not be high representative.


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- Merely studying a number of health care contents for EL, the contents of:
nutrition, nursing exercise regime...research has not been mentioned.
Chapter 3: RESULTS
3.1. Situation needs, access to and use of medical services for elderly people
and ability of commune health stations to meet the demand in Binh Duong
3.1.1. Some characteristics and living conditions of elderly people
70.5% EL in this study were women; groups from 70-79 years old
accounted for the highest percentage (52.3%), only 21.3% EL with
secondary school or higher level; 40.9% EL was widowed; 12.2% EL
remained to earn his living; only 9.6% EL was working normally ...There
were 47.3% EL to cook, only 25.4% EL self-evaluation of conditions were
adequate food, comfortable; main caregiver for EL was the daughter,
wife/husband...
3.1.2. Needs, access to and use of medical services for elderly people
3.1.2.1. Health care needs of elderly in four commune studies
Table 3.8. Distribution of the elderly under the condition
and needs treatment at health facilities
Elderly patients (n = 770)
Current status

Quantity
472

61.3

298

38.7

205

26.6

Health Station

239

31.0

314

40.8

No need to treat

Orientation for
further treatment

Mild disease
Moderate and severe

disease
Cure at home
Hospital

Current condition

%

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1.6

Of the 770 EL currently infected, 61.3% EL had a mild illness, only
38.7% moderate and severe disease. There were 40.8% needed treatment in
hospital, the remainder could be treated in health stations (31.0%) and
treatment at home (26.6%) and without treatment (1.6%).
Table 3.9. Estimated frequency of illness/person/year of EL by gender
Estimate the frequency of illness /
Total
Commune / Ward
person / year (respectively)
Elderly
research
Male (n = 452) Female (n = 1,078) (n = 1,530)
Tan Dong Hiep
1.89
2.34
2.11
An Phu
1.92

2.23
2.07
Khanh Binh
2.08
2.12
2.10
Phu Hoa
2.15
2.19
2.17
Total 4 communes /wards
2.01
2.22
2.11


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Estimates of the incidence of illness in EL commune research was
2.11 / person / year. However, the frequency of EL sick women was 2.22
times, of EL male was 2.01 times.
3.1.2.2. Accessibility of health cilities of the elderly in four commune studies.
Table 3.10. Distribution of the lderly over time access to health
facilities
Unit:Ratio%
Time at health facilities
Health facilities
Under 10’
10’-30’
31’-60’

Over 60’
Commune health centers
85.5
13.2
1.3
Private pharmacies
65.7
30.3
4.0
Private Physicians
60.5
28.5
8.1
2.9
Region General Clinic
58.2
23.5
11.7
6.6
Hospital
10.5
30.1
28.7
30.7
About time EL access to medical facilities. For communal health stations
most under 10 minutes EL approach (85.5%), while 13.2% EL reach from 10-30
minutes and only 1.3% was approached from 31-60 minutes. For private pharmacies,
private physicians and Region General Clinic, from 58.2% - 65.7% EL approached
under 10 minutes, from 23.5% - 30.3% EL reached from 10-30 minutes, from 4.0% 11.7% EL reached from 31-60 minutes, the EL remain to reach over 60 minutes.
Particularly for hospitals to reach 40.6% EL approached under 30 minutes; 28.7%

EL reached from 31-60 minutes and 30.7% EL reached over 60 minutes.
Table 3.11. The average time to reach health facilities
of the elderly by income group
Unit: minutes
Income group
Q1
Q2
Q3
Q4
Q5
Health facilities

p

n1= 34 n2= 260 n3= 1,035 n4= 196 n5 = 5
(1)
Commune health centers 15.3 (1)
14.7
11.1
10.8 8.5(1)
<0.05
Private Pharmacies
18.5
16.7
14.3
12.6
9.5
Private Physicians
15.1
15.8

11.6
12.7
11.0
Region General Clinic
16.9
14.7
15.1
11.2
9.9
Hospital
62.8 (2)
49.2
42.3
35.5 30.4(2) (2)<0.05
For the group Q1 (very poor group), the average time to reach communal
health stations, private pharmacies, private physicians and Region General
Clinic range from 15.1 to 18.5 minutes, but access to the hospital was 62.8
minutes. For the very rich group (Q5), the average access time to the hospital
30.4 minutes, to other medical facilities from 8.5 to 11.0 minutes.


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Time access to communal health stations and hospitals of the group
was 2 times Q1 versus Q5 and this difference was statistically significant with
p <0.05.
Table 3.13. Distribution of the elderly by the opinion about the first
medical facilities to reach when health care needs
Elderly (n = 1.530)
Health facilities

Quantity
%
Village health
32
2.1
Communal health stations
610
39.9
Region General Clinic
202
13.2
Hospital districts and provinces
282
18.4
State Pharmacies
88
5.8
Private pharmacies
170
11.1
Private clinics
146
9.5
When EL need clinic, 39.9% EL came to communal health stations; 18.4%
EL came to district or provincial hospital; 13.2% EL came to Region General Clinic
and 9.5% came to private clinics or to private pharmacies to buy medicine.
3.1.2.3. Use of medical services for elderly people
Table 3.15. Opinions of elderly people on why not choose commune
health stations to treat the disease
Elderly (n=1,107)

The reason
Quantity
%
Mild Disease
326
29.5
Withdrawal
163
14.7
Less interest
121
10.9
Do not trust
307
27.7
The attitude is not good
143
12.9
Like the private health sector
41
3.7
Away
6
0.6
Reviews of EL about reasons not to choose communal health stations
to have clinic when being sick, there was 29.5% EL for mild disease and
27.7% did not trust the abilityHS
Communal clinic of communal health stations. Also,
from 10.9% - 14.7% EL thought communal health stations lack of
medicine, Health staff attitude was not good and less interest in the clinic at

stations...
Hospital

Average line

Table 3.6. BLorenz chart about EL rate use Medical services is
Communal HS and Hospital by income group


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When EL had demand, 31.9% EL self-treating, 27.6% El came to health
stations and 17.7% EL to hospital. Only a small percentage of EL did not have
treatment but traditional drugs (2.2% and 6.3%). In terms of income groups,
when needed clinic, the proportion of very poor EL group (Q1) selected form
of self-treating and to stations higher than the very rich group (Q5) (44.7%
versus 5.4% and 36.4% versus 17.2%), with p<0.05. In addition, the hospital
rate of EL was much lower in group Q1 versus Q5 (0.3% versus 31.9%), with
p<0.05.
3.1.2.4. Health care costs and affordability of the elderly
Table 3.16. Medical expenses of elderly people by health services
Unit: 1,000 USD
Type of health service
Clinic costs
Average/EL/1 times
Self-treatment drug
87.3
Traditional medicine treatment
108.4
Village Health

45.7
Commune Health Station
74.6
Private Health
247.8
Clinical outpatient hospital
89.5
Clinical inpatient hospital
1315.3
Region General Clinic
145.1
Total
264.2
Clinic average cost / EL / time, the highest was inpatient hospital
clinic (over 1.3 million), followed by private health (247.8 thousand),
Region General Clinic and treatment in traditional medicine, outpatient
hospital clinic (from 89.5 to 145.1 thousand)...


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Chart 3.7. Distribution ratio the average cost/1 time clinic
compared to PCI / month of the elderly
The average of a time clinic cost compared to PCI / month of EL in
the hospital inpatient services was 9.5 times, while private health sector was
2.1 times; traditional medicine was 1.1; outpatient hospital was 0.7 times ...
especially at health stations just 0.6 times.
Table 3.18. The rate of elderly households with debt 1 month before
the survey in five income groups
Unit: Ratio%

Income group
Total
Content
Q1
Q2
Q3
Q4
Q5 (n=153
(n1=
(n2=
(n3=
(n4=
(n5 =
34)
260)
1035)
196)
5)
General debt
69.1
37.4
14.5
19.9
57.2
20.4
In that
Loans to treat
45.8 (1) 41.9
35.7
5.6 (1)

0
34.3
Loans to business
47.5
39.3
48.3
71.2
80.8
48.5
Loans for other
6.7
18.8
16.0
23.2
19.2
17.2
purposes
Compare
p1 <0.05
20.4% of EL households had loans a month before the survey. Among
them 69.1% of households in group Q1; 37.4% households in group Q2;
14.5% of households in Q3 group; 19.9% of households in group Q4 and
57.2% in Q5 group. However, the purpose of debt in each group was
different. For Q1 and Q2 groups, nearly 50% (41.9% - 45.8%) households
in the household debt used for treatment, while this rate in group Q4, Q5
was very low (5.6% and 0%). The difference between the Q1 and Q4 was
statistically significant with p<0.05.
3.1.3. Ability of the commune health center / ward to meet the medical services
Table 3.19. Indicators of health workforce by 4 commune health stations / ward
Index manpower

Commune/ward health stations
Tan
An
Khanh
Phu
Dong
Phu
Binh
Hoa

Average/
Commune


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Hiep
No. of people in commune
24,747 31,674 23,196 23,840
23,364
No. of people /1 health officer
1,178
1,204
1,105
1,254
1,198
No. of Doctor/ Health staff of HS
2/7
2/8

1/8
1/8
1.5/7.8
No. of Village Health staff
12
8
12
10
10.5
Researched in four communes on average 1198 people /1Health
officer, the highest of Phu Hoa (1254 people /1Health officer) and lowest in
Khanh Binh (1105 people /1Health officer). The communes both had doctors,
including Tan Dong Hiep and An Phu had 2 doctors. Total number of Health
officer of Health Station and Health village was from 18-21 people/commune.
Table 3.21. Budget situation of the commune health centers / wards, 2009
Commune health stations/ward
Avera
Tân Đông
An
Khánh Phú
Index
ge
Hiệp
Phú
Bình
Hịa
Average health budget /
360
345
324

321
337
station/year (million VND)
Health budget /capita /year
14,547
15,917 13,967 13,464 14,424
(VND)
Percentage distribution of commune budget (%):
71.4
67.8
79.6
74. 5
73.3
- Wages and allowances
23.6
30.3
17.6
22.1
23.4
- The health plan
5.0
1.9
2.8
3.4
3.3
- Support for local
Each commune health stations average funding was 337 million/1 year,
the highest Tan Dong Hiep (360 million) and lowest in Phu Hoa (321 million).
Health budget/person/year of the four general communes was 14,424 VND,
which was the highest of An Phu (15,917 VND) and lowest in Phu Hoa (13,464

dong).
Of the total health budget for health stations each year, an average
of 73.3% was for salaries and allowances for Health officers and 23.4% for
health programs, the rest (3.3%) was local support.
3.2. Effective of health care model for elderly people rely on health facilities
3.2.1. Comparison of some common characteristics and illness conditions of elderly
people in control commune and intervention commune before and after intervention
Table 3.27. EL rate with neurological syndrome, hearing,
speaking, limbs, before and after intervention
Commune intervention (n1=382)
Commune control (n2=383)
Symptoms of
BI (1)
AI (2)
BI (3)
AI (4)
1. Neurological symptoms: p(1,2) <0.001; p(2,4) <0.001
Conscious
85.9
95.0
Confusing
8.6
0.0

87.5
6.0

87.5
3.9

15

Other
5.5
5.0
6.5
8.6
2. Symptoms of hearing: p(1,2) >0.05; p(2,4) >0.05
Normal
84.6
78.5
86.7
79.9
Difficult
13.9
19.9
12.5
19.3
Deaf
1.5
1.6
0.8
0.8
3. Symptoms speaking: p(1,2) <0.05; p(2,4) <0.001
Clearly
86.4
92.1
71.5
68.4

Hard to hear
13.6
7.9
28.5
31.6
Dumb
0
0
0
0
4. Symptoms of limbs: p(1,2) >0.05; p(2,4) <0.05
Normal
74.3
80.6
88.0
73.9
Weak
25.4
18.6
11.7
25.8
Quadriparesis
0.3
0.8
0.3
0.3
For neurological symptoms, the EL percentage of commune
intervention in a state of consciousness at the time after intervention higher
than before intervention (95.0% versus 85.9%) and the EL rate in state of
confusion after the intervention time lower than before intervention (0%

versus 8.6%) and were statistically significant with p <0.001. In addition,
post-intervention time, the percentage of EL conscious in commune
intervention was higher than commune control with p<0.001 and confusion
EL rate in commune intervention was lower than commune control with p
<0.001. With symptoms speak, at the time after intervention, the percentage
of EL speak clearly in commune intervention was higher than commune
control (92.1% versus 68.4%) and the rate EL said unclearly in commune
intervention was lower than that in commune control (7.9% versus 31.6%),
with p <0.001...
Table 3.29. The rate of elderly cardiovascular disease, respiratory,
digestive, urinary and genital, before and after intervention
Commune
Commune control (n2=383)
Organ pathology
intervention
(n1=382)
BI (1)
AI (2)
BI (3)
AI (4)
1. Cardiovascular disease: p(1,2) >0.05; p(2,4) <0.05
No
95.3
92.1
Yes
4.7
7.9
2. Respiratory disease: p(1,2) >0.05; p(2,4) <0.05
No
89.0

84.6
Yes
11.0
15.4
3. . Digestive Diseases: p(1,2) >0.05; p(2,4) <0.05
No
88.2
83.8

92.2
7.8

86.9
13.1

86.4
13.6

77.8
22.2

85.4

77.5


16

Yes
11.8

16.2
14.6
22.5
4. Urologic disease: p(1,2) >0.05; p(2,4) <0.001
No
97.6
95.0
96.1
88.8
Yes
2.4
5.0
3.9
11.2
5. Genital disease: p(1,2) >0.05; p(2,4) <0.05
No
99.0
97.4
99.5
94.5
Yes
1.0
2.6
0.5
5.5
At post-intervention time, the percentage of EL with cardiovascular
disease, respiratory disease, digestive disease, urinary disease, genital disease in
commune intervention was less than that in commune control, with p <0.05.
Table 3.31. Current sick status of the elderly through a medical
examination, before and after intervention

Intervention
Control commune
Current disease status
commune (n1=382)
(n2=383)
BI(1)
AI (2)
BI (3)
AI (4)
1. Disease suffering: p(1,2) >0.05; p(2,4) <0.05
No
62.0
69.1
72.1
61.6
Yes
38.0
30.9
27.9
38.4
2. Disease status: p(1,2) >0.05; p(2,4) <0.01
Mild
91.1
92.9
95.8
86.4
Severe
8.9
7.1
4.2

13.6
At post-intervention time, in intervention commune the rate of
current EL with disease was lower than the control commune (30.9% versus
38.4%), the difference was statistically significant with p <0.05.
At post-intervention time, in intervention commune the rate of EL was
currently in the severity of disease was lower than that in control commune
(7.1% versus 13.6%), the difference was statistically significant with p
<0.01.
3.2.2. Assessing the effectiveness of health care model for elderly people
rely on facility health.
3.2.2.1. The health management network of the elderly in commune
health stations
Table 3.32. The situation of clinic management
for the elderly in two communes, before and after intervention
Activity

Intervention
communes
BI
AI

Primary health care Board have content Once/y
on primary health care for EL (times)
ear

Once/
month

Control communes
BI

AI

Once/year

Once/year


17

Primary health care Board received
0
Yes
0
0
reports about EL monthly
Number of time discussion among Once/
Once/
Once/
Once/
village health officers monthly (times)
month
month
month
month
The rate of Village health staff had
0
100%
0
0

health monitoring notebook for EL (%)
The rate of Village health staff had
0
100%
0
0
health monitoring for EL monthly (%)
The rate of Village health staff coming
0
100%
0
0
to EL’s home monthly (%)
Number of times health educated
7 times
0
0
0
communication for EL/year (times)
/year
Organize clinic periodically for EL in
0
Yes
0
0
HS
The rate of Village Health staff
measuring blood pressure for EL
0
100%

0
0
periodical monthly in village(%)
Number of times District Health Center
once
once
once
once
had periodical clinic for EL/year (time)
In two villages at the time before intervention, and in control
commune at post-intervention time, the management of clinic for EL was
not interested, paying attention. Specifically: The primary health care board
was not reported on EL monthly; village health officers had no Health
monitor notebook for EL, had no EL health monitoring monthly, did not
come to EL’s home every months, had no blood pressure measure
periodically every months in the village; EL was not communicated about
health care and was not examined periodically at health stations. After
implementing the commune intervention model (Khanh Binh commune),
the activities above have changed significantly compared to previous time
before the intervention and compared with controls. Monthly reports were
sent to the Commune Primary Health Care Board, 100% of Commune
Health Officers had EL Health monitoring notebook, EL health was
monitored monthly and went to EL’s home monthly, with monthly blood
pressure measure. El was communicated about health 7 times / year and
periodic medical examinations at commune health stations.
3.2.2.2. Clinic management periodically for elderly at commune health stations
Table 3:33. Clinical situation periodically for the EL
at 2 communes, before and after intervention
Intervention
Control

Activity
commune
Commune


18

BI

AI

BI

AI

Routine checkup at the commune
health station, or village
0
7times
0
0
(times/year)
The number of day had medical
specialties on tuberculosis,
0
2
0
0
ophthalmology, psychiatry...
(Day/year)

The number of days for EL had CL
on holidays during the year
0
1
0
0
(days/year
The number of days had clinic for
EL upper 90 years per year
0
1
0
0
(days/year)
The number of clinic
1
1
1
1
periodically/year for
time(6/2 time(6/ time(6/ time(6/
EL(times/year)
010)
2011)
2010)
2011)
In intervention commune in 2011, has implemented seven times
clinic periodically at commune health stations or villages; had two days
examine the specialized department of tuberculosis, ophthalmology,
psychiatry, dermatology; 1 clinic for EL on holidays, and a clinic for EL

was upper 90 years of age. Meanwhile, at control commune as well as at the
time before the intervention, there was no activity above.
Table 3:34. The situation of clinic for elderly people in two communes,
before and after intervention
Unit:%
Intervention
Control Commune
Commune
(n2=383)
Activity
(n1=382)
BI (1)
AI (2)
BI (3)
AI (4)
1. The rate of EL had clinic
and health counseling
monthly
2. The rate of RL had clinic
and health advise at
commune health station
during the year
3. The rate of EL had
sputum test during the year
4. The rate of EL had

0

67.3

0

0

35.3

100.0

31.6

34.7

3.1

15.2

1.1

1.1

1.3

1.8

0.5

0.5


19

tuberculosis treatment
during the year
5. The rate of EL had blood
pressure treatment during
0
25.7
0
0
the year
6.The rate of EL had
psychiatry treatment
1.1
1.1
0.5
0.3
during the year(%)
Comparison: p(1.1), (1.2) <0.05; p(1.2), (1.4) <0.05; p(2.1), (2.2) <0.05; p(2.2), (2.4)
<0.05
p(3.1), (3.2) <0.05; p(3.2), (3.4) <0.05; p(6.1), (6.2) <0.05; p(6.2), (6.4) <0.05
After intervention 67.4% EL in intervention commune had health
counseling and clinic monthly, these activities were taken place at both two
communes that before the intervention were not carried out. In intervention
commune, the rate of EL had clinic and advice at stations during the year, had
sputum test, blood pressure treatment at post-intervention time was higher than
before the intervention and greater than control commune, with p<0.05. The rate
in intervention commune that EL had tuberculosis treatment and mental illness
treatment was higher or the same as that at before intervention and higher control
commune, but the difference was not statistically significant with p>0.05.

Chart 3.8. Comparison of clinic management activities for elderly at the time
after intervention in intervention commune and control commune.
Results in chart 3.3 showed, at the time after the intervention, the
index rate used, the rate used enough and best used in intervention
commune were higher than the indicators in control commune.
3.2.2.3. Elderly managing blood pressure monitoring at the village


20

Chart 3.9. Comparison of blood pressure monitoring
management activities for elderly in intervention commune and control
commune at the time after intervention
Results Chart 3.4 showed, at the time after intervention, although
the rate of two communes approach was the same and were 100%, but the
rate index OMCB including available rate, used rate, the rate used enough
and the rate best use of the intervention commune (100% and 100%, 78.6%,
52.6%) was higher than control commune (the percentage of these are:
0%) .
Table 3:37. Effectiveness of some indicators of the
health care model for the elderly based on facility health
Unit:%
Intervention
Intervention
Control commune
Indicators
commune
Effect
Effect
Effect

BI
AI
BI
AI
Index
Index
- The rate of EL had clinic
and health counseling in
35.3 100 183.3 31.6 34.7
9.8
173.5
health station during the
year
-The rate of EL had sputum
3.1 15.2 390.3 1.1
1.1
0
390.3
test during the year
-The rate of using clinical
management activities for 35.1 100 184.9 31.6 34.7
9.8
175.1
EL in HS
- The rate of using enough
clinical management
45.5 87.7
92.7 40.5 41.4
12.2
90.5

activities for EL in HS
- The rate of best using
clinical management
35.1 100 184.9 31.6 34.7
9.8
175.1
activities for EL in HS


21

Effectiveness of some intervention indicators was quite high: The
index EL had clinic and counseling in HS during the year was 173.5%, the
percentage of EL had sputum test is 390.3%; the rate of using the clinic
management activities was 175.1%; the rate of using enough clinic
management activities for EL at HS was 90.5% and the rate of best use the
clinic management activities for EL was 787.8%.
Chapter 4: DISCUSSION
4.1. On the status of demand, access to and use of medical services for
elderly people and ability to meet of commune health stations in Binh
Duong Province, 2010
4.1.1. On the demand, access to and use of medical services for elderly
people in four studied communes
4.1.1.1. Regarding health care needs of elderly
EL and disease have been associated with closely. When old, defensive power
and endurance of the human against the elements and external factors as well as
inside a lot less, which is favorable for disease arise and develop. Research results
showed that the rate of infecting EL currently accounts for 50.3%, the highest of
which is accounted for 14.0% of ophthalmology disease, followed by
musculoskeletal diseases (10.8%), hypertension (9.5%), Odontological Disease

(6.7%), gastrointestinal diseases (5.6%), diabetes (4.2%), respiratory diseases (4.1
%), vestibular disorders was 3.1%...This result was lower than the general trend of
EL diseases in the country's research of Dam Huu Dac et al. 2010, of which 95.0%
Vietnam elderly had disease and mainly chronic non-contagious disease such as
osteoarthritis (40.6%), cardiology and blood pressure (45.6%), urinary disorders
(35.7%) and pulmonary chronic obstructive bronchitis (12.6%)...Model and the
causes of disease is changing rapidly that make the burden of "double disease" of EL
increasing clearly. On the one hand, EL are suffering from diseases caused by aging,
on the other hand, EL also suffer the diseases caused by lifestyle changes under the
impact of changing socio-economic as dementia and depression ...
4.1.1.2. Accessibility of health facilities of the elderly
In order to facilitate access to the medical facility, the first factor is
the mean of transport in EL family. According to our results, 69.0% of EL
households had motorbikes. On-time access to medical facilities of the EL,
for communal health stations, most of EL approach under 10 minutes
(85.5%). Thus, we can see, in Binh Duong province, most of EL did not
take much time when approaching health stations, but, when needed clinic,
only 39.9% of EL selected communal health stations. In fact, the causes
that reduced the possibility and rate of access to health care services of the
EL, apart from reasons of distance access, while other important reasons
such as facility health systems were weak, lack of medicines and equipment


22

to have clinic for EL, the burden of health care spending, health services
network for EL was weak and below the health care needs of EL...
4.1.1.3. On the use of medical services for elderly people
On the use of health services when clinic, up to 31.9% of EL usually had
self-treatment, 27.6% of EL used health stations; 17.7% of EL came to the

hospital and also a small percentage of EL rely on traditional drugs or no
treatment. Thus, still a high percentage of EL self-treatment of sickness and this
fact is making health care work for the EL is not guaranteed and illness’s EL may
be worsening, EL risk of disability is very high. The average cost of one time EL
examination was 264,200 VND. This result was double compared to 2001
according to research by Nguyen Van Tap in 28 rural communes (134,500VND).
Thus, the medical costs of EL had increased rapidly recently and this fact fully
consistent with the trend of increasing overall medical costs in the country today.
4.2. Effectiveness of model, "Health care for elderly people rely on facility health"
4.2.1. On the result of implementing the model
From the scientific basis and practice, we built models of "Health care for
elderly people rely on facility health," whose aim is to find a model for EL health
care in line with local realities, with low medical costs but bring efficiency in the
health care for the EL. The model focuses on the following activities: health
management, health care organizations, blood pressure monitoring ... because
this was the most urgent needs of the EL and to achieve the immediate goal was
to reduce the risk of disability for EL, while expanding some other
comprehensive care activities for the EL group in conditional execution. The
intervention activities were conducted in Khanh Binh, Tan Uyen commune,
intervention activities included the following contents: Enhance clinical
management capacity for EL by strengthening the clinical network for the EL;
Enhance Community-based operating (CBM) Capacity in clinic for EL through
organizing regular clinical activities for EL at commune; monitoring
management, detect blood pressure disease in the village; Carry out
communication activities and health counseling for EL; organize some social
activities for EL...
4.2.2. Assessing the effectiveness of the model
After 1 year of implementing the model, we investigated and
evaluated the effectiveness of the model compared with that before the
intervention and compared to controls:

Firstly, clinical management capacity for EL in the commune of
Khanh Binh had changed markedly. Commune primary health care Board
had improved in quantity and quality. Health sector, communism Party,
authorities, departments, branches and organizations, society and
community participated actively in health care for the EL. The participation


23

of these organizations had created conditions for EL have the opportunity
and motivation to participate more positively in social activities.
Examination result of the EL at the end of model tests showed that in
intervention commune 30.9% of EL had disease, less than control commune
with 38.4%, in addition, in the number of current EL with disease, in
intervention commune 7.1% of EL was in serious condition, while in control
commune, this rate was 13.6%, p<0.01. Thus, we can see very clearly, after the
development of the model, EL of intervention commune has made a change in
condition illness at the positive trends, the incidence and extent of EL severe
disease were reduced. Model has helped EL better awareness of the importance
of the health care.
After implementation of the model in the intervention commune
(Khanh Binh), EL clinical management activities has changed markedly
over time in intervention commune and compared with control commune.
At the time after intervention in intervention commune, monthly reports are
sent to the social primary health care Board, 100% of village health staff
had health monitoring notebook for EL, monitored the EL health monthly
and went to EL’s home every months, with periodic blood pressure
measurement in village periodic monthly. EL had health communication 7
times / year and had periodic medical examinations at communal health
stations. Meanwhile in control commune, clinical management for EL

hardly be of interest, focus, these activities above have not been
implemented, such as primary health care Board was not reported about EL
monthly; village health staff had no health monitoring notebook for EL, no
health monitoring monthly for EL, no regular blood pressure measuring; no
health care communication for EL, no routine examination for EL ... Thus,
differences in clinical management activities for EL in two communes
showed very clear about the shortcomings and limitations in the health care
sector for EL in the communal health. The cause of this condition are
primarily due to limited funding investment so limited improvement of
capacity and skills for staff, health workers, EL health care and this
impacted much the EL health care services quality. The deployment model
"health care for elderly people rely on facility health" at the commune that
made the Communism Party Committee , authorities, departments,
associations and medical staff to change the perception about health care
for EL, strengthen and further enhance responsibility in ensuring access to
health services for EL when needed.
When the clinical management activities are enhanced, the EL will have
better health care. After intervention, at intervention commune, routine
examinations were implemented 7 times in communal health stations or
village health stations; 2 day exam with specialist: ophthalmology, psychiatry,


24

dermatology; 1 clinical time on holiday; and 1clinical time for EL over 90
years old . Meanwhile, in the control commune, there were no these activities
above. In addition, at intervention commune, 67.3% of EL had clinic and
counseling monthly, 100% of EL had clinic and consulting in the year, 15.2%
of EL had sputum test, 25.7% of EL had blood pressure treatment, while in
control commune, respectively 0% , 34.7%, 1.1% and 0%. The difference was

statistically significant with p <0.05. Thus, this result was demonstrated in
commune of the model, EL has been receiving services more than the
commune not tested this model. In fact, the level of understanding of health
care and self-health care for the EL was low despite facing many health risks.
Research results of Duong Huy Oanh, Tran Thi Mai Luong (2006) showed
that most of EL did not know the symptoms of hypertension (66.5%), did not
know what caused the risk of hypertension (84.1%) or how to prevent
osteoarthritis pain (74.6%). Therefore, if EL had advice regularly and
treatment promptly, they would have good health, so that their life would
become meaningful and useful to society.
In clinical management activities for EL, we evaluate the index
OCBM (CBM). On the rate available index, the two health stations both
reach 100%, but the rate of access indicators, while in intervention
commune at post-intervention time reached 100%, the control commune is
0%. Thus, although many communal health stations have a high available
rate but the rate of approach of the EL is low or zero. This gives the status
of a lack of initiative and flexibility in health care for people in general and
in particular the elderly in healthcare facilities, especially the commune.
The cause of this situation may be due to the limited qualifications of
health staff, due to lack of resources or assigned too much work, but a very
important cause, which is awareness of the communist Party committees
government and health officials still incomplete about the meaning, role
and importance of health care for people and especially those who require
priority in which the elderly. Therefore, we should concentrate, further
strengthen communication work about health care for the communist Party
committees, authorities, agencies, branches and organizations, social
organizations, communities and all people.
In addition, in commune intervention at the time after intervention,
indicators include the rate used, rate used enough, best use rate respectively
reached 100%; 87.7% and 59.4% , while in control commune in turn are

34.7%; 41.4%; 3.6%, the difference among the rates on the statistical
significance with p<0.05. Intervention Effect (IE) of some indicators is very
high: the proportion IE of clinical and counseled EL and at health stations is
173.5% in year. The IE of EL had the sputum test is 390.3%. IE of use rate the
clinical management activities for EL at health stations is 175.1%. IE of enough


25

use rate the clinical management activities for EL at health stations is 90.5%.
IE of best use rate the clinical management activities at stations is 787.8%. All
these results are evidences of the effectiveness of the "health care for the
elderly based on facility health."
Communicate activities were also an important content to be
deployed in the model. Through communication, consultation, EL
knowledge about disease prevention has been enhanced, correctly
understand the blood pressure preventive dietary, rehydration after diarrhea,
avoiding risk factors like smoking, get right form of nursing exercise and
training responsibility for self-health care to actively come to village health
station to measure blood pressure or to go to health station if health
abnormalities. For EL, mental health care is the most important so health
care consulting services for EL to learn more about the risk of illness, injury
or disability and how to prevent. However, these services are not
commensurate with development needs and we did not have any specific
policies to guide and encourage the development of this service. EL health
care requires communication skills, geriatric professional good but the
shortage of trained manpower for providing this service has not been
overcome and poor proper attention.
CONCLUSION
1. Situation needs, access to and use of medical services for elderly people

and ability to meet of commune health centers in Binh Duong province, in
2010.
- Health care needs of elderly people in Binh Duong Province were
quite high: Estimate of the frequency of sick elderly people in the research
communes was 2.11/person/year. 50.3% of elderly people currently
infected, of which 61.3% mild disease and 38.7% moderate and severe
disease. The structure of diverse diseases, ophthalmology diseases rate is
highest (14.0%), musculoskeletal (10.8%), hypertension (9.5%),
odontology (6.7%), gastroenterology (5.6%), diabetes (4.2%) ...
- Access to health care services at the commune relatively favorable, in
particular: 85.5% of the elderly have access to health stations under 10 minutes;
from 81.7% to 89.0% of elderly access to private pharmacies, private
physicians and regional general clinics less than 30 minutes. However, only
40.6% of elderly people access to hospitals less than 30 minutes.
- When the elderly was sick, self-treatment rate was 31.9%, 27.7% of
elderly used the health stations, the rest rate is up to hospitals and other
health facilities. Health care costs an average of once for elderly is 264,200,
of which, the highest one is inpatient hospital cost (1,315,300 vnd),
followed by private health sector (274,800 vnd) and the lowest health cost
is village health cost (45,700 vnd), health stations (74,600 vnd).