AIDS lần thứ IV năm 2010

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Managers perceptions of job satisfaction in HIV prevention and

’

control in Vietnam: A qualitative study

Pham Nguyen Ha1,2, Myroslava Protsiv1, Mattias Larsson1,
Ho Thi Hien3, Daniel H. de Vries4, Anna Thorson1

1Division of International Health (IHCAR),

Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
2Department of Public Health, Hanoi Medical University, Hanoi, Vietnam
3 Department of Biostatistics and IT, Hanoi School of Public Health, Hanoi, Vietnam

4 Centre for Global Health and Inequality,
Amsterdam Institute for Social Science Research,
University of Amsterdam, Amsterdam, the Netherlands
Abstract

Background: Recent development of the HIV epidemic in Viet Nam has led to a growing need for treatment,
care and support to people living with HIV. This puts greater demands on HIV prevention and control in the
country, primarily on managers as well as employees in the sector. The study aimed to explore managers’
perceptions of job satisfaction and to gain understanding of the factors influencing job satisfaction of
employees within the contexts of HIV prevention and control in Viet Nam.

Methods: A qualitative exploratory study used data collected by IntraHealth International’s USAID-funded
Capacity Project from a human resources for health assessment in the Vietnamese HIV/AIDS sector. Data was
obtained from seven focus group discussions involving 80 participants and 15 semi-structured individual
interviews at different levels of the governmental agencies responsible for HIV in five cities and provinces in
Viet Nam. The combination of the inductive and theory-driven approach of content analysis was applied.

Open coding was used to inductively classify data into themes and data examined for regularities and
variations in relationships between and within themes.

Results: Job satisfaction of employees within HIV prevention and control was found to be affected by poor
compensation, uneven distribution of career development opportunities, lack of positive feedback and rewards,
and poor supervisory competencies. Also new factors which were not included in the original theoretical
framework were found to be specific to employment within the HIV sector. These included stigma and fears of
contracting HIV and TB. The stigma both enacted towards people living with HIV and experienced by
employees due to association with their HIV positive patients had negative impacts on their job satisfaction.
The stigma was found to contribute to added stress and high perceptions of risk of being infected by HIV.

Conclusions: Along with addressing known problems causing dissatisfaction in employees of health sector
in Viet Nam, there is a need for stigma-reduction intervention aimed at employees in HIV areas involving both
their families and their colleagues. Efforts of agencies and health facilities should be targeted at managing
work-related stress, and improving work safety.

Keywords: HIV, AIDS, job satisfaction, motivation, health workers, Viet Nam, stigma 
Background

One of the crucial requirements for a functioning health system is the availability of a qualified and
motivated workforce. Shortage of human resources has been often cited as a major barrier for implementing
scale-up for HIV and AIDS services in low- and middle-income countries [1] [2] [3]. Years of under-investment
in human resource development, combined with restrictive employment policies and fragmented, time
consuming and ineffective human resource management systems, have resulted in health staff being underpaid
and unskilled to deliver new health services (such as antiretroviral therapy). They are consequently demoralized,
and unable to meet demands for even basic health services [4].

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During the period 2007-2008, international sources accounted for 90% and the Government sources almost
10% of total AIDS spending. The sustainability of the response is a significant issue as Viet Nam approaches
middle income country status and donor funding is likely to decrease. Therefore, a human resource strategy to
retain qualified staff and provide capacity building opportunities for staff at all levels, especially provincial level
is important task for the Government.

Studying job satisfaction of health staff is important because it can reveal factors causing satisfaction and
dissatisfaction, thus make recommendations to improve the staff work motivation. There have already been a
variety of studies on health workers’ job satisfaction in different settings which showed similar finding. Some
factors increasing job satisfaction were: continuous education and career advancement opportunities [7],
professional conscience and ethos [8], supportive supervision and fair performance appraisal [9]. Other factors
decreasing job satisfaction were: low income, heavy workload, and lack of recognition [10], job stress, role
conflict and ambiguity, lacks of organizational and professional commitments [11].

Besides these common factors among health workers, the studies on impacts of work with HIV patients
showed some specific effects such as more stress and burnout [12], fear of transmission [13], concerns about
becoming stigmatized [14]. However, the work to help HIV patients have stable health status, overcome the
desperation and find the fresh hope in life, also bring the employees feeling of humanitarian accomplishments
[12] and pride about their work [14].

This study aimed to explore factors causing job satisfaction of managers in particular and employees in
general within the HIV prevention and control in Vietnam, identify measures to enhancing the positive factors
and limiting the negative factors, thus improving their work motivation.

Theoretical framework

There have been several theories on job satisfaction. The Maslow’s 5-level hierarchy of needs [15] suggested
that job satisfaction depends on fulfilment of individuals’ needs, first basic needs and then higher needs of
belongingness, love, esteem and self-actualization.

The job dimensions proposed originally by Hackman and Oldham [16] are mediated by critical
psychological states and result in variations in degrees of motivation, performance, absenteeism and overall job
satisfaction.

The Motivation-Hygiene theory by Herzberg [17], suggests that job satisfaction and dissatisfaction are not

extreme points of one dimension, but rather two separate concepts. Satisfaction factors are understood as
intrinsic motivation, whereas hygiene factors are related to basic needs satisfaction.

Kudo et al. [18] focused on seven facets such as: work as a specialist, workplace safety, and relationships
with colleagues, supervisors, work-life balance, communication and salary.

According to Spector [19], job satisfaction is seen as an attitudinal concept that results from employee
cognitive processes of assessing his various aspects of the job. The theory sees the employee’s job satisfaction
as a multifaceted concept that consists of nine facets as pay, promotion, supervision, fringe benefits, contingent
rewards, operating conditions, co-workers, and the nature of the job in question and levels of communication
open to the employee.

In our study, we used the Job Satisfaction Survey (JSS) developed by Spector [20] as the theoretical
framework. As the original JSS was designed for surveys, we used its nine facets of job satisfaction as
categories and applied them to a theory-driven analysis [21].

(Figure 1 is about here)

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Study setting

The present study was part of the IntraHealth led Capacity Project Assessment of Human Resources Needs
for Management and Coordination of HIV/AIDS Prevention, Treatment, Care and Support Programs in Vietnam
[22] funded by USAID, in collaboration with Vietnam Administration of HIV/AIDS Control (VAAC).

The Capacity Project in Vietnam was conducted interfacing with different levels of the governmental
agencies for HIV prevention and control in two provinces of Quang Ninh, Khanh Hoa, and three cities of Ha
Noi, Ho Chi Minh and Can Tho. These selected provinces and cities represent the North, Central and South
parts of Vietnam and have relatively high HIV prevalence rates and large number of donor-funded projects.

Data collection

Seven focus group discussions, with a total of 80 participants and 15 semi-structured individual interviews
were conducted during February- March 2009.

The study participants were selected from the top and middle managers who have direct roles in managing
and coordinating AIDS programs within the National Committee for AIDS, Drugs, and Prostitution Prevention
and Control at three different levels: central, province and district. The participants included those from
Vietnam Administration of HIV/AIDS Control (VAAC), Provincial AIDS Centres (PAC), local authorities, the
police, social workers, representatives of civil organizations, and other partners who share responsibility for
implementing the HIV/AIDS prevention and control in Vietnam. The groups were diverse in terms of
participants’ different experiences of direct contact with PLWH in everyday practice. For example, health
workers in hospitals would have contacts with PLWH routinely while representatives of central institutions
would have hardly any contact with PLWH in their work. Consequently, it was decided gather these diverse
groups under the term “employees in HIV prevention and control”. Because the number of issues to cover was
numerous and complex, each focus group discussion had two meetings in two days, each lasted for
approximately 2.5 hours.

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Two professional facilitators and two secretaries were engaged in data collection in interviews held at all
sites. The interviews and group discussions were tape recorded and, in addition, written notes were taken by the
secretaries. After each discussion and interview, the secretary and the facilitator listened to the tapes and
expanded and/or corrected the notes. Thereafter, the notes were translated into English.

Data analysis

Collected data was coded and analyzed in NVivo 8 software [23] for data coding, creating nodes and
organizing them in node-trees.

The study applied Spector’s theory of job satisfaction [19] to the theory-driven content analysis [21]. This
means that data was coded according to a prior established list of nine categories. Simultaneously, we applied
data-driven coding in order not to avoid the possibility of missing some important context-related factors that

could not be accounted for in the original theory. It was achieved practically by detecting meaningful parts in
the text, labelling them and coding these according to the content of the information it contains. Hence, the
approach to data coding combined deductive and inductive techniques as described by Miles and Huberman
[24] and Fereday and Muir-Cochrane [25].

Trustworthiness

We used the analyses criteria of Dahlgren et al. [26] to ensure study trustworthiness. Credibility was
established thorough the inter-coder check, which meant comparing the coding in Vietnamese performed by the
first author and coding into English by the second author. Preliminary results were also checked in a similar
fashion. Transferability was achieved by detailed descriptions about study setting, participant selection, data
collection and data analysis. Dependability was gained through the description of data analysis and the
application of theory-driven coding. The study findings are illustrated with quotations from interviews and focus
groups to help illustrate the main points being made.

Triangulation

Triangulation was performed by applying different data collection methods, considering findings in relation
to documents and reports on similar issues and taking into consideration the possible different investigators’
perspectives in the research team.

Using data collected via both interview and focus group discussions helped ensure triangulation of data
collection methods. Triangulation of findings was achieved through comparing the findings with technical
reports like the Vietnam’s fourth country progress report on following up on the declaration of commitment on
HIV/AIDS [27], health financing in Viet Nam [28], and human resources for health in Vietnam [29].

The collaboration of researchers engaged with the current study with different backgrounds ensured to a
certain extent triangulation of researchers’ perspectives.

Ethical considerations

Informed consent by oral agreements was received from all respondents before interviews and focus groups
before data collection proceeded.

Results

In the process of analysis, the different aspects of “job” as described by participants were grouped into the 9
categories corresponding to the facets of job satisfaction, while the categories altogether constituted an overall
assessment of employees’ job satisfaction.

We generated six themes related to job satisfaction of employees of HIV prevention and control as presented
in Table 1.

(Table 1 is about here)

Table 1. Themes and their relations to categories and subcategories

Themes Categories Sub-categories

Unsatisfactory

compensation Pay Limited opportunities for additional income generation;Unsatisfactory salaries;
Fringe benefits Uneven distribution of benefits

Work hazards Risk of being infected with HIV or TB
Lack of positive

feedback, reward and
appreciation

Supervision Lack of positive feedback from supervisors;

Contingent rewards Rewards tied to annual appraisal: weak and poorly implemented;
Communication Outdated and inefficient ways of communication;
Uneven distribution

of career
advancement
opportunities across
levels and provinces

Career opportunities Uneven distribution of job opportunities;

Fringe benefits Uneven distribution of training opportunities;
Lack of management

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supervisors Communication Outdated and inefficient ways of communication;
Contingent rewards Rewards tied to annual appraisal: weak and poorly implemented;
Fear of contracting

HIV and avoidance of
direct contact with

PLWH

Stigma Negative attitudes towards key populations at risk in the society;
Stigmatization of HIV+ patients by employees;

Stigmatization of employees by association with their HIV+ patients;
Working hazards Perceived risk of being infected through contact with HIV+ patients;

Work-related stress;
Increasing work load
Stigma

One of the most important factors contributing to the staff dissatisfaction was stigma.

The employees share popular attitudes towards the HIV key populations of high risk and therefore resist
having direct contact with HIV patients at work wherever possible.

“The biggest constraint from HIV/AIDS control and prevention is that staff may not want to have direct
contacts with HIV affected people. /…/ you see, most of the people living with HIV now have some relations
with social evils. Therefore the others still feel quite reluctant to contact directly/.../”

Interview participant, Hanoi

The other factor as high perception of risk of HIV infection emerges while discussing characteristics of the
work within HIV prevention and control.

“For those who work on the area of HIV, there are very typical constraints and problems, e.g. the risks of
infections, working with patients who have ulcerated bodies, and very low incentives.”

Interview participant, Hanoi

Due to the concentrated pattern of the HIV epidemic in Viet Nam, HIV patients are mostly coming from key
populations like IDUs and SWs. These groups are highly stigmatized in the society and the behaviours have
officially earlier been referred to as “social evils”.

“In Quang Ninh province, the HIV prevalence rate due to drug injection is very high. Hence, many people
still see HIV as a social evil. This perception is very hard to change.”

Interview participant, Quang Ninh

The common attitude to PLWH is that they are harmful to the society and that they have deserved their
condition for practicing unacceptable behaviours and therefore it’s not worthwhile to treat them.

“HIV patients always engage in activities that damage the order of the societies, so there are series of
prejudices which consider that it is not a normal disease and that people deserve to get that disease, and it is
not worth curing them.”

Focus group participant, Ho Chi Minh City

Moreover, PLWH tends to be avoided as well as the health facilities that they are using.

“I have observed such cases: in the clinic of the district 4, there is X-ray, TB, and venereal sections, and we
offer x-ray for HIV patients. One patient showed up in X-ray section, saw “HIV” and left immediately. We
asked why, she said: “If the neighbours see me in that area, they may think I am same as HIV people. I will go
to other place to have X-ray.”

Focus group participant, Ho Chi Minh City

The employees are associated with the patients they are treating; hence there is a great deal of prejudice from
their colleagues in the other domains of the health sector.

One participant: Due to the prejudice toward patients, there is also prejudice towards the health workers
who care for HIV patients. I even said to the Board of Directors did it mean we are treating patients so we
should be put in the same group with them.

Other participant: I agree with you. Doctors who are assigned treating HIV are also considered as lower
graded than doctors in other departments”

Focus group participants 07 and 02, Ho Chi Minh City

Yet another issue is attitudes of the family members of the people employed within HIV sector, which are
often negative and they try to convince the workers to quit their dangerous job.

“Some people are not keen on working with HIV affected people, because their families, i.e. their husbands
or children, want them to leave that job, and it may not be their own decision.“

Interview participant, Hanoi

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Work hazards

The risk of getting infected with HIV or TB while performing work tasks was discussed as one of the
concerns of health staff. However, the discussion about these work hazards concentrated mostly on the fact that
in view of the dangerous nature of the job, the health employees directly exposed deserve better compensation.

“Our staff does counselling and make contact with HIV affected people, but they don’t have any allowance.
In prison No. 1, prisoners designated HIV+ are numerous. Many of our staff also gets infected with
tuberculosis. We have proposed that doctors and nurses who work directly with these prisoners should be given
some incentives.”

Focus group participant, Hanoi

The participants talked about monetary incentives with respect to high risk, whereas the issue of work safety
was not brought up.

On the other hand, currently there is no clear understanding of policies about occupational accidents
involving the health staff. They report to be highly concerned about whether getting infected with HIV at work
would be compensated.

“They are most afraid of being infected by the disease. At the moment, there have been no regulations on the
benefits for the staff that are infected by HIV. They don’t know whether they will receive compensation for
occupational accidents.”

Interview participant Quang Ninh

The risk-perception of being infected with HIV at work is still high for some of the employees, especially in
those that probably have had less contact with HIV patients and less experience, for example among young
professionals

“Because they are afraid of the danger that the job may bring, especially for the young people, they may be
the most frightened. But if working for a long time, they may feel they like the work and become attached to it.
The difficult thing is to make people love this job. It is not only the issue of money”

Interview participant, Khanh Hoa
Or employees in rural areas:

“The reason why people leave HIV/AIDS is their lack of knowledge, or fear of being infected with HIV, or
the fear of contracting tuberculosis from AIDS patients. Nowadays, especially in the countryside, people are
still scared and try to be away from patients.”

Focus group participant, District health centre in Ho Chi Minh City

By contrast other employees realize that the risk of HIV infection is exaggerated. The risk of getting TB, on
the other hand, is seen as a more serious threat.

The participants communicated that their work can be very stressful. Moreover, the level of stress becomes
higher due to the worries about HIV infection and TB and dealing with “special patients” that are stigmatized in
the society.

“The general situation of preventive health care is that it is very difficult to recruit staff. There are not any
doctors who are willing to move to preventive care because the work is very stressful, very time consuming and
salaries and benefits are low. /…/ moreover, in HIV/AIDS they have to deal with special patients. Carrying out
ARV treatment for patients at the last stage of AIDS whose health has decreased to a major extent is very
stressful. There are also many patients with TB, and with TB and AIDS together. And they also face stigma”.

Focus group participant, Ho Chi Minh City

Hence, the work-related stress for staff within HIV prevention and control is reported rather high due to the
stress resulting from worries about the risk of exposure to HIV and TB through contact with patients and the
caring for PLWH that are viewed as “special patients” because of stigma in the society.

There were concerns expressed about the increasing workload within the HIV sector due to growing number
of newly infected cases and therefore an increasing demand for HIV treatment, care and support.

“We lack staff and cannot recruit doctors and nurses. Newly recruited staff stayed with us for a few days
then moved to other departments, or to other hospitals where working conditions are better, less infection and
less stressful./…/ the workload increases but support structures remain the same.”

Focus group participant, Ho Chi Minh City

The increasing workload puts higher demands on the staff, which results in a high staff turnover, and vice
versa the high turnover rate increases the overloading of remaining staff.

“I know the need for staff but still haven’t done anything./.../ I have just recently totalled up the number of
infected patients, newly infected patients and I know that ARV treatment will have to expand to cover about
1,000 or 1,100 patients next year. Still, the number of staff is unchanged. Staff is complaining a lot about this.”

Interview participant, Ho Chi Minh City

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“A lot of the dispensers are overworked, contributing to the high staff turnover. Workload management is a
problem, and it is hard to keep staff well motivated in the bigger hospitals than in the smaller clinics.”

Interview with an expert in pharmaceuticals

A feeling of being overloaded at work is a factor known to influence one’s attitude towards job. However in
our findings, the dissatisfaction of the employees with growing overload could be further increased by the
feeling that no effort is done from the management side to improve the situation.

Pay

The study participants reported that employees in the HIV area are generally dissatisfied with the levels of
salary which they receive. The level of pay is very low and can therefore not meet the needs of the staff to make
sufficient income to support both themselves and their families. This could be a reason for many leaving their
healthcare jobs. As a focus group participant at the central level noted:

“They left because the salary was not enough for living. I can still sit here because I can rely on my
husband. My own salary is not enough to buy medicine for us“

Focus group participant, VAAC

Managers were convinced that current levels of pay are not able to attract new personnel to the HIV
prevention and control sectors.

“Let’s face it; I am a specialist with 20 years of experience in HIV and AIDS. My total income is VND 3.9
million, which is the highest in the Centre. So how can we attract people? I do this job as I believe this is my
karma. If I worked outside, in an NGO, I would earn a dozen of million dong a month easily. The new
graduates, who would dare to follow us?”

Interview participant, Can Tho

The current level of salaries of employees in the HIV prevention sector is perceived as insufficient to satisfy
basic living needs. Therefore, the staff is forced to look for alternative ways of making their income.

The additional income generating opportunities, which are common in the rest of the health sector like
organizing private practices, are however not possible for employees in the HIV prevention and control because
normal patients are reluctant to go to see the doctors who are working in that healthcare domain.

“/…/doctors working on HIV/AIDS cannot have clients if they work part-time in the private sector. So how
can they support their family? Thus, it’s very hard to carry on the profession.”

Focus group participant, Quang Ninh

Also services provided to HIV-patients are considered to be potentially unprofitable to include them in the
range of services provided by private health facilities.

“Because it is difficult to privatize health care services for HIV prevention, since the low, or non-profitable,
nature of these services cannot attract the private sector. Thus, the staff working on HIV doesn’t have many
opportunities to improve their income.”

Interview participant, Hanoi

The inability to have private practice and get payments from the patients does not only restrict the
employees’ chances to make income, but also brings frustration. Limited opportunities for income generation
further complicate the healthcare employees’ situation about adequate compensation and therefore cause
dissatisfaction with pay and this appeared to be the major factor that contributes to overall job dissatisfaction.

Career opportunities

Taking into account that the availability of jobs was brought up by the participants from the two big cities,
while there were nothing mentioned on the matter from other sites, which means that there are less opportunities
at lower levels of the health sector such as in districts and communes, as well as in rural areas, compared to
urban settings.

The following quotations illustrate the uneven distribution of job opportunities across the various levels of
the health sector in Viet Nam.

"At the commune level, where people have low skills, there is no opportunity for career advancement. At the
district level, there is some chance of getting promoted e.g. to a provincial hospital. At the province level,
however, there are more opportunities for advancement. And at the central level, there are lots of opportunities
for training, involvement in donor programs, etc. However, the opportunities are pretty much in the big cities,
whereas there’s little opportunity for advancement for those in rural areas."

Interview with an expert, Policy Unit of Ministry of Health

Consequently, the employees involved in HIV prevention and control in big cities have more job
opportunities and career options, while those in the urban areas that lack of such opportunities might be
expected to feel less satisfied.

Supervision

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included decentralization of decision-making and management. The managers received the authority to
supervise people without having prior training in supervision and many areas related to management. The
limited capacity of supervisors impacts upon employees’ job satisfaction.

“/…/the main concern now is the capacity of supervisors. I am trained so the work is less difficult, but my
subordinates do not have experience in supervision because they lack training. Even medical universities do not
train on this. They assess based on their feeling so it is not as good as the ones who have gone through
training.”

Interview participant, Quang Ninh

In addition to managers’ lack of supervision capacity, other staff members have limited understandings of
supervision. Junior staff tend to be afraid of strict supervisory measures that they refer to as “inspection” and try
to resist it, while the supervisors have to rely on their own judgments about how the supervision should be done.
“People don’t understand what is meant by supervision. They view it as inspection, and get very nervous
about it – try to hide things from supervisors.”

Focus group discussion with study facilitators

The participants communicated lack of positive feedback from supervisors. Examples of this lack of positive
feedback are represented by the following two quotations:

“If our performance in this is good, nothing will happen, but in the case of performance not being so good, it
will be reflected in our evaluation.”

Participant of focus group, Ho Chi Minh City

“Yes. It will be taken into account if we fail and nobody will comment if we do it well”.

Participant of focus group, Ho Chi Minh City

The lack of positive feedback from supervisors was related by the participants to the current ineffective
system of monitoring of working tasks, which fails to record and recognize employees’ good performance and
achievements. This unsystematic way of monitoring performance is perceived as unfair and reaction to this by
interviewees may be related to dissatisfaction.

Fringe benefits

Due to the low level of wages, fringe benefits are an essential part of employees’ income, which supplements
the earning of the payroll employees. Receiving lower or no benefits is considered a major cause for
dissatisfaction in the staff. Nevertheless, the distribution of the benefits is unequal between staff categories.
Some professions, not necessarily the ones with the highest wages, are receiving small or no benefits at all.

The distribution is uneven and varies according to the level of health facility

“Allowance for workers at communes and wards are around VND 120,000 which is just enough to fill up the
gasoline tank really, thus it is hard to require them to concentrate only on work. I myself feel so sad thinking
about this. There is no insurance system for them as they are not full-time but social workers. The staff working
for provinces or districts in contrast has official payroll positions”.

Focus group participant, Can Tho
Treatment versus prevention:

“Health workers engaged in HIV work in hospitals receive an allowance of 50% [sectoral hazardous
allowance], low but something, while preventive health workers receive nothing. Preventive care is declared to
be the priority of health care, but in the case of preventive care, remuneration is considered as a minor problem
(laughed).”

Interview participant, Can Tho
And payroll versus project:

“Project staff is at a disadvantage compared to government staff working in the same OPC who also receive
a hazardous allowance equivalent to 30-45% of salary. This allowance for direct caregivers is 45percent of
salary while project staff receives only their fixed salary.”

Interview participant, Ho Chi Minh City

Training opportunities are among the top reasons for staff satisfaction. There are plenty of training

opportunities within HIV prevention and control; however they are mostly only available for middle-level staff
at provincial and central levels. The study participants recognize the importance of training for staff:

“They have more opportunities. Working on HIV means working in a rapidly changing environment.
Working here for a short period of time, your capacity will be much improved. /…/ there is a lot of
opportunities for learning, both in the country and overseas.”

Focus group participant, VAAC

The training opportunities, however, are also unevenly distributed just as the other fringe benefits.

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Interview Participant, Hanoi

Contingent rewards

Under the section of contingent rewards the annual “emulation” was discussed as the example of reward and
recognition for the staff. On the basis of annual staff appraisals, staff is often awarded with honourable titles
along with monetary rewards.

The current rewarding system was criticized for poor encouragement measures that cause dissatisfaction
among healthcare employees.

“Regarding the shortcoming in division of work, the ones who are productive are usually assigned more
work; whilst the ones who are useless are assigned less. But the salary payments are the same. The assessment
of work for promotion and awards is also unfair because the one who does a lot of work may make more
mistakes so he is ranked average while another who does less work makes fewer mistakes and thus is ranked
excellent.”

Focus group participant, district health centre in Ho Chi Minh City

Being awarded with an emulation title was considered important for several reasons. First of all it is very
honourable to receive emulation title like “The best staff member”.

“For example, if they work well on treatment for HIV patients, the city may give them a reward, possibly in
cash. There are also many honourable titles to be awarded, for example, fighter for emulation, or excellent
cooperatives in emulation, etc.”

Interview participant, Hanoi

Emulation titles also can be viewed as quite positive experience for the employee, which comes along with
monetary reward as well as a demonstration of recognition from society.

“I myself am keen on this work because it is relevant to my expertise and interest. Many people work
because of their love and responsibility to the work. In addition, your work is also compensated and respected
by the others.”

Interview participant, Khanh Hoa

The second reason why the emulation award is perceived important is that it gives a possibility to be
recognized by the management, which later might lead to promotion.

Overall, it was concluded that employees value rewards in terms of monetary benefits as well as recognition
from society. Nonetheless, the system of monitoring staff performance, which serves as a basis for distributing
awards, was assessed by employees as unfair. For job satisfaction, it means that rewards and recognition are
positively influencing attitude about one’s job; however, the inconsistent implementation of delivering annual
awards on the other hand is a reason for employees to be dissatisfied.

Operating procedures

Among the most important personnel policies, the one on hazard allowance and recruitment policy were

discussed. The policy on hazard allowance, which grants to the medical staff that has risks associated with
exposure to HIV through direct contact with blood, benefit in size of 30 percent to 50 percent of the salary, was
criticized for being inconsistent and for excluding some categories of staff.

“/…/But when I visited prisons and orphanage centres, I found that the staff working there did not have any
allowance. So I think that the policy should be consistently applied to all staff whose work is related to HIV
healthcare. In reality, I have seen that some people who do not directly work on HIV are still entitled to that
allowance. So it is very important to ensure that staff having direct contacts with HIV-affected people benefit
from good policies.”

Interview participant, Hanoi

If the applied policy is excluding some part of the staff within one organization, it may be seen as unfair
from the point of view of the excluded staff, while managers can take decisions to restore fairness by dividing
available benefits.

Nature of work

The staff liked to perform their work tasks because of the humanitarian nature of work

“Most people working on HIV/AIDS are dedicated to the social development and human values, so they are
happy to carry out these activities/…/”

Focus group participant, Ho Chi Minh City
And their sympathy and willingness to help:

“After some time of working here, I also have found something interesting. I also feel sympathetic towards
the patients, if you think they are your relatives, you will have more sympathy.”

Focus group participant, District Health centre in Ho Chi Minh City

Doing this job was related to higher morale and awareness of doing well among the staff.

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work and the earning of respect from others.

“We love our job, and we devote our efforts to work to gain effective outputs. Some external organizations
have offered me a job with good salary which is good for my family, but that job cannot contribute as much as
the current one. Here my work will have broader influence/…/.”

Focus group participant, VAAC

Communication

The current modes of communication in the organization were discussed in terms of being outdated,
insufficient and time-consuming, but still widely applied.

Managers recognized that due to the growing workload they are unable to visit numerous meetings, which is
affecting their subordinates as they reported missing information.

Question: Leaders may have different ways of working. Your boss doesn’t go regularly to meetings, possibly
due to his desire of empowerment or due to his extremely busy agenda?

“He is too busy. If he was less busy, he just would have to reserve 5 minutes for a dialogue, and it would be
very quick. Dialogues before giving any task would be helpful, and there would not be any need of revision or
modification for several times during the implementation. But the boss is too busy.”

Participant of focus group, VAAC

The capacity of using IT for communication is still limited and uptake of these new technologies is a slow
process.

“If there is anything that requires my contribution, it can be sent to me using the internet and I can then give
my comments. However, may be because the ability in organization, administration is still limited in many units,
so many tasks cannot be done using the internet.”

Interview participant, Ho Chi Minh City

Overall, the employees perceive themselves as poorly informed, which could be seen as one of the causes for
dissatisfaction.

Discussion

We indentified the following themes that cause HIV healthcare employees’ job dissatisfaction. These were
poor compensation, unevenly distributed career and training opportunities, lack of positive feedback and
rewards, and lack of competencies in staff management and supervision in managers. We also detected two
additional themes which are specific for the work in HIV prevention and control: Fear of contracting HIV and
TB; and avoidance of direct contact with PLWH, which suggested that employees were influenced by stigma in
their work, both of the perceived and enacted kinds. The presence of these themes related to fear of contracting
HIV and TB and stigma might suggest that the work within HIV prevention and control may be different from
how employees experience their employment in the rest of the health sector.

Therefore, in this Discussion part, we want to focus on some specific factors which affect the job satisfaction
of employees within HIV area.

Low pay

Low salary is the main factor which affect the work motivation of the employees. This factor has been
mentioned in many different studies on motivation of health staff in many countries as well as in Vietnam. In
this study we found that the differences of salaries between the government staff and contracted staff in donor
funded project lead to inconvenient comparisons. Working as government staff gives the feeling of stable jobs

but salaries are lower than the ones as contracted by the projects. The Vietnam’s UNGASS 2010 [5] has pointed
out that “ HIV treatment and care services rely on a large number of contract health workers. The majority of
these positions are funded by projects” which shows a concern on the sustainability of the future national
response to HIV. Due to the needs of speeding up the implementation, the donor projects try to attract qualified
staff with competitive salaries and pay the allowances for government staff working in these projects. These
trends are difficult to change and are considered as short term solutions. However, long term and sustainable
solutions in regards to human resources and their salaries need to be identified.

NEGATIVE ATTITUDES TOWARDS KEY POPULATION AT RISKS IN THE SOCIETY

The stigma on HIV patients especially the IDUs have been addressed in many previous studies. This leads to
the decrease of the work motivation of the employees within HIV area. Actually, the IDUs cum HIV patients
are often the ones who commit crimes in order to get money for purchasing drugs. Therefore, increased drug
rehabilitation for IDUs with different methods, enhanced implementation of methadone substitution, creating
more jobs for them, will lead to improving the society’s stability feeling. This will also improve the motivation
of the employees working in HIV area.

The study of perspectives of HIV-related stigma in a community in Vietnam [30], described exactly the same
perceptions of the PLWH. Therefore, we concluded that those attitudes are very common in the Vietnamese
context and are shared by many people, including staff in HIV prevention and control.

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previous studies in other countries as well as in Vietnam. The stigma affects negatively on the employees and
their families members. This affects the employee’s motivation and their work pride. The employees work more
effectively only when they proud of their works.

Stigmatization of HIV-patients by employees

In this study, we found that stigma towards the risk-groups is manifested as resistance of staff to have direct
contact with HIV-patients. These staff are influenced by the common negative attitudes to the IDUs and SWs
because they are “not immune to the prejudice in society”[14].

Concerning the reasons behind this reluctance, fear of transmission of HIV is likely a contributing factor,
which was further supported by empirical evidence from quantitative [31] [32] and qualitative research [33].

In our study, we found that resistance to having direct contact with HIV patients, especially in younger
employees, was possibly due to lack of experience.

Further, stigma and avoidance is found to result in sub-standard care or even refusal of health services. This
might not affect the staff directly, but the example of an indirect effect could be a feeling of guilt because the
HIV patients were neglected and rejected by their colleagues trying to avoid contact with HIV patients.

Stigmatization of employees by association with their HIV+ patients

In the current study we found that staff of HIV prevention and control were exposed to stigma due to
association with PLWH from their colleagues and to some extent from society. Taking into account the social
role of a doctor in Vietnamese culture, which is regarded as a very respectful and honourable profession, we
could make a hypothesis that stigmatization of the staff by association with PLWH can have a very negative
impact on the staff ’s view on their job and profession.

Another finding is the negative view of staff family members on the jobs in HIV prevention and control.
Similar findings were cited in the literature review [14].

Risk of contracting HIV and TB

This study identified the employees’ concerns on risks of contracting HIV or TB. These concerns might be
overestimated. However, our study showed that risks are serious in certain settings such as in prisons or in the
centres 05, 06 for rehabilitation of drug users and female sex workers where substantial numbers of HIV
patients live in a crowded and close settings. According to Vietnam’s UNGASS report 2010 [5] that “05/06
Centres often lack both facility-based services and continuum-of-care to link drug users to community-based
HIV treatment, care and support services” and that “ART is not available in any prisons and only a few are

providing TB treatment”. The study participants have mentioned the serious risks of contracting TB in the
prisons and these centres. These risks become more serious when there is new type and antibiotic resistant TB
available in Vietnam.

The study participants perceived the risk of contracting HIV as a considerable threat and, hence, any work
with HIV patients is dangerous. Some participants mentioned HIV as a serious occupational hazard, while
others recognized risk of exposure to TB as a more potent threat. Fears of HIV were resulting in stress and
higher perception of occupational risk. These fears were showed in the extensive literature review by Horsman
and Sheeran [14] and Barbour [34].

Going back to our finding about HIV work hazards, we wonder whether in our findings the perception of the
job as being dangerous and of high risk of contracting HIV and TB was found rather high due to compromised
work safety measures. Li et al. [31] argues that with better access to preventive measures such as better
availability of gloves, sufficient health insurance and access to training about work safety, employees would
perceive themselves as better protected and more comfortable with their work.

Training opportunities

Training opportunities are the most appreciated positive factors on the staff motivation. Due to the
substantial international financial resources and technical assistance, there are many training opportunities for
the staff working in HIV. With the knowledge and skills gained from these training, the staff have more chances
to apply for the new jobs with higher salaries in donor projects. However, most of the training courses are short
term and focus more on project implementation skills. Therefore, the long term training on HIV and AIDS at
medical universities is necessary to have a sustainable human resource with comprehensive knowledge on HIV
prevention and control.

Humanitarian and morale significances of the HIV work

Most of the Vietnamese people practice ancestor worships and strongly affected by Buddhism philosophy
that doing humanitarian activities will bring the happiness to them and their families. Being influenced by this

belief, many employees within HIV area feel that they are doing humanitarian and morale works with HIV
patients . This work brings their job satisfaction and leads to the sympathy in the society towards PLWH,
reducing the stigma and discrimination. This also enhance the staff work motivation.

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working tasks because of the humanitarian nature of work, sympathy, their eagerness to help as well as they
found their encouragement in the meaningful tasks. This finding is supported by other studies on positive
feelings of health workers related to HIV care is likely related to an ability to help and provide non-judgmental
care to stigmatized people [14, 35]. The study findings also suggest that recognition from patients as well as
the support and positive feedback from supervisors is extremely important to reduce burnout and attrition of the
staff.

Conclusions

Job satisfaction of employees within HIV prevention and control in Viet Nam is influenced by both
commonly known factors within health sector, which were initially included into the JSS and some specific
factors for HIV such as stigma and fear of contracting HIV and TB.

The known factors are: unsatisfactory compensation; uneven distribution of career development
opportunities; lack of positive feedback, reward and appreciation as well as lack of management competency in
supervisors. The impact of stigma toward PLWH from employees’ families, colleagues and society, on
employee’s job satisfaction, was confirmed in our study. In practice, stigma reduction should therefore be
targeted at staff members, their families and colleagues. Results of the study also suggest the need to improve
working conditions within HIV prevention and control in order to reduce the fears of infections and
work-related stress.

(Figure 2 is about here)

Methodological Considerations

In our study we explored managers’ perceptions of employee’s jobs satisfaction, which could be viewed as a

proxy-measure of job satisfaction of their subordinates. However, we should recognise that managers
themselves are employees within HIV prevention and control.

The theory-driven method of data coding has the risk of trying to “fit” the data into categories. However, we
believe that this was overcome to some extent by combining theory-driven coding with data driven coding
approaches and by establishing a strategy of recognizing facets of job satisfaction in the data. In a process of
data analysis, we faced challenges related to the work with translated material. There was a great risk for
misunderstanding and misinterpreting data. We tried to address these issues by comparing the data coding with
Vietnamese coding, and also compared preliminary findings in this language and double checked for more
accurate translation of the quotations used for the reporting of the findings.

List of abbreviations

AIDS Acquired immunodeficiency syndrome

HIV Human immunodeficiency virus

IDU Injecting drug user

JSS Job satisfaction survey

MSM Men who have sex with men

PAC Provincial AIDS centre

PLWH People living with HIV

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TB Tuberculosis

VAAC Viet Nam Administration of HIV/AIDS control

Competing interests

The author(s) declare that they have no competing interests.

Authors' contributions

PNH and AT designed the study. PNH conducted data collection, coding, data analysis and drafted the
manuscript. MP conducted data analysis and drafted the manuscript. AT and ML revised the paper critically for
substantial intellectual content. DV and HTH participated in study design and coding. All authors commented
critically on the drafts and approved the final manuscript.

Acknowledgements

The study uses the data collected by IntraHealth led Capacity Project Assessment of Human Resources
Needs for Management and Coordination of HIV/AIDS Prevention, Treatment, Care and Support Programs in
Viet Nam (The Capacity Project, 2010) by USAID in collaboration with Viet Nam Administration of
HIV/AIDS Control (VAAC).

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A NEEDS ASSESSMENT OF PLHA SELF-HELP AND SUPPORTED GROUPS (SSGS)

IN VIETNAM

Nguyen Nguyen Nhu Trang, Nguyen Duy Tung
Tran Lan Anh, Luong Thi Tinh

Ngo Tri Tue , Ngo Thi Thu Thuy, Dong Duc Thanh
Center of Promotion for Quality of Life, Ho Chi Minh City, Vietnam

Health Policy Initiative Vietnam, Abt Associates Inc., Hanoi, Vietnam
 Center for Community Health and Development, Hanoi, Vietnam

Vietnam 2008 UNGASS Report

HIV/AIDS Policy in Vietnam: A Civil Society Perspective.
Public Health Watch-Open Society Institute. New York : November 2007
1. Background

Self-help and supported groups for people living with HIV/AIDS have developed rapidly in Vietnam in
terms of quantity, capacity and scope and areas of work. As reported in the UNGASS 2008 report, the years
2006 – 2007 have seen a strong improvement in involvement and participation of civil society organizations in
all HIV/AIDS-related aspects including prevention, treatment, care and support, behavioral change
communication, counseling and testing, reducing stigma and discrimination, promoting harm reduction,
economic support, and improving quality of life of PLHA. To date, very few self-help and supported groups
have been legally established; which is a major barrier that prevents these groups from expanding their activities
into policy advocacy and policy development and accessing direct international funding.

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with men (MSM)), supported groups and clubs (collectively hereafter termed self-help and supported groups
[SSGs]). During April and May 2009, HPI Vietnam and two of its local partners – Centre for Community
Health and Development (COHED) and Vietnam Network of PLHA (VNP+) – conducted a mapping and
capacity building needs assessment of the SSGs in the 7 PEPFAR focus cities/provinces of Vietnam.

2. Objectives of the assessment

1)To explore and analyze SSGs’ capacity, needs and gaps in organizational development; and

2)To recommend a capacity building plan in coordination with other stakeholders of capacity building
support.

3. Study units and assessment methods
3.1 Study units

* Self-help groups: are groups that were created by its own members. These groups are managed by
themselves, through a selected management team, and thus have autonomy and decision making power over the
group’s operation and development.

* Supported groups: are groups that were established by the City/Provincial AIDS Committee (PAC), or
I/VNGOs. These groups are commonly managed by these organizations and do not have independent decision
making power.

122 active SSGs were identified in the 7 PEPFAR focus cities/provinces among the working list of 178 of
those groups compiled by HPI with support from VNP+. Province-based members of the VNP+ helped make
contact with leaders of these groups to arrange interviews.

* Leaders of active SSGs

SSGs that have been making progress towards registration or were successfully registered were identified for

in-depth interviews to learn about their experiences in obtaining their operation permits.

Leaders of the active groups were identified by the assessment team during the structured interviews and in
consultation with the local health/AIDS authorities and VNP+ members in their respective provinces.

* Capacity building partners

Agencies, e.g. UNAIDS, Pact, Care Vietnam, Institute for Social and Development Studies (ISDS) that host
Vietnam Civil Society Partnership Platform on AIDS (VCSPA) and Center for Community Enhancement and
Management (CECEM) were identified for their active contribution to providing capacity building to SSGs.

* Agencies involved in legal registration

Agencies such as the Ministry of Home Affairs (MOHA) and the Vietnam Union of Scientific and
Technology Associations (VUSTA) are the concerned agencies facilitating legal registration to form
associations and organizations by the Decree 88 and Decree 81 . The Provincial AIDS Committees/Centers or
HIV/AIDS Associations, Provincial Red Cross and other similar entities can also form groups as their
associated members.

3.2. Assessment methods

The assessment applied both quantitative and qualitative methods as follows:
* Mapping of SSGs and Clubs in the 7 PEPFAR-focus cities/provinces.
* Desk review on available legal documents for registration of SSGs.

* Structured interviews with leaders of the mapped SSGs using a semi-structured questionnaire.
* In-depth individual interviews with an interview guide:

* Leaders of the selected SSGs and Clubs and HIV/AIDS activists
* A representative from each of the registration concerned agencies

* A representative from each of the capacity building agencies

Most in-depth interviews were audio-recorded unless not permitted by the respondents. In such cases, the
assessment team took notes. Each interview was approximately 45-60 minutes long.

4. Results

1. Profiles of the participating groups: (1) Mean group life (to the time point of assessment): 38 months
(n=upload.123doc.net); (2) On average each SSG has 3 management members; and (3) 32% management
members with university or higher degree

2. Organizational development-related skills: Figures 1-3 show the skills in which SSGs reported having
been trained, those skills which they had actually applied in their work, and those skills in which they felt they
needed improvement. Nearly half of SSGs had received group management and facilitation skills but still
reported need for further training. This is because: (1)Trainings are not appropriate to groups’ current work; (2)
No refresher trainings;(3) Ongoing assistance to apply the covered skills is not available; and (4) Overlap of
trainings results in over-training or under-training for some group members (SSG management members).

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Figure 2: Project management related skills trained, applied and still needed to work better

Figure 3: Other technical skills trained, applied and still needed to work betterMost important skills needed

According to the survey, these were the three most necessary skills for groups’ development:

Self-help groups (n=65) Support groups (n=55)

Group management and facilitation: 33.8%
Proposal design: 18.5%

Communication skills: 15.4%

Care for PLHA: 29.1%

Group management and facilitation: 21.8%
Communication skills: 20%
SSGs’ Legal registration needs:

* 70 groups (57%) desire legal registration – some do not want the sponsorship/supervision from a
government or quasi-government agency that is required.

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* 32 SSGs reported needing support with registration process.
5. Discussion

With regard to legal registration, there has been a considerable level of interest among both self-help and
supported groups in exploring registration options. However, there is a lack of information and guidance on
which options are feasible given the group’s current capacity. In response to this need, HPI and UNAIDS have
developed and are widely disseminating a handbook summarizing the requirements for legal registration under
all currently available options.

The participating groups expressed a high degree of need for group management skills and skills related to
sustainable development of the organization e.g. project design. Priority skills areas are fairly similar between
the two groups.

• Priority skills for self-help groups:
* Group management and facilitation
* Project design

* Communication skills

• Priority skills for supported groups:

* Care for PLHA

* Group management and facilitation
* Communication skills

Coordination of capacity building efforts among organizations is deemed necessary. Overlap of training
programs was reported and some group members working as peer educators were either over-trained or
under-trained.

6. Recommendations

* To provide all groups with information on the existing registration policies and advice or consultation on
registration options to groups who expressed interest and commitment to registration. Additionally, such groups
would need to receive support in organizational (and program) strategic planning.

* Capacity building should be focused on the set of skills that are considered most necessary by the groups,
as summarized above.

* Coordinate with agencies working with the same SSGs to harmonize or agree upon an improved
coordinated capacity building plan overall and/or at the provincial level.

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Improving Data Quality to Maximize Using in Program Planning

and Managing, Experience from Pact Vietnam

Thi Chu Phuc, MD, MPH, Pact Vietnam
Nathan Wilkinson, MSc, Pact Vietnam
Abstract

Monitoring and evaluation (M&E) activities crucial to program success. M&E data are used at all levels in
planning, implementing, and evaluating HIV prevention and control. Data quality is important in promoting not

only quality services but also effective program management. With PEPFAR funding from USAID, Pact
analyzed potential data quality problems and preventative measures within the HIV/AIDS programs it supports
in Viet Nam, and then implemented comprehensive remedies for narrowing gaps in data quality. A range of
measures were deployed systematically to all levels of reporting systems for all Pact partners: developing or
refining standardized, appropriate data collection tools and operations for programs; providing frequent,
intensive on-site supportive supervision; developing Indicator Protocols (IPs); implementing periodic data
audits to assess data collection, management and reporting systems; and establishing a database to coordinate,
track and manage information gathered across partners. These efforts improved data quality and facilitated
effective program planning and management. Stakeholders recognize the need for further actions to ensure data
quality and facilitate data use for evidence-based decision making.

I. Background

HIV infections in Viet Nam have been steadily increasing since the first case of HIV was detected in 1990.
In 2012 over 280,000 people are projected to be living with HIV (Ministry of Health, 2009). The Vietnamese
Government and international organizations have devoted great efforts to combating this epidemic. While
international assistance for the HIV/AIDS prevention and control in Viet Nam has significantly increased, the
management and implementation of HIV/AIDS programs in Viet Nam is still a concern, especially regarding
the effectiveness of foreign assistance and investments.2 The accuracy and the relevance of program data are
vital to quality services and effective program management.4, 5, 7 To support the efforts of the Viet Nam
Administration for AIDS Control (VAAC) and international partners in strengthening the Monitoring and
Evaluation System in Viet Nam, many M&E and data quality issues need to be solved.8 Following a review of
constraints on HIV/AIDS data quality for M&E in Viet Nam, this paper presents the measures implemented and
results achieved by Pact and 25 Pact partners in improving the quality of reported data and maximizing data use
for program management. PEPFAR funding for this work was provided by USAID. Recommendations are
proposed for future actions to strengthen the Monitoring and Evaluation System.

The HIV M&E Technical Working Group’s 2009 situation analysis of the national M&E system pointed out
many weaknesses in the M&E system in Viet Nam. There was a lack of a standard and coherent monitoring and
evaluation system for HIV/AIDS programs across the implementing agencies, particularly with regard to tools

and indicators for measuring quality of services and effectiveness of HIV/AIDS projects. A survey revealed
that, in many instances, M&E activities are built into a project just to make the project document look
“complete”; at least 50% of HIV/AIDS projects were not evaluated. Evaluation work is commonly used in
formally closing projects, rather than identifying shortcomings to improve implementation.2 Capacity of
program staff in management and supervision of program implementation is also limited, due to lack of
experience and understanding regarding evaluation methods for HIV/AIDS programs. Project monitoring is
carried out mainly through traditional methods: big folders of documents, without a good information storage
system, management or statistical work. Although projects devote large amounts of money and human resources
to implementation of project activities, the budget for M&E is negligible.

Even if managers were to develop the skills and habits to use data, evidence-based decision making is
impeded by poor-quality data that is missing, out of date or drawn from inconsistent sources. Double counting
of individuals is a common problem due to the range of services they receive via different providers.
Organizations often have not implemented systems for tracking the services they deliver, because of
fragmentation of the referral system and lack of cooperation among service providers. Surveillance data from
data triangulation groups were found to be out of date, small-scale and not nationally representative, being
unavailable for many areas outside PEPFAR focus provinces.2

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difficult to increase and sustain the quality of data for monitoring program effectiveness. Ensuring
confidentiality of client data can be a challenge due to poor storage of data or policies and procedures
implemented by the facility. The focus is mainly on the services provided and production of reports, with little
regard to controlling the quality of data for completeness, accuracy or timeliness. Quality of supervision is weak
due to lack of manuals and tools.

II. Major content: Measures implemented by Pact and Pact partners

To deploy comprehensive measures systematically across all levels of reporting systems, Pact grantees were
first requested to review their data collection, reporting and tracking systems with attention to USAID and Pact
requirements. Forms and data collection tools were revised to ensure accuracy of data collected, Standard
Operating Procedure checklists were developed for monitoring a minimum package of caregiver, peer educator

and supervisor activities, and a list of core indicators was identified for broader, intercomparable program
monitoring and learning purposes. Organizations implementing behavior change communication (BCC)
activities adopted specialized program monitoring forms with core output indicators . A standardized
information management system for home-based healthcare programs, based on Excel datasheets, was designed
to efficiently counting indicators, especially those disaggregated by HIV status, gender and age. This feeds into
a Pact database for coordinating, tracking and managing information gathered across partners and program areas
during country operational planning, reprogramming, and related processes.

Pact also addressed gaps by building M&E capacity across all partners, though two yearly training modules:
one on monitoring, evaluation and reporting skills, and the other focused mainly on developing data quality
management systems to maximize utility of the data generated. Participants received frequent, intensive on-site
supportive supervision by Pact staff.

A final measure implemented to ensure data quality is periodic data audits, either internally or by an external
data quality audit team). Data audits verify the quality of the data reported at service sites for validity,
completeness, reliability, timeliness, accuracy and integrity, as well as assess the system that produces the data.
The project or internal team follows up every six months or year to see if recommended improvements have
been implemented.

III. Results

M&E systems were found to be considerably strengthened, with improved quality of reported data and
facilitated program planning. The standardized guidelines and data collection tools helped users avoid mistakes,
freeing time for data aggregation and better program management. Many partners stated that their old forms
were confusing, making it difficult to keep track of patients and aggregate data. The development of a
systematized client management system makes it feasible to assess the quality of care at each visit. Partners also
reported that the Excel sheet is working very well to count PEPFAR indicators and follow up on clients served
under their projects, for example when beneficiaries die or contact is lost.

Capacity building through training modules and on-the-job support helped to improve data collection and

monitoring of outreach and home-based healthcare activities. Supervision trips found that program data is
recorded in a consistent fashion. Consistent data collection and monitoring enables managers to identify
strengths and weaknesses and appropriately revise program activities: For example, data was used to access and
provide services to new hotspots, and add services to some projects. The data also are used to monitor the
progress of coverage by prevention programs as well as performance of peer and outreach educators.

Integrated and supportive supervision is implemented frequently, as recommended. Reports from some
partners showed that project staff, outreach group leaders and local HIV/AIDS bureau program staff supervised
at least 50% of all activities planned. Documents submitted with reports were found to have fewer mistakes and
better-quality data.

Data audits that Pact conducted of some partners revealed consistent data recorded in registers and
summarized at various levels. Data quality at the sites audited was acceptable in terms of accuracy,
completeness, timeliness and integrity.

Increasing coordination meetings between partners reduced overlap of services, facilitated access to services
and improved resource allocation. Collaborations helped minimize double counting of clients served. Most
partners have proceded to analyze their data, for example by creating graphs and charts, and in the case of some
partners using SPSS. Some partners used data to estimate the number and distribution of higher-risk populations
for effective allocation of prevention resources.

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Strengthening M&E systems improves data quality, which in turn supports evidence-based planning and
program management. It is important to develop appropriate, streamlined, standardized forms and definitions.
Peer educators and caregivers rquire detailed instructions on use of the forms and logbooks, and these should
contain real examples for easier understanding and retention.

M&E capacity building can be implemented through different means: refresher trainings, on-the-job training
and supportive supervision. Capacity building for peer educators and caregivers should be emphasized and
conducted regularly on topics such as communication skills, accessing clients and especially their own
self-esteem.

Data quality is likely to correlate positively with a sense of data ownership among program staff, peer
educators and caregivers, which can improve their engagement to catch potential data issues. Mistakes in data
collection and aggregation should not be blamed on individuals, but encouraged through a culture of common
ownership and combined effort.

Various forms of supervision should be carried out for peer educators and caregivers: direct and remote
observation, review of daily work diaries and crosschecking with beneficiaries and other community members.
Data quality assurance should be integrated into routine supervision using a standardized methodology. Formal
data quality auditing should be conducted on a periodic basis for selected indicators. More effort must be
devoted to encourage effective use of data in decision-making processes.

Weaknesses in data quality for monitoring and evaluation need to be overcome with support from leaders of
Government, international organizations and local non-government organizations. Following are
recommendations to continue improving data quality and usage:

 Develop comprehensive M&E systems from the beginning of program formulation: clearly designing

organizational M&E structures, developing effective tools and indicators for measuring the results of HIV/AIDS
projects, and developing comprehensive methods/strategies to make data available and control for quality.

 Equip management and M&E staff working in agencies and localities with essential skills, such as the

requirements of M&E activities, knowledge and training to perform M&E, and use of information technology to
support M&E activities.

 Continue efforts to reduce existing weaknesses: more data on quality of services need to be established,

impact and outcomes evaluations should be conducted, and databases should be developed for connecting
programs (especially outreach, voluntary counseling and testing, antiretroviral and methadone treatment,

outpatient clinics and home-base healthcare). Information sharing between government agencies and donor
organizations in planning, management and monitoring of HIV/AIDS prevention and control programs should
be strengthened to provide necessary data and information for the Government’s long-term planning and
management of HIV/AIDS programs.

 Encourage partners and managers to use reported data, surveillance data and evaluation information in

planning, managing and developing programs.
References:

1. “Annual report of VAAC on HIV/AIDS prevention and control programs”, VAAC, 2006, 2007, 2009
2. “Coordination, management & utilization of foreign assistance for HIV/AIDS prevention in Vietnam”,
Center for Community Health Research & Development, Ha Noi, 2006

3. “National M&E framework for HIV prevention and control program”, The MOH; Hanoi, 2007

4. Online Forum on Data Quality Assurance for Reproductive Health Information System and Monitoring
& Evaluation, 2009

5. “A guide for project monitoring and evaluation – managing for impact in rural development”.
International Fund for Agricultural Development. Rome, Italy (see www.ifad.org/evaluation/)- IFAD (2002)

6. Lora Sabin, et all, Evaluation of President’s Emergency Plan for AIDS Relief (PEPFAR) - Funded
Community, Outreach HIV Prevention Programs in Vietnam: Report on Findings, 2009

7. “Handbook on M&E for Results United Nations Development Program”, New York, USA (see
www.undp.org/eo/rbm/index.htm) - UNDP (2002)

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Sexual Risk Behaviours among Male Migrant Freelance

Labourers in Urban Vietnam: Prevalence and Correlates

Nguyen Van Huy1, 2, Michael P Dunne2, Joseph Debattista3,
Nguyen Tran Hien1,4 & Dao Thi Minh An1

1Faculty of Public Health, Hanoi Medical University, Vietnam
2School of Public Health, Faculty of Health,

Queensland University of Technology, Australia
3Brisbane Sexual Health & HIV Service,
MetroNorth Health Service District, Australia
4National Institute of Hygiene and Epidemiology, Vietnam
ABSTRACT

Like many other developing countries, Vietnam is experiencing an increasing wave of
rural-urban migration. This process of migration, whether voluntary or not, may result in
the spread of HIV infection both to those who migrate and to members of the
communities that receive migrants. This study examined self-reported risk behaviours among 450
male migrant freelance labourers in urban Hanoi, Vietnam, in 2009-2010. Risk of acquiring or transmitting
HIV and other Sexually Transmitted Infections (STI) was high among these men. One third of the sample
reported having intercourse with commercial sex workers and one quarter had casual sex partners.
Approximately one in every 12 men reported homosexual or bisexual behaviour. The men on average had 3
partners within the preceeding year. In general, condom use was inconsistent. These men have limited HIV
knowledge and only moderate motivation and perceived behavioural skills for protective behaviour. The study
provides strong evidence for preventive further interventions. To be effective, a comprehensive public
health approach tailored to the specific needs and vulnerabilities of these men should be
applied. It is important to include such factors as the pervasive peer influence to ‘live
dangerously’, persistent myths about low risk from sex with people who look healthy or
with casual partners not classified as ‘sex workers’ and the low group norms for HIV
prevention motivation.

Key words: Vietnam; Migrant Labourer, HIV/AIDS; IMB Model; Sexual Behaviour; Sexual Risk
Behaviour.

INTRODUCTION

Most previous studies of HIV risk behavior in Vietnam have focused on traditional “core transmitter” groups
(Agence France-Presse, 2001; N. T Hien, 2002; N.T Hien, Long, & Huan, 2004; Tuan et al., 2007; Vietnam
Commission for Population Family and Children, 2003). However, this concentration on high risk groups may
leave others under-protected or unprepared for prevention. For male migrant workers, the separation from
family, breakdown of social networks, lack of social controls and support and anonymity of living in a city
make them especially vulnerable to HIV infection. These men may have multiple sexual encounters with
different, changing partners, and usually without condom protection (Jochelson, Mothibeli, & Leger, 1991), and
consequently have higher rates of HIV as compared with non-migrant men (Lurie, Williams, Zuma, Mwamburi,
et al., 2003).

Although there is growing interest of research in migrant labourers (Duong, Anh, Hong, Trung, & Bach,
2005), little is known about patterns and determinants of risky or safer sexual behaviours for HIV (N. V Huy,
Dunne, Debattista, Hien, & An, 2010).

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The main goal of this study was to examine prevalence of HIV risk behaviour and factors associated with
risky - or safer - sexual behaviour among male migrant freelance labourers in urban Vietnam. To understand
factors associated with such a behaviour, we adopted the IMB model with an additional components –consisting
of alcohol use, migration index, social connectedness, depression, and access to AIDS information as a basis to
examine these associations. Our study hypothesized that social structure, information and motivation would be
associated with protected sex self-efficacy and this self-efficacy would be associated with the level of safer sex
behaviour among male migrant labourers.

The current study has been informed by two qualitative sub-studies. The first of these illuminated migrants’
life experiences in urban space, including stressors related to physical, financial and social factors among
migrant labouring men and the strategies they use to cope with them (N.V. Huy, Dunne, Debattista, & An,

2010). The second sub-study explored how social contexts shape HIV risk behaviours (N. V Huy, et al., 2010).
The current quantitative survey study was carried out as part of a larger, multi-disciplinary project attempting to
understand determinants of HIV risks among male migrant freelance labourers in Vietnam.

METHOD

Research Site. The site for this study is in urban and suburban Hanoi in northern Vietnam. Hanoi is one of
the two large cities in Vietnam and one of the most frequent choices for rural-urban migrants , including those
who become unregistered labourers.

Sample Size and Participants. Based on a definition freelance labourers by Duong et al. (2005) and
Simpson and Weiner (1989) participants were males aged 18-59 who work for private owners or self-earn
without a labour contract. A sample of 450 was identified given the following formula of (Lwanga &
Lemeshow, 1998)

for sample surveys of simple random sampling.

(Z2

1-α/2 )P(1-P)N

n =

---D2 (N-1) + (Z2

1-α/2 )P(1-P)

Where α refers to a statistically significant level at .05; (1-α) is a confidence level (95%); Z yields 1.96, a
value derived from the Z-table corresponding to α of .05; P is defined as an estimated population proportion
with protected sex (36.2% based on our pilot survey); d is an absolute precision at .04; N is the population size
with 5000 as estimated for male freelance workers in Hanoi based on the data of ANU (2003) and Duong et al.
(2005); n, a minimum sample size according to the formula, is 450.

A sampling frame was made by social mapping venues of migrant labourers in districts of Hanoi. We aimed
to identify as many venues of male migrant labourers within the city as possible. A group of researchers were
formed and trained on mapping. Each member was assigned a number of districts where he or she was expected
to visit. Afterwards he or she identified venues at which migrant labourers congregated. In each district field
workers searched for men in casual employments. Typically this is in streets, markets, construction sites, bus
stations, small business shops, or by such other social services as schools, hospitals, and factories. In each venue
key informants such as migrant labourers themselves, local people living close to the venue, local leaders,
experienced researchers from prior studies on mobile populations, peer educators and outreach officers were
consulted for mapping the next venues. At the same time, field workers were asked to estimate the number of
male migrant labourers as a basis for approaching respondents in the main survey. Finally a list of all the venues
and the estimated number of respondents was created.

Survey Procedures. This study began with 16 explorative qualitative interviews to identify key variables to
be included in the modified IMB model. The draft research instrument was evaluated with a sample of 55
participants. The pilot showed that the instrument was technically feasible for the main survey (Cronbach’s
α>.70 for most subscales) and an average number of 770 participants were estimated from 13 potential districts
within the city. Experience from prior research indicated that 10% of the sample would refuse interviews and
about 30-35% changed locations; therefore in this study we approached the entire population to conduct
structured interviews.

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Measures

Social Structure. Access to AIDS information was formed from 12 items (α = .55). The ratio of the number
of migratory cities to years of total migration was employed as an index of mobility (Li, Fang, Lin, Mao, Wang,
Yang, et al., 2004). Alcohol use was a composite of the number of standard drinks and frequency of use over the
past 4 weeks (α = .60). Social connectedness was assessed with 6 items of (Hawthorne, 2006) (α = .74). To
measure Depression, a short version “Boston form” of CEDS was used as it is made up of concrete
experiences that participants with less formal education could interpret in the context of

their daily lives, it has been proven reliable and valid though with less items in prior research, as well

as validated in the a labor migrants, most of whom are males with life experiences (Joseph, Joseph, Laura,
Thomas, & Sara, 2006). With ten 4-point items the scale of depression experience has an α

of .88 (Andresen, Carter, Malmgren, & Patrick, 1994; Cole, Rabin, Smith, & Kaufman, 2004; Kohout,
Berkman, Evans, & Cornoni-Huntley, 1993; Santor & Coyne, 1997). The above five indicators serve as

a latent construct of social structure (α = .60).

Information. AIDS preventive information was assessed with ten true/false/don’t know items (Bryan,
Fisher, & Benziger, 2001; Misovich, Fisher, & Fisher, 1997). Scoring the information scale was accomplished
by dichotomizing each item into a value of 1 (correct) and 0 (incorrect or don’t know) and then summing the
item values to form a composite score with higher scores on this scale reflecting increased knowledge about
AIDS prevention (α = .60). The scale is split into two subscales. One subscale includes 5 items (α = .57)
measuring theoretical knowledge or relevant to the sexual transmission of HIV (e.g., “Using condoms when you
have sex can reduce the chance of getting HIV”); the sum of correct responses is the sexual transmission
information score. The other subscale comprises 5 items (α = .62) that address HIV prevention heuristics (e.g.,
“Once you trust your partner you don’t need to use condoms with them”). The sum of correct responses is the
heuristic information score. These two scores serve as indicators of the latent construct of AIDS prevention
information.

Motivation was measured by twenty one 5-point items assessing respondents’ attitudes towards condom use
[e.g., “How good or bad would it be if you talked about condom use (to keep from getting HIV/AIDS) with your
sex partner(s) before having sex with them during the next month?”]; subjective norms or generalized
perceptions of social support for their practice of condom use (e.g., “Most people who are important to you
think you should talk about condom use with your partner(s) before having sex with them during the next
month?”; and intentions to perform each condom behaviour (e.g., “If you have sex during the next month, you
intend to talk about condom use with your partner(s) before having sex with them?”) (Ajzen & Fishbein, 1980;
Fishbein & Ajzen, 1975; Misovich, Fisher, & Fisher, 1998). Respondents rate their performance of twenty one

condom use statements on a 5-point semantic scale (bad-good) from 1 (negative evaluation) to 5 (positive
evaluation). A composite score was obtained by summing responses to items with higher composite scores
indicating higher levels of motivation toward condom use (α = .90).

Behavioural Skills. Behavioural skills toward safer sex were assessed with seven items dealing with
perceived self-efficacy to perform behaviors related to condom use. The answers are on a 5-point semantic scale
ranging from very hard (1) to very easy (5) (e.g., “How hard would it be for you to consistently use condoms
with a partner every time you have sex with?”) (Bryan, et al., 2000; Misovich, et al., 1998). A composite score
was obtained by summing responses to items with higher scores reflecting higher levels of behavioural skills for
condom use (α = .86).

Protected Sex Behavior was assessed with three subscales measuring discussion of safer sex, condom
accessibility, and condom use (Misovich, et al., 1998), employed in a variety of safer versus riskier sexual
practices. Safer sex discussion was measured with two items that if the respondent has discussed safer sex
(condom use) with sexual partner(s) and if he has tried to persuade a sexual partner to practice safer sex using a
condom (α = .73), which were summed to create an indicator of safer sex discussion. Condom accessibility was
assessed with two items asking respondents how often they have purchased condoms and the extent to which
they have kept easily available (α = .86), which were summed to create an indicator of condom accessibility.
Condom use during sexual intercourse was assessed with four items asking respondents about their frequency of
condom use during intercourse (α = .83), which were summed to produce an indicator of condom use. The
above three subscales were summed to form a composite score of safer sex behaviour (α = .90).

Analysis Strategy. The Pearson’s Product Moment correlation coefficient was used to determine whether
pairs of factors are significantly associated with each other. We used a conventional p value of .05 for these
analyses. Descriptive statistics (frequency, percentage, mean, SD, and range) were adopted to identify
prevalence and levels of risky sexual behaviour.

FINDINGS

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the sample were ethnic Kinh, 84% were married, 73.8% followed one type of religion (Buddhism, catholic, and

ancestor worship). Mobility was fairly high as most (63%) were born in rural areas. Almost 70% resided in
urban centres before traveling to Hanoi. In the whole sample, 87% were migrants; the average number of cities
for paid work was 2.4; and the average number of years in cities for paid works was 16.4. The mean age was 39
years and most had low levels of education (mean years completed=8.19). The majority (almost 60%) were
farmers when in their hometowns and the most common occupation in urban areas were motorbike driver
(~65%), followed by manual laborer and construction worker, each contributing more than 10% of the total. The
average monthly income was 2.6 million VND (equivalent to U.S.$140). Despite a fairly low level of alcohol
consumption per drinking occasion, nearly all men consumed alcohol sometimes (over 90%). Level of access to
HIV information was limited (M=3; range=0-9).

Table 1. Selected Socio-Demographic Characteristics

Variable (N=450) n (%)

Mean ± SD

Age (year, range=18-59) 39.23±10.29

Marital status
Unmarried
Married
Separation/divorced/widowed/cohabitation
46(10.2)
378(84.0)
26(5.8)
Race
Kinh

Minors 444(98.7)6(1.3)

Religion
Buddhism
Catholic/Christian
Ancestor worship
None
116(25.8)
9(2.0)
207(46.0)
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Education level (class completed, range=0-15) 8.19±2.52

Place of birth
Urban

Rural 167(37)283(63)

Place of residence before Hanoi
Urban

Rural 314(69.8)136(30.2)

Number of cities traveled for paid works 2.41±2.68

Number of years in cities for paid works 16.36±14.10

Mobility 392(87%)

Living with whom in urban area

Alone

Peers and friends

Sex partners (wife, lovers, casual partners, sex workers & others)
Family and relatives

46(10.2)
147(32.7)
202(44.9)
55(12.2)
Main occupation during urban stay

Manual laborer

Construction worker and subcontractor
Porter
Motorbike driver
Small trader
Others
55(12.2)
49(13.1)
29(6.4)
291(64.7)
19(4.2)
7(1.6)
Main occupation during hometown

Farmer
Construction worker

Office staff and factory worker

Militant
Motorbike driver
Student
Unemployed
263(58.5)
36(8.0)
40(8.9)
7(1.6)
55(12.2)
19(4.2)
30(6.6)

Average income (million Vietnam dong, $USD1=VND18,000; range=.09-12) 2.60±1.30

Alcohol Use

Level of consumption (0-28.50)
Percentage

5.66±4.83
416(92.22)

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Depression

Level of depression (0-27)
Percentage

6.65±5.16

113(25.11)

Access to AIDS Information (0-9) 3.01±1.32

As can be seen in Table 2, there were deficits in HIV prevention behaviour. More than 70% incorrectly
believed that condoms only need to be used with prostitutes. More than 50% incorrectly believed that once you
trust your partner, you no longer need to use condoms with them, and many believed there is a cure for AIDS.
Around 60% incorrectly believed that oral sex is just as risky as vaginal intercourse for transmitting the virus,
and as many men believed that you can tell by looking at someone if they have HIV, and there is currently a
vaccine that prevents AIDS. On a more positive note, over 98% knew that using condoms when you have sex
can reduce the chance of getting HIV and more than 86% did not believe that it is safe to use the same condom
more than once.

Table 2. Percentage and Level of Correct Responses to Knowledge of HIV/AIDS

Variable (N=450) n (%) # of Correct Responses

# of items n(%)
Using condoms when you have sex can reduce the chance of getting HIV (true) 443(98.4) 1 4(.9)

It is safe to use the same condom more than once (false) 389(86.4) 2 23(5.1)

Oral sex is just as risky as vaginal intercourse for transmitting HIV (false) 190(42.2) 3 44(9.8)

Condoms only need to be used with prostitutes (false) 127(28.2) 4 62(13.8)

Once you trust your partner, you don’t need to use condoms with them (false) 129(48.6) 5 101(22.4)

It is safe to have sex without a condom if it’s with your wife (false) 50(11.1) 6 85(18.9)

As long as both partners wash themselves after sex, it is not necessary to use

condoms (false) 270(60.1) 7 79(17.5)

You can tell by looking at someone if they have HIV (false) 191(42.4) 8 30(6.7)

There is a vaccine that prevents AIDS (false) 171(38.0) 9 15(3.3)

There is a cure for AIDS (false) 207(46.0) 10 7(1.6)

Table 3 displays general patterns of risk sexual behaviours for HIV. Most participants (92.2%) reported that
they were were heterosexual, 5.6% were bi-sexual, and 2.2% were homosexual. The number of reported lifetime
sexual partners ranged from 0 to 77 with a mean of 10 (SD=7.5). Number of partners in the past year ranged
from 0 to 20 with a mean of 3.2. Around 95% of the participants had sexual encounters with regular partners,
one third with sex workers, and almost 25% with casual partners. Safer sex discussion with sex partners before
having sex was fairly limited, with just over 50% of the participants saying that they talked about condom use.
Access to condoms was also relatively limited – those reporting buying condoms and keeping a condom
available were in the minority. Condom use among participants was inconsistent and with the proportions being
just under one third with regular partners and commercial sex workers and very low (17.6%) with casual
partners.

Table 3. Prevalence and Levels of Sexual Risk Behaviours for HIV

Variable n (%)

Mean ± SD

Sexual orientation (N=450)
Sex only with men
Sex only with women

Sex with both men and women

10(2.2)
415(92.2)

25(5.6)

Age at first sex (N=435) (range=15-52) 22.46±3.69

Types of sexual partners (N=450)

Regular partners (participants don’t pay for sex)
Commercial sex workers (participants pay for sex)
Casual sex partners (participants don’t pay for sex)

427(94.9)
147(32.7)
109(24.2)
Multiple sex relations (N=450)

# of different partners (lifetime) (range=0-77)

# of different partners (past year) (range=0-20) 10.13.17±2.10±7.54

Safer sex discussion with sex partners before having sex (past year) (N=435)
Talking about condom use with sex partners before having sex

Level of persuading condom use with sex partners before having sex (range=0-2)§ 255(58.6).78±.70
Condom accessibility (past year) (N=450)

Level of buying a condom (range=0-4)§

Level of keeping a condom available (range=0-4)§ 1.55±1.101.81±1.29
Condom use

Last sex with regular partners (N=426)
Last sex with commercial workers (N=149)

Last sex with casual partners (N=110)

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Level of past year condom use with regular partners (N=427) (range=0-4)§
Level of past year condom use with commercial workers (N=152) (range=0-4)§

Level of past year condom use with casual partners (N=112) (range=0-4)§
Level of past year condom use with all sex partners (N=435) (range=0-4)§

3.32±1.10
2.47±1.42

1.83±1.04

Protected sex behaviour (range=0-26) (n=450) 14.70±6.24

Range from 0 to 4 with higher scores indicating higher levels of the practice.

The means, standard deviations and intercorrelations between key factors in the modified IMB model with
an additional factor – social structure - are shown in Table 4. HIV knowledge was limited (M=4.40;
range=1-10), whilst motivation, perceived behavioural skills, and preventive behaviour were moderate. With regard to
intercorrelations among constructs, the majority of the scale scores were moderately to closely related to one
another (r’s=.30-.60; p<.05).

Table 4. Correlates of Key Factors with Protected Sex Behaviour

Variable (N=450) Mean ± SD 1 2 3 4 5

Social Structure (range=34.5-105.3)¥ 83.40±11.86 _

HIV Knowledge (range=1-10)¥ 4.40±1.83 .21*** _

HIV Motivation (range=28-105)¥ 82.16±13.31 .50*** .11* _

Behavioural Skills (range=7-35)¥ 25.79±5.20 .57*** .15** .60*** _

Safer Sex Behaviour (range=0-26)¥ 14.70±6.24 .34*** .12* .24*** .16** _

Ranges with higher scores indicate higher levels of the scale.

DISCUSSION

Like many other developing countries, Vietnam is hosting an increasing number of
migrants from rural to urban areas. Other research in Asia and Africa has shown that
people who migrate for work are at increased risk for HIV (Decosas & Adrien, 1997; M. N.

Lurie, Williams, Zuma, Mwamburi, et al., 2003). They often have higher infection rates

than those who do not move (M. N. Lurie, Williams, Zuma, Mwamburi, et al., 2003). In

this study, as most respondents (87%) were migrants, we examined the effect of mobility
on sexual risk behaviour in relation to a wide spectrumof possible influences..

The findings reveal a general pattern of sexual risk among the Vietnamese migrant labouring population,.
The perrcentage of migrants in the present study who reported having intercourse with commercial sex workers
(32.7%) was similar to reports among the Chinese migrants (31%) (Li, Fang, Lin, Mao, Wang, Liu, et al., 2004),
and was substantially higher than commencial sexual activity among indigenous rural Chinese (7.8%) in other
studies (Liu et al., 1998). The number of lifetime and past year sexual partners, the percentage and level of
condom use discussion and persuasion to take precautions with sexual partners also indicate high levels of risk
sexual behaviour among migrant labourers. These results are consistent with data from other countries in both
Asia and Africa (M. Lurie, Harrison, Wilkinson, & Aldool Karim, 1997; M. N. Lurie, Williams, Zuma,
Mkaya-Mwamburi, et al., 2003).

The current study has shown that many factors, including those constructs adopted from the IMB model, are
associated with risk sexual behaviours in this population. In particular, sexual risk was associated with limited
knowledge of HIV and low motivation and perceived low behavioural skills toward safer sexual behaviour.
When the bivariate correlation between these factors is assessed in isolation, the contributions of all of the IMB
model constructs with behaviour were significant. This finding is consistent with other studies conducted in
developed and developing countries (Bryan et al., 2001; Cornman et al., 2007; Fisher, J., & Fisher, W. A.,
1998). This is one of the first studies in Vietnam demonstrating the applicability of these theoretical constructs
in behavioural decision making related to sex. However, it is important to consider the limitations of the
standard IMB model. Bryan, et al (2000) and Odutolu (2005) have argued that a main limitation of the IMB
model was that its constructs were largely individual-level based, suggesting a need for building models that
more explicitly take into account the larger social context. In this study we introduced a broader range of social
variables to examine how they are associated with each construct of the IMB model and with sexual behaviour.
The associations of social structure with all the IMB constructs and with the risk sexual behaviour were
significant.

It is recommended that future preventive interventions should address all aspects of
migrants’ vulnerability to infection, not only their needs for information. As argued by Li,
Fang, Lin, Mao, Wang, Liu, et al. (2004), an HIV prevention program is unlikely to be effective for people who
are disconnected from formalized education, employment, and health care, and other social
services.

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assessment. Second, we are subject to the usual limitations of self-report bias in measures of sexual behaviour.
Also, our study has not simultaneously assessed the contributions of all of the IMB model constructs and social
structure with behaviour using structural equation modeling – SEM, consequently the fit of the IMB model with
an additional construct – social structure has yet to be analysed. Further research, ideally with an intervention or
a longitudinal design is needed to determine causal relationship among the model constructs as well as the effect
of the intervention on male migrant freelance labourers’ behaviour. To be effective, more prevention
programs and a comprehensive public health approach to the specific needs and

vulnerabilities of these men should be applied. There is a great need to improve access to condoms

for these men especially given the high numbers of casual and commercial partners, and also to have messages
tailored for the substantial proportion of non-heterosexual men among these migrant labourers (about 8%).

Understanding and application of this IMB theoretical model for best practice may
facilitate more effective HIV/AIDS prevention intervention programs in Vietnam and
countries that have similar contexts.

ACKNOWLEDGEMENTS

This study was supported by a combined grant by the Institute of Health and Biomedical Innovation from the
Queensland University of Technology, and the Australian Government's Overseas Aid Program (AusAID). Dr.
Jeffrey D. Fisher, Professor of Psychology, Director, Center for Health, Intervention, and Prevention, University
of Connecticut, USA, was greatly acknowledged for his provision of the related invaluable materials. The
authors also thank the field teams for their tireless efforts to assist this study. The authors gratefully
acknowledge the participation of all male migrants labourers in the survey interviews in Hanoi city, Vietnam.

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A Picture of HIV Drug Resistance in Vietnam and the Region

Todd M. Pollack, MD

HIV-AIDS arose in Asia in the early to mid 1980s and Asia is now home to the second highest number of
people living with HIV (PLHIV). Since 2003, the roll-out of antiretroviral therapy (ART) in the region and
across the globe has occurred at a rapid pace. At the end of 2009, 5.2 million people living in low- and
middle-income countries were receiving ART. Vietnam and its neighboring countries have experienced a nine-fold
increase in the number of people receiving treatment in the last five years. The success of ART has led to
significant reductions in morbidity and mortality among people living with HIV/AIDS. Despite these successes,
less than 40% of people who need HIV treatment are receiving ART in the region. As the roll-out of ART
continues to accelerate, close attention must be placed on the emergence of drug resistance in the region.

Early predictions that rapid roll-out of ART would lead to the widespread emergence of HIV drug resistance
(HIVDR) have proven untrue. Nonetheless, due to the limited number of regimens available in resource-limited
countries, minimizing HIVDR remains particularly important. In particular, there is increasing concern about
the development of drug resistance as treatment coverage rates increase in the region. A recent mathematical
model of the HIV epidemic in a Southeast Asian setting predicted that after 10 years of universal treatment
access, up to 20% of treatment-naïve individuals with HIV may have drug-resistant strains.

This review will focus on published data regarding HIV drug resistance in Southeast Asia and in Vietnam,
Cambodia, and Laos in particular. Specific topics will include: (1) Transmission of HIV drug
resistance, (2) HIV drug resistance associated with the prevention of mother-to-child HIV
transmission, (3) Characterization of genotypic resistance mutations following failure of
ART, and (4) Implications of drug resistance on health policy in the region.

Biography:

Dr. Pollack is Medical Officer with Harvard Medical School AIDS Initiative in Vietnam (HAIVN). He is a
Clinical Instructor of Medicine at Harvard Medical School and holds a joint faculty position in the Division of
General Medicine and Primary Care and in the Division of Infectious Diseases at the Beth Israel Deaconess
Medical Center in Boston.

Tools for HIV Estimation and Projection
UNAIDS

HIV/AIDS has been a serious problem in many countries. In order to slow down HIV epidemic in a country,
it is important that the country need to know whether their epidemic is growing. If so, how fast is the epidemic,
where it is, and in what groups? What will most effectively slow or stop this growth? And what are the future
treatment needs? Modeling tools for HIV estimation and projection are used to answer these questions.

There are many modeling tools that have been developed and used to estimate and project HIV/AIDS and its
impacts. The common modeling tools that have been applied in many countries include the UNAIDS
Workbook, UNAIDS Estimation and Projection Package (EPP), Spectrum, and Asian Epidemic Model (AEM).
These models have range from very simple to very complex model. They have different amount of inputs and
outputs.

To determine which tool to be used in a country, it is depended on the availability of data. When little data is
available, the most common used tool is UNAIDS Workbook. It has been widely used in Asia due to data
limitations in many countries. The Workbook model was designed to be a simple model and requires only the
size of subpopulations at risk and their HIV prevalence. Because it is simple, the model can only produce a
single year estimate of number of people living with HIV/AIDS.

For countries with moderate data available, the most common tools used are EPP and Spectrum. EPP is a
curve fit model that requires size of subpopulations and series of HIV prevalence among those subpopulations.
EPP can project the HIV prevalence and HIV incidence for each subpopulation. This prevalence curve or
incidence curve from EPP is used as an input for Spectrum to generate some impact figures. Spectrum is not an
epidemic model. It is an impact model. Spectrum needs input that is an HIV epidemic curve from other models

such as EPP model. It also requires demographic data, disease progression, and treatment information as inputs.
Outputs of Spectrum include number of people living with HIV, new infections, deaths, needs for treatment, and
children infections.

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In conclusion, modeling tools are useful for estimating and projecting number of HIV/AIDS. However,
countries need to know their data availability and understand the advantage and limitations of each modeling
tools before applying them.

COMMUNITY AND HOME-BASED CARE IN VIET NAM: KEY FINDINGS AND

RECOMMENDATIONS FROM A REVIEW OF PACT-SUPPORTED COMMUNITY- AND 
HOME-BASED CARE PROGRAMS

I. Background

Since 2004, Pact has supported community- and home-based care (CHBC) programs for people living with
HIV/AIDS in Viet Nam, with PEPFAR funding via USAID. Implemented by international and local
organizations with management, financial and technical assistance from Pact, these CHBC programs provide
direct care and support services to adults and children living with HIV/AIDS and help link them to health and
social services. They also help build skills for self-care among people living with HIV (PLHIV), and provide
support and training to their family caregivers. Indirectly, many other stakeholders benefit from the training and
community mobilization activities supported by CHBC programs, including HIV/AIDS service providers, local
government authorities and other community members.

II. Major content

In 2010, Pact completed a review of nine of these CHBC programs, including seven CHBC programs that
are operated by community-based groups and two CHBC programs that are operated as part of clinic-based,
comprehensive HIV/AIDS care and treatment programs. The primary objectives of the review were to:

* Document the program model and core activities of partners

* Assess the achievements of each partner, including quality, access and sustainability of CHBC services
* Determine the strengths, weaknesses and gaps in services offered by each partner, with a focus on case
management and referral systems

* Document client needs and outcomes, with a focus on program responsiveness to clients’ evolving needs
over time

* Document lessons learned and emerging innovations, which will help inform future directions for CHBC
across the Pact portfolio

The review is a small-scale study, intended to provide a snapshot of program functioning and client
experiences with CHBC. The review team used a range of qualitative methods (in-depth case reviews, in-depth
interviews, observations, focus group discussion) to collect information from a variety of stakeholders,
including adult clients, family members of adult and OVC clients, CHBC service providers, CHBC program
managers and key stakeholders (including representatives from HIV/AIDS outpatient clinics and local
authorities, such as DOLISA, the Women’s Union and the People’s Committee).

III. Results

The review found that CHBC programs have reached many PLHIV and OVC who need care and support,
including PLHIV who are socially isolated and may be disconnected from care and treatment systems as well as
from social support systems (e.g. PLHIV returning to communities from prison or rehabilitation centers).

CHBC workers provide important healthcare services, including home management of simple symptoms,
and coach PLHIV and their family members in antiretroviral adherence and self-care. CHBC workers often act
as “bridges” to healthcare systems, helping PLHIV register for ongoing medical care such as antiretroviral
treatment at HIV/AIDS outpatient clinics and referring PLHIV and HIV-affected children to clinics for
treatment of complex health problems. However, the review also found that CHBC workers’ assessments of

client health needs are currently completed in a verbal, informal way, without job aids or reference materials
(including referral lists and screening/referral algorithms).

Stakeholders – including PLHIV, family members, CHBC workers and representatives from local authorities
– reported significant improvements in the health of CHBC clients, which they attribute to the care provided –
or referred to – by CHBC workers. Some CHBC programs serve PLHIV who enrolled in the late stages of
HIV/AIDS (e.g. PLHIV who were released from rehabilitation centers when they became seriously ill). For
these clients, CHBC workers provide essential end-of-life palliative care to PLHIV and families.

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problems.

All CHBC programs offer small packets of staple foods to PLHIV, prioritizing clients who are very poor
and/or appear to be malnourished. These food packets mostly help offset other caregiving costs and support
food security at the household level. Some CHBC workers offer very general nutritional advice, with a few
programs providing practical coaching to families on practical, sustainable strategies using food to support
ARVs and help manage the symptoms of opportunistic infections.

CHBC programs have integrated some prevention services into routine care and support. CHBC workers
consistently counsel PLHIV and their partners on preventing sexual transmission of HIV, as well as distributing
condoms and coaching on correct condom use. Some programs offer specialized counseling and support for
discordant couples and prevention of HIV transmission through caregiving. As part of routine health checks,
CHBC verbally screen and refer clients for STI/RTI diagnosis and treatment, but as noted before, without job
aids or screening/referral tools. All CHBC programs promote condom use to prevent HIV transmission and
provide counseling and referral for pregnant women, but other sexual and reproductive health services are
poorly integrated. Only one program offers pre-conception counseling and proactively refers couples to
mother-to-child transmission services to help them plan safe and healthy pregnancies. Only a few programs counsel
female clients to seek routine annual gynecological exams. Risk-reduction counseling for injecting drug users is
not provided systematically by any program, and referrals to harm reduction programs (needle/syringe
exchange) and methadone programs are inconsistent, due in part to the poor coverage of these programs.

Throughout the review, all stakeholders reiterated that meaningful employment and income generation
activities (IGA) are among the top priorities of PLHIV: There are currently very few IGA programs in Viet
Nam and this need has largely been unmet. A few CHBC programs offer small-scale IGA, including group loan
projects and vocational training, that only benefit a few clients and are not all well-designed or well-managed.
To date, CHBC programs have not systematically referred clients to IGA programs where they exist.

Most CHBC programs in this review do not offer specialized services to support the holistic development of
HIV-affected orphans and vulnerable children (OVC). Programs offer small stipends to help families with
school-related expenses and support social events for children. With a few exceptions, CHBC workers do not
routinely monitor the physical development of OVC; programs provide packets of basic foods to families with
OVC but only a few provide specialized nutritional supplementation for children and infants. No programs have
trained CHBC workers to monitor children’s social or cognitive development; nor are they trained to provide
psychosocial support to children and teens. Most CHBC programs do not have child protection policies and are
not consistently monitoring and referring for neglect or abuse.

HIV/AIDS-related stigma and discrimination (S/D) remains a considerable barrier to care and support for
PLHIV and OVC. Stigma and discrimination appears to be fairly common in healthcare facilities that do not
specialize in HIV/AIDS care and treatment, such as emergency rooms, surgical wards or OB/GYN departments.
Fear of stigma and discrimination remains a major disincentive to enrolling in HIV/AIDS-related care programs,
including CHBC. In addition, OVC still routinely experience discriminatory treatment in schools, including
isolation from other children by teachers and bullying and teasing from fellow students.

IV. Lessons learnt

Each model of CHBC has its own advantages and barriers in providing services for PLIHV. The review
found that the clinic-based CHBC programs provided care and support services, with effective referral links
between CHBC services and clinic-based services, and strong supervision and support to CHBC workers by
social workers and case managers based at clinics. However, these two programs had limited reach, prioritizing
clients who are taking ARV and/or who are in ill health. These programs might be missing opportunities for
providing regular CHBC to other PLHIV and OVC who are in good health but could benefit from psychosocial

support, referral to other services such as income generation activities, and coaching for self-care and early
detection/care-seeking for health problems.

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relationships between CHBC programs and healthcare facilities, referrals are based on personal knowledge and
relationships of individual CHBC workers, and there is no organizational support to ensure consistent referral
and follow-up or to address barriers to referral. Job aids or reference materials (including referral lists and
screening/referral algorithms) would help CHBC to more systematically screen, manage and refer for
opportunistic infections and antiretroviral side effects. Another area where CHBC can be expanded is in routine
screening for serious psychological problems such as depression and anxiety, and referral to specialized mental
health services when they are locally available, including at OPCs (many of which are currently developing
mental health services). Program leaders or other program staff should be trained in specialized counseling
skills and empowered to “back up” CHBC workers whose clients need time-intensive or specialized counseling.

Determinants of health-related quality of life in adults with

HIV/AIDS in Vietnam

Tran Xuan Bach1, Nguyen Thanh Long2,
Nguyen Thu Anh1, Nguyen Huong Thao3

1Hanoi Medical University, Institute for Preventive Medicine and Public Health,
Department of Health Economics (Email: )

2Ministry of Health, Administration of HIV/AIDS Control
3Strategic Consultancy Company, Hanoi, Vietnam.
Abstract

Background: Health-Related Quality of Life (HRQL) is a good indicator to monitor and evaluate healthcare
services for adults with HIV/AIDS. This study described HRQL of adults with HIV and its determinants, and
compared it with HRQL for the general population. Methods: A cross-sectional study with a national
multistage sampling of households with and without HIV-positive people was conducted in 2008. Six provinces

were purposively selected to represent areas of the country and progressions of HIV epidemics. Households
were sampled with probability-proportional-to-size, following the selection of rural and urban districts. A total
of 820 HIV-positive and HIV-negative adults (mean age: 32.5; 38.7% female) was interviewed. Among 400
HIV-positive people, 52.3% had history of injecting drug, and 56.3% were at AIDS stage and receiving
antiretroviral treatment (ART). HRQL was measured using the EQ-5D. Multiple regression models were
purposefully constructed to examine the determinants of HRQL. Results: The EQ-5D index and VAS score in
less advanced HIV people (0.90, 69.3) and AIDS patients (0.88, 65.2) were significantly lower than those of the
general population (0.96, 81.6) (p<0.001). The frequency of reported problems across EQ-5D dimensions in the
HIV population (2.4% to 30.9%) was significantly higher than in the general population (0.7% to 12.1%).
Compared to ART patients, those at earlier HIV stages reported having problems at similar proportions across 4
HRQL dimensions, except pain/discomfort, where ART patients had significantly higher proportion. Injecting
drug users taking ART perceived lower HRQL score than non-injecting drug users. Multiple regression
determined that joblessness (p<0.01) and inaccessibility to health services (p<0.05) were associated with lower
HRQL. In addition, involvements in self-help groups significantly improved HRQL among HIV-positive
participants (p<0.05). Conclusion: The findings highlight the need to improve the health service referral system
and enhance psychological and social supports for patients in early stages of HIV infection in Vietnam.

INTRODUCTION

With substantial supports from global health initiatives, antiretroviral treatment (ART) services have been
rapidly scaled up in Vietnam. However, the effectiveness of ART might be confined given the majority of
treated patients were IDUs. Drug use was related to a rapid HIV disease progression, delayed access to ART,
and more importantly, adherence difficulties once ART had been started. Therefore, to develop health care
policies and services for adults with HIV/AIDS in Vietnam, evaluation of health outcomes and their predictors
are essential.

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over time, and related to treatment adherence and viral load. Measuring HRQL, therefore, has the potential to
assess the impact of health interventions, identify the need for health services improvements, and monitor
changes in health status of HIV+ patients over time.

There has been a growing body of evidence in various aspects of HRQL in HIV populations [1, 2].
Nevertheless, very few of them conducted in developing countries where large HIV populations exist [1]. The
purposes of this study were to measure and compare HRQL of HIV+ adults with that of the general population,
and to explore the determinants of HRQL in HIV populations.

METHODS

Study settings and sampling

A cross-sectional household-based survey was conducted during October 2008 to April 2009. Six provinces
involved in the study represented the differences in ecological regions and progressions of HIV epidemics. A
sample frame of HIV population was constructed including lists of the total HIV+ cases in all districts.
HIV-affected households were sampled with probability-proportional-to-size, following the random selection of rural
and urban districts in target provinces. The study populations consisted of HIV+ individuals 18 years and older,
and a comparison group of HIV- adults in general population. HIV-affected households were referred by
peer-HIV educators. These included both peer-HIV+ people at an advanced stage of peer-HIV infection and receiving ART
when CD4 counts < 200 cells/µL and/or WHO stage 4 AIDS (56.3 %), and those not yet required ART (43.7
%). There were not HIV+ individuals in need of but not taking ART in this sample. For each HIV-affected
household involved, there was one conveniently selected adult in a surrounding household with similar living
standard and family size.

Instruments

Respondents were interviewed face-to-face using structured questionnaires. Health-related quality of life was
measured using the EuroQOL 5-dimensions questionnaire (5D), and a visual analog scale (VAS). The
EQ-5D consisted of a weighted sum of 5 domains: Mobility, Self-care, Usual activities, Pain/Discomfort and
Anxiety/Depression, whichprovided a simple descriptive profile and a single index value for health status [3].
Each dimension had 3 levels: no problems, some problems and severe problems that enabled the EQ-5D to
define 243 health states. Each state was then assigned a preference weight using tariffs of general populations
based on the time trade-off or the visual analogue scale valuation techniques. Although the EQ-5D single index

reflects full health and death as 1 and 0, in some severe health states, it results in negative values, which indicate
that the health states are considered to be worse than death. This study applied the UK tariff which has a
possible score range of [ −0.59 to 1.00] [3]. Besides, the VAS recorded respondent’s self-rated health on a
vertical, 20-cm visual analogue scale resembling a thermometer where the endpoints (0, 100) were labelled
“Best imaginable health state” and “Worst imaginable health state” [3]. The Vietnamese version of EQ-5D
instruments was provided by EuroQOL Group.

Data analysis

Population weights were constructed based on the selection probabilities and the sampling weights of each
stratum. Descriptive statistics were used to describe the health status, socio-demographic and HIV-related
characteristics of respondents.

Multivariate linear regression was used to identify independent factors associated with overall single index
of HRQOL and VAS in statistical models. Candidates for multivariate analysis included those variables that met
one of the following three criteria: (1) biological association with the outcome of interest; (2) previously shown
to be associated with the HIV-specific quality of life among Vietnamese population; and (3) significant
difference between groups when screened by univariate analysis. The significance level was set at p < 0.05.
Logistic regression analysis was performed to determine the association of reported problems in each dimension
of health-related quality of life while controlling for the effect of confounders.

Internal consistency reliability of HRQL measurement, an average inter-item correlation of the 5 dimensions,
was estimated using Cronbach’s alpha. Spearman’s rank correlation was estimated to test for correlation
between EQ-5D Index score and VAS score. Cross-sectional construct validity was evaluated by testing ‘a
priori’ hypothesis that the measurement was capable to distinguish HRQL of HIV+ individuals at different
disease progression and their HRQL was lower than that of the general population.

RESULTS

Characteristics of the study participants

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people were living with their spouse or partners while it was 82.7% in the comparison group (p<0.001). In
addition, HIV+ population was younger and had lower level of education than the comparison group. (Table 1).

Table 1. Socio-demographic profile of respondents

Characteristics Total (N=820) HIV+ (N=400) Non HIV (N=420) p - value
Age (years)

Mean (95% CI) 30.0 (37.2 - 38.9) 30.8 (30.1 - 31.8) 44.9 (43.7 - 46.2) <0.001*

Sex n % n % n %

Male 503 61.3 251 62.8 252 60.0 0.419**

Female 317 38.7 149 37.3 168 40.0

Ethnics

Kinh people 757 92.3 369 87.9 388 92.4 0.603**

Others 63 7.7 31 7.4 32 7.6

Marital status

Living alone 295 37.1 224 58.3 71 17.2 <0.001**

Living with spouse/ partner 501 62.9 160 41.7 341 82.8

Level of education

Secondary school and lower 487 59.4 278 69.5 209 49.8 <0.001**

High school and upper 333 40.6 122 30.5 211 50.2

Occupation

Having a job 636 78.7 285 73.1 351 84.0 <0.001**

Retired 50 6.2 1 0.3 49 11.7

Unable to work 33 4.1 21 5.4 12 2.9

Jobless 89 11.0 83 21.3 6 1.4

* Student t-test
** Chi-square test

Stages of HIV infection and social supports structure

Of the HIV+ population, 56.3% were taking ART, and 43.8% were asymptomatic and/ or had not yet met the
criteria for treatment. Mean length of living with HIV was 5 years (95% CI = [4.7; 5.3]), and ART patients
having longer time (5.3 years) than those at earlier HIV stage (4.7 years) (p<0.05). Among HIV+ individuals,
52.3% reported historically injecting drug.

The percentage of HIV+ respondents receiving social support services, such as loan, tuition fee for children,
health care, food, medicine, was significantly higher in those with ART (89.2%) than among others (76.0%)
(Chi2=12.3, p<0.01). Peer-group involvement was reported to be similar 44% in the PLHIV taking or not yet
taking ART.

Health-related quality of life

Table 2. Comparison of health-related quality of life between HIV+ population and general population
HIV+ population General population

(N=420) p-value
Taking ART

(N=225)

Not yet required ART
(N=175)

EQ-5 Dimensions n (%) n (%) n (%)

Mobility

No problems 205 (91.1) 165 (94.3) 411 (97.9) <0.01*

Some problems 19 (8.4) 10 (5.7) 9 (2.1)

Severe problems 1 (0.4) 0 (0) 0 (0)

Self-care

No problems 217 (96.4) 173 (98.9) 417 (99.3) 0.07*

Some problems 7 (3.1) 2 (1.1) 3 (0.7)

Severe problems 1 (0.4) 0 (0) 0 (0)

Usual activities

No problems 208 (92.4) 166 (94.9) 410 (97.6) 0.026*

Some problems 15 (6.7) 9 (5.1) 9 (2.1)

Severe problems 2 (0.9) 0 (0) 1 (0.2)

Pain/discomfort

No problems 182 (80.9) 156 (89.1) 395 (94) <0.001*

Some problems 39 (17.3) 19 (10.9) 23 (5.5)

Severe problems 4 (1.8) 0 (0) 2 (0.5)

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No problems 151 (67.1) 119 (68) 369 (87.9) <0.001*

Some problems 62 (27.6) 45 (25.7) 42 (10)

Severe problems 12 (5.3) 11 (6.3) 9 (2.1)

EQ-5D Index score

Median (IQR) 1.00 (0.85 - 1.00) 1.00 (0.85 - 1.00) 1.00 (1.00 - 1.00) <0.001***
Mean (95% CI) 0.88 (0.85 - 0.91) 0.90 (0.88 - 0.93) 0.96 (0.94 - 0.97) <0.001**

VAS score

Mean (95% CI) 65.2 (63.3 - 67.1) 69.3 (66.9 - 71.8) 81.6 (80.3 - 82.9) <0.001**

Median (IQR) 70 (50 - 75) 70 (60 - 80) 80 (75 - 90) <0.001***

* 3x3 Khi-square test for the difference in percentages of reported problems
**Adjusted Wald test

***Kruskal-Wallis equality-of-populations rank test

Adjusting for age and gender, the EQ-5D index and VAS score in early HIV stage people (0.90, 69.3) and
ART patients (0.88, 65.2) were significantly lower than those of the general population (0.96, 81.6) (p<0.001).
The frequency of reported problems across EQ-5D dimensions in the HIV population (2.4% to 30.9%) was
significantly higher than in the general population (0.7% to 12.1%) in every dimension. Compared to ART
patients, those at earlier HIV stages reported having problems at similar proportions across 4 HRQL dimensions
(Table 2), except pain/discomfort, where ART patients had significantly higher proportion (Fisher exact test, p =
0.027).

Table 3: Health-related quality of life of HIV+ adults with and without history of injecting drug

Groups N EQ-5D Index score VAS score

Mean 95% CI p-value Mean 95% CI p-value

Taking ART 225

non IDU 107 0.88 0.84 0.91 0.67* 66.9 63.4 69.4 0.01*

IDU

uplo

ad.1
23do

c.net 0.89 0.85 0.92 63.6 61.3 65.9

Not yet on ART 175

non IDU 84 0.90 0.86 0.93 0.14* 71.0 68.1 73.9 0.85*

IDU 91 0.91 0.88 0.93 67.8 64.9 70.7

Overall 400

non IDU 191 0.88 0.86 0.91 0.61** 68.7 66.5 70.9 0.04**

IDU 209 0.89 0.87 0.92 65.4 63.4 67.5

* Analysis of covariance to compare means adjusted for age and sex

* Analysis of covariance to compare means adjusted for age, sex and disease progression

Table 3 compared HRQL between HIV+ individuals with and without history of injecting drug. At early HIV
stage, both EQ-5D index score and VAS score were not different between the 2 groups. However, during ART,
IDUs reported significantly lower VAS score than non-IDUs (p=0.010)

Predictors of HRQOL among HIV+ population

Multivariate analysis was carried out to examine the influence of socio-demographic variables, HIV-related
factors and social supports structure on HRQL in adults with HIV. Linear regression results determined that
joblessness (p<0.001), having difficulties in accessing to health services (p<0.001) were significant independent

predictors for lower scores in both EQ-5D index and VAS. Moreover, injecting drug behaviours and disease
progression were also associated with lower VAS score in HIV+ population (Table 4).

Table 4: Determinants of HRQOL score in HIV+ populations

Predictors EQ-5D Index score VAS score

Coef. 95% CI p value Coef. 95% CI p value

Predisposing factors

Jobless vs. Working -0.11 -0.16 -0.07 <0.001 -9.90 -13.44 -6.36 <0.001

Female vs. Male -0.01 -0.05 0.03 0.79 0.67 -2.51 3.85 0.68

Single vs. married/ live with partners -0.03 -0.07 0.01 0.17 -1.93 -5.07 1.20 0.23
Secondary school and below vs.

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Age (years) 0.00 -0.01 0.00 0.08 -0.12 -0.36 0.13 0.34
HIV-related factors

Years of living with HIV/AIDS -0.02 -0.04 0.00 0.11 0.72 -1.16 2.60 0.45
Taking ART vs. not yet required

ART -0.02 -0.06 0.02 0.36 -4.19 -7.27 -1.11 0.01

Historically injecting drug vs. Non 0.01 -0.03 0.05 0.52 -3.33 -6.40 -0.26 0.03
Social support structure

Have social supports vs. Non 0.01 -0.06 0.09 0.70 2.16 -3.85 8.17 0.48

Involve in self-help groups vs. Non 0.05 -0.10 0.00 0.07 2.48 -1.96 6.92 0.27

Difficulties in health care access:

No vs. Yes 0.14 0.07 0.21 <0.001 6.42 0.35 12.49 0.04
Barriers in education for children:

No vs. Yes 0.13 0.03 0.22 0.01 0.56 -7.76 8.87 0.90

Table 6 indicated the odd ratios of having problems in various HRQL dimensions. Similarly to HRQL index
and VAS score, joblessness and having barriers to health care services were strongly associated with almost all
HRQL domains. Besides, disease-related progression was also found to influence HRQL dimensions. For every
1 more year living with HIV, the risk of having problems in self-care, usual activities, and anxiety/ depression
increased by 122%, 107% and 29% respectively. In addition, the HIV+ patients taking ART were about 2 times
more likely to have poorer physical health as compared to those had not yet met the criteria for ART.
Furthermore, those without self-help group involvements were 5 times more likely to have problems in usual
activities than others (Table 5).

Table 5: Predictors of having problems in each dimension of HRQL in HIV population

Predictors Mobility Self-care Usual

activities

Pain/
discomfort

Anxiety/
depression
OR p value OR p value OR p value OR p value OR p value

Predisposing factors

Jobless vs. Working 4.82 <0.001 13.38 <0.01 2.88 0.01 2.99 <0.001 2.48 <0.001

Female vs. Male 0.61 0.29 1.05 0.95 1.03 0.94 1.30 0.38 1.32 0.23

Living alone vs. married/

live with partners 0.79 0.60 1.57 0.52 0.93 0.88 1.37 0.29 1.43 0.12
Secondary school and

below vs. higher 1.96 0.17 0.45 0.24 1.49 0.42 1.52 0.20 1.17 0.53

Age (years) 1.02 0.48 0.99 0.77 1.00 0.99 1.02 0.34 1.02 0.32

HIV-related factors
Years of living with

HIV/AIDS 1.49 0.10 2.22 0.09 2.07 0.01 1.07 0.70 1.29 0.06

Taking ART vs. not yet

required ART 1.57 0.26 3.06 0.16 1.41 0.42 1.93 0.03 1.02 0.93

Historically injecting drug

vs. Non-injecting 1.34 0.46 1.27 0.72 0.69 0.37 1.21 0.49 0.70 0.10
Social support structure

Have social supports vs.

Not 1.65 0.65 1.89 0.62 1.61 0.67 2.63 0.21 0.51 0.13

Involve in self-help groups

vs. Not 1.87 0.37 0.29 0.33 6.30 0.03 1.75 0.20 1.33 0.42

Difficulties in health care
access:

No vs. Yes 0.20 0.02 - - 0.19 0.02 0.31 0.02 0.16 <0.001
Barriers in education for

children:

No vs. Yes 0.27 0.13 - - 0.81 0.85 0.29 0.05 0.19 0.01

- : variable dropped

Validity of EQ-5D instruments

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respectively. EQ-5D instrument demonstrated a good cross-sectional construct validity which distinguished
patients at different HIV progression (Table 2).

DISCUSSION

This study, for the first time, measured HRQL in a nationally representative sample of adults living with
HIV, and compared it with HRQL of the general population in Vietnam. We identified substantial impacts of
HIV/AIDS on physical and psychological well-being in adults living with HIV. Particularly, compared with the
general population, the results indicated a considerable negative influence of HIV infection on psychological

functioning.

Several studies have found that physical functioning was worse in AIDS patients than those who had less
advanced HIV disease [4-6]. Our findings were consistent with these prior works. In addition, we found that
ART patients who had history of injecting drugs perceived lower HRQL score than non-IDU. Besides, although
problems in physical functioning were much higher at advanced HIV stage, we observed reported psychological
problems at similar proportions across different HIV stages. This highlighted the demand for early psychosocial
support interventions and health care services for adults with HIV/AIDS, particularly IDUs, in Vietnam

Although ART has been rapidly scaled up in the country, it is necessary to make this service accessible to all
those requiring treatment, which in turn improves quality of life of patients as well as treatment outcomes. In
our study, barriers of access to health care services were identified as significant predictors of decreases in
HRQL. This was in line with previous studies in Vietnamese settings where perceived stigma and access to
HIV-related information influenced health seeking behaviours. HIV testing have been popularly introduced in
the country through friendly HIV voluntary testing and counselling (VCT) services. In fact, scaling up ART
services has the potential to encourage an earlier detection of HIV cases as the accessibility to ARV encourages
testing for HIV infection. For the efficiency of HIV care and treatment programs, it is crucial to improve the
quality of VCT services with particular focus on post-counselling and referrals.

The limitation of our study included the recruitment of respondents which was referred by
peer-HIV-educators. Because of that, we were not able to reach people who had not disclosed their HIV status, and those
who were being at in-patient clinics. Several clinics-based surveys showed a lower HRQL score among patients
initiating treatment and/ or having severe opportunistic infections. However, given the fact that advanced HIV
patients require life-long ART like other chronic illness, after treatment for opportunistic infections, most of
them will be taking drugs at home.

The validity of EQ-5D instruments was shown to be able to measure population health in Vietnam. This
study provides a norm of HRQL in general population in Vietnam that would be useful for identifying
health-related problems in specific population such as HIV/AIDS. Nevertheless, EQ-5D items showed a relatively high
ceiling effect. Application of EQ-5D for measuring changes in health status and in longitudinal assessment,

therefore, should be considered.

Consequently, as the first household survey on the HRQL in HIV+ population in Vietnam, this study
provided comparable and representative evidences for developing health care services and conducting economic
evaluations of HIV care and treatment alternative strategies in Vietnam as well as large-populations in
low-income settings.

References

1. Beard, J., F. Feeley, and S. Rosen, Economic and quality of life outcomes of antiretroviral

therapy for HIV/AIDS in developing countries: a systematic literature review. AIDS Care, 2009.

21(11): p. 1343-56.

2. Clayson, D.J., et al., A comparative review of health-related quality-of-life measures for use in

HIV/AIDS clinical trials. Pharmacoeconomics, 2006. 24(8): p. 751-65.

3. EuroQOL Group, User Guide. Basic information on how to use EQ-5D. @Euro QOL, 2009.

4. Anis, A.H., et al., Quality of life of patients with advanced HIV/AIDS: measuring the impact of

both AIDS-defining events and non-AIDS serious adverse events. J Acquir Immune Defic Syndr,

2009. 51(5): p. 631-9.

5. Tangkawanich, T., et al., Causal model of health: health-related quality of life in people living

with HIV/AIDS in the northern region of Thailand. Nurs Health Sci, 2008. 10(3): p. 216-21.

6. Hays, R.D., et al., Health-related quality of life in patients with human immunodeficiency virus

infection in the United States: results from the HIV Cost and Services Utilization Study. Am J Med,

2000. 108(9): p. 714-22.

</div>

AIDS lần thứ IV năm 2010

<b>Managers perceptions of job satisfaction in HIV prevention and</b>

’

<b>control in Vietnam: A qualitative study</b>

Table 1. Themes and their relations to categories and subcategories

<b>A NEEDS ASSESSMENT OF PLHA SELF-HELP AND SUPPORTED GROUPS (SSGS)</b>

<b>IN VIETNAM</b>

According to the survey, these were the three most necessary skills for groups’ development:

<b>Improving Data Quality to Maximize Using in Program Planning</b>

<b>and Managing, Experience from Pact Vietnam</b>

<b>Sexual Risk Behaviours among Male Migrant Freelance</b>

<b>Labourers in Urban Vietnam: Prevalence and Correlates</b>

for sample surveys of simple random sampling.

Table 1. Selected Socio-Demographic Characteristics

Table 2. Percentage and Level of Correct Responses to Knowledge of HIV/AIDS

Table 3. Prevalence and Levels of Sexual Risk Behaviours for HIV

Table 4. Correlates of Key Factors with Protected Sex Behaviour

<b>A Picture of HIV Drug Resistance in Vietnam and the Region</b>

<b>Todd M. Pollack, MD</b>

<b>Determinants of health-related quality of life in adults with</b>

<b>HIV/AIDS in Vietnam</b>

1. Beard, J., F. Feeley, and S. Rosen, Economic and quality of life outcomes of antiretroviral

therapy for HIV/AIDS in developing countries: a systematic literature review. AIDS Care, 2009.

21(11): p. 1343-56.

2. Clayson, D.J., et al., A comparative review of health-related quality-of-life measures for use in

HIV/AIDS clinical trials. Pharmacoeconomics, 2006. 24(8): p. 751-65.

3. EuroQOL Group, User Guide. Basic information on how to use EQ-5D. @Euro QOL, 2009.

4. Anis, A.H., et al., Quality of life of patients with advanced HIV/AIDS: measuring the impact of

both AIDS-defining events and non-AIDS serious adverse events. J Acquir Immune Defic Syndr,

2009. 51(5): p. 631-9.

5. Tangkawanich, T., et al., Causal model of health: health-related quality of life in people living

with HIV/AIDS in the northern region of Thailand. Nurs Health Sci, 2008. 10(3): p. 216-21.

6. Hays, R.D., et al., Health-related quality of life in patients with human immunodeficiency virus

infection in the United States: results from the HIV Cost and Services Utilization Study. Am J Med,

2000. 108(9): p. 714-22.

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