Geographical Difference in Patient Satisfaction with Healthcare Services for Older Adults in Vietnam

Geographical Difference in Patient Satisfaction with Healthcare Services for Older Adults in Vietnam | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Geographical Difference in Patient Satisfaction with Healthcare Services for Older Adults in Vietnam Nguyen Anh Tuyet, Le Duc Dung, Nguyen Tuan Anh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4720983/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract As economic growth and a rapidly aging population drive substantial demand for healthcare services in Vietnam, it is salient that more attention be paid to assessing patient satisfaction among older adults. Specifically, the study aims to shed light on the critical aspect of patient satisfaction among older adults, which has not been extensively explored in previous research conducted within the country. By utilizing national data from the Vietnam Aging Survey, our analysis showed that approximately 83.2% of older patients were satisfied with healthcare services. Notably, there were significant differences in healthcare service satisfaction between the Northern and Southern regions. Furthermore, healthcare satisfaction varied based on educational levels and social insurance holding status. While insurance coverage and socio-demographic factors played important roles in narrowing the gap between the Northern and Southern regions, the type of facility widened the regional difference in healthcare satisfaction. In light of these results, our study underscores the importance of national policies prioritizing enhancing social insurance mechanisms and improving the quality of healthcare services at the district level in rural areas. These measures are crucial for achieving geographic equity in patient satisfaction with healthcare services in Vietnam. Geriatrics & Gerontology Geographical difference patient satisfaction healthcare older adults Vietnam Introduction Population aging, as one of the four global demographic ‘megatrends’, is projected to bring profound impacts on sustainable development (United Nations, 2019 ). As reported in the Global Status Report on Noncommunicable Diseases, older adults (defined as those aged 65 and over) are at higher risks of age-specific health problems compared to younger age groups in societies (WHO, 2014). Such circumstances have overburdened the healthcare delivery system (WHO, 2022). As a result, it poses huge socio-economic challenges to governments in developing countries, where the health care system for older adults has been underdeveloped. Vietnam is one of the most rapidly aging countries in the Asia-Pacific region due to increasing life expectancies and declining fertility rates (General Statistics Office of Vietnam, 2016 ; United Nations, 2019 ; Giang et al., 2020 ). In addition, various studies indicate that older adults in Vietnam are also more vulnerable to disability, health status, and non-communicable diseases (NCDs) (Dam et al., 2010 ; Le, Leon-Gonzalez, Giang, & Nguyen, 2020 ; Nguyen TA, Giang LT, 2021). Such a substantial change in demographic trends, along with increased risks of diseases due to age-specific health issues, are expected to put greater pressure on Vietnam’s healthcare system in the coming years. The Vietnamese healthcare system is now a mix of public and private facilities (Nguyen & Wilson, 2017 ). The public healthcare facilities include commune health centers (CHCs), district hospitals, provincial hospitals, and central hospitals (World Health Organization, 2016 ). In terms of healthcare services, while affordable services for the general public who have a social health insurance (SHI), premium services for those who can afford and willing to pay for them out-of-pocket (Le, Groot, Tomini, & Tomini, 2018 ). Differences between the two types of healthcare services in terms of facilities, costs, and services offered have also impact on satisfaction levels among patients. However, little is known about how the Vietnamese people in general, and older people in particular measure health care services in practice. Vietnam's shape resembles a rough "S," extending approximately 1,650 kilometers from north to south. Its width from west to east varies, reaching a maximum of around 600 kilometers and narrowing to a minimum of about 50 kilometers (Glassman, Jim, 2015). Although Vietnam's healthcare system has significantly improved since Doi Moi in the late 1980s, regional differences existed in the utilization of healthcare services among older patients in Vietnam, with those residing in the Central region showing a higher tendency to seek healthcare compared to their counterparts in the Northern region (Nguyen TA, Giang LT, 2020). Also, inefficiencies and lack of quality are critical challenges in the healthcare system of Vietnam (Somanathan, Tandon, Dao, Hurt, & Fuenzalida-Puelma, 2014 ; Wagstaff & Lieberman, 2009 ). One of the major reasons is an unequal distribution of health personnel and infrastructure systems between urban and rural areas or geographic regions in Vietnam. Specifically, socio-economic barriers to accessing to healthcare system in rural areas such as long - distance to healthcare stations, lack of facilities, poor service quality, and healthcare costs lead to differences in satisfaction levels between rural and urban people (Somanathan et al., 2014 ; Takashima, Wada, Tra, & Smith, 2017 ). In response to those challenges, the government of Vietnam issued the Vietnam National Action Program for the older adults for the period 2012–2020 under Decision No.1781/QD-TTg in 2012, aiming to improve the quality of care for older persons. Most recently, the Vietnam Ministry of Health promulgated the Health Care for the older adults Project for the period 2017–2025 according to Decision No.7618/QD-BYT in 2017, with the objective to meet older people’s needs for health care by population aging”. Given such existing programs, it is timely and essential to conduct studies on the evaluation of health care satisfaction among older people, aiming to provide informative evidence-based for policymakers. To the best of our knowledge, this is the first study to examine the geographic difference in patient satisfaction with healthcare services for older people in Vietnam. Understanding and measuring health care satisfaction among older people would contribute considerably to formulating or reviewing national plans/policies that meet the specific needs of groups for older people. This study is therefore to examine the geographic difference in patient satisfaction with healthcare services for older people in Vietnam and explore whether the healthcare satisfaction varied due to educational attainment, and social insurance holding status in both places of residence and living regions. Methodology Data source This study used the 2011 Vietnam Ageing Survey (VNAS), a nationally representative survey on aging in Vietnam, as the data input. The objectives, sampling design, and methodologies of VNAS were presented elsewhere in detail (Vietnam Women Union, 2012). In brief, the sample of VNAS was drawn using a multistage stratified random sampling method. Specifically, the probability proportional to size sampling method was used to select provinces, communes, and villages. Respondents were selected randomly in each selected village. At the household level, the survey collected information on income, assets, and housing conditions. Also, information on demographic characteristics (e.g., age, gender, marital status, place of residence, and region), socioeconomic status (e.g., education and employment status), and health were collected at the individual level. A total of 4,007 people aged 50 and older were interviewed. In this study, older people, defined as those who were 60 years of age and older, are of interest which results in a sample of 2,789 people. Furthermore, the sample for this study was restricted to those who used healthcare services in the last 12 months only. The final sample, thus, consisted of 878 older people. Variable measurements Dependent variable The dependent variable in this study was healthcare service satisfaction, which was derived from the question “Overall, how satisfied were you with the healthcare services you received in the last 12 months?” and possible responses were: very satisfied (6.83%); satisfied (77.68%); neither satisfied nor dissatisfied (8.66%); dissatisfied (6.38%); and very dissatisfied (0.46%). Next, we dichotomized the dependent variable [1] : satisfied and dissatisfied. Specifically, those who were satisfied or very satisfied with the healthcare services received were assigned to the satisfied group. Conversely, the dissatisfied group included the remaining three categories (e.g., neither satisfied nor dissatisfied; satisfied; and very satisfied). Independent variables In this study, we controlled for a set of demographic characteristics and socioeconomic status. Specifically, the former set included: age (60-69=1; 70-79=2; and 80+=3); gender (man=0 and women=1); marital status (married=0 and unmarried=1); place of residence (rural=0 and urban=1); region of Vietnam (North=0; Center=1; and South=2); and location of healthcare facilities (Central hospitals=0; Provincial hospitals=1; District hospitals=2; Commune health centers=3; private hospitals/clinics=4; and others=5). The latter set included: education (no schooling/incomplete primary school=0; primary school=1; secondary school=2; and high school and above=3); employment status (non-working=0 and working=1); and social health insurance (no=0 and yes=1). Statistical analysis The existing literature has demonstrated the importance of model specification to avoid biased and misleading estimates (Deb et al., 2017; Pregibon, 1980). In this study, our dependent variable is binary so standard logistic or probit regression models (known as link functions) are appropriate here. We, however, used logistic regression models in this study. Next, we used Pregibon’s link test (Pregibon, 1980) to examine the specification of independent variables. The link test results indicated that the independent variables used here were well specified, as the prediction squared had no explanatory power when we regressed our dependent variable on the prediction and prediction squared (Pregibon, 1980). Also, the variance inflation factor (VIF) was used to check for multicollinearity before we performed regression analysis. The VIF results showed that the VIF value of each dependent variable was smaller than 3, implying there was no evidence of near-perfect linear combinations of one another among independent variables. We first provided a descriptive analysis of respondents’ characteristics, disaggregated by place of residence and region of Vietnam. We used the chi-square test to examine the differences in socio-demographic variables concerning place of residence and region of Vietnam. Logistic regression models were used to determine the association between healthcare satisfaction and independent variables by the full sample and disaggregated by place of residence and region of Vietnam. To examine the association of each set of dependent variables with healthcare satisfaction, we constructed four nested logistic models for the full sample analysis. Specifically, we only controlled for the place of residence and region of Vietnam in Model 1. Socio-demographic characteristics were added to Model 2. Next, we controlled for social health insurance in Model 3 and types of health facilities in Model 4 . In all calculations, we used survey data commands (svy) to account for complex survey designs (e.g., sampling weights and clustering). The results of regression analyses were reported as odds ratio (OR). All statistical analyses used in this study and the significance levels were set at p < 0.05. To answer our research question and examine the hypotheses, i.e. whether health satisfaction rating varies by place of residence and living regions, and whether the evaluation of health care satisfaction among older people might be significantly different due to educational level and social insurance holding status we created four groups (please see Tables 4 and 5 for more details). In the next step, we computed the predicted probability of reporting satisfaction with healthcare services in each hypothetical group by Long and Freese (2014). Furthermore, we examined whether the predicted probabilities among the hypothetical groups showed statistically significant differences using the relevant statistical techniques, as also developed by Long and Freese.. [1] We tested the proportional odds assumption to determine whether ordered logistic/probit regression was appropriate. The result of the likelihood ratio chi-square value ha p<0.000, indicating that ordered logistic/probit regression was not appropriate here. Results [Table 1 about here] Descriptive analyses for the full sample and rural-urban stratification and three regions were presented inTable 1 . The results of rural-urban stratification from columns 1 and 2 show that the majority of patients were generally satisfied with the health services received (83.24%), and that there was no difference in healthcare satisfaction between urban and rural older patients. However, educational levels and types of health facilities used were significantly difference between rural and urban areas. Specifically, while education in rural and urban areas shares its similarity in the percentage of those with the lowest education, it differs from the proportion of those with the highest education, i.e., the proportion of those with the highest education in urban areas is more than doubled as compared to their counterparts in rural areas. High educational attainment was therefore more prevalent in the urban areas. Overall, more than a quarter of respondents (27.91%) used health services at District hospitals, followed by Provincial hospitals (22.65%), Central hospitals (14.84%), private hospitals (12.13%), and CHCs (8.81%). The results also show that healthcare utilization at District and CHC facilities was more prevalent in rural than urban areas, while Central hospitals, Provincial hospitals, and private healthcare services were more utilized by urban residents than their counterparts in rural areas. Columns 3, 4, and 5 summarize the descriptive results disaggregated by living regions, which show significant differences in healthcare satisfaction among the three regions. Out of the three regions, older people living in Northern had the lowest satisfaction rates with health care services. In addition, distributions of educational level, employment status, and types of health facilities used differ significantly among the three living regions. Specifically, older people living in the north were more likely to be educated, not working, and having health treatment in District Hospitals and Central Hospitals compared to those in the South and Central. [Table 2 about here] The multiple logistic regression results for the full sample are presented in Table 2. Model 1 (controlled for place of residence and living region only), shows that older patients living in Southern Vietnam had 3.66 times higher odds of reporting satisfaction with healthcare services than those living in the Northern region, whereas older patients in urban areas had 0.24 times lower probability than rural older patients in reporting healthcare services satisfaction. Adjusting for socio-demographic factors, Model 2, substantially reduced the Southern – the Northern gap by 0.83 times and the urban-rural gap by 0.13 times. Gender and educational level were positively and significantly associated with healthcare satisfaction. Upon the introduction of social health insurance in Model 3, the difference in healthcare satisfaction between Southern and Northern regions was further narrowed (from 2.83 to 2.57 times). Interestingly, controlling for types of facilities factors in Model 4, the Southern - Northern difference in healthcare satisfaction was further widened (from 2.57 to 2.94 times), and remained statistically significant and favored the South. Also, the urban-rural gap in healthcare satisfaction was further widened 0.15 times. These results show that the differences in the distribution of gender, insurance, education and type of facilities can explain a significant degree of the Southern–Northern differences in healthcare satisfaction [Table 3 about here] The Chow test results (not shown here) show that the differences in regression coefficients estimated for urban and rural areas were statistically significant at p-value < 0.01, which implies that the null hypothesis (e.g., the regression coefficients estimated for urban and rural areas were identical) was rejected. Following this, to identify factors associated with the probability of reporting service satisfaction between older people in urban-rural areas and living regions, we estimated separate logistic models in Table 3. Columns 1 and 2 of Table 3 show factors associated with healthcare satisfaction among older people in urban-rural areas. The results show that social health insurance, employment status, and education level were significantly associated with healthcare satisfaction in urban areas, while types of health facility, marital status, educational level, and living region were the determinants of healthcare satisfaction in rural areas. Specifically, those with higher levels of education were less likely to report satisfaction with healthcare services than lower-educated groups in both places of residence. Besides, in urban areas, people who had social health insurance, working, and more educated had 0.03 times, 0.13 times, and 0.22 times, respectively, lower probability of reporting satisfaction with healthcare services than their counterparts in corresponding reference groups. In rural areas, older patients in the South were 4.19 times more likely to be satisfied with healthcare services than their counterparts in the North. In addition, older people who used health services at District Hospital had a 0.19 times lower probability of reporting being satisfied with healthcare services than those who used health services at Central Hospital. Columns 3, 4, and 5 identify factors associated with the healthcare satisfaction of older people among three living regions. The results show that gender and educational level were significantly correlated with healthcare satisfaction for older people living in three regions. Notably, the types of health facilities and social insurance were significantly associated with health care satisfaction used for older patients living in Southern areas. Specifically, in the Southern region, respondents having health insurance were 0.04 times less likely to get satisfied when compared to uninsured. Moreover, the older patients who received health treatment at provincial hospitals and district hospitals had 0.01 times and 0.004 times respectively lower probability of reporting healthcare satisfaction compared to those coming to central hospitals. Probability of reporting healthcare satisfaction among selected groups Vietnam is a lower middle-income country and the healthcare sector faces a number of obstacles, however, the percentage of overall patients satisfied with healthcare services in Vietnam was higher than that reported in previous studies in both developed and developing countries (Yaya et al., 2017; Ali Mostafa et al., 2018; Chandra et al., 2019). Besides, the results from Table 2 indicate that education, social health insurance, and living regions were associated with healthcare satisfaction in both places of residence and living regions. In addition, the majority of older people in Vietnam had no schooling and incomplete primary school due to the War in the past. The question remains whether the probability of health care satisfaction was higher in the lower educational attainment, and social insurance holding status in both places of residence and living regions. To shed light on this issue, Table 4 shows the results from the probability of reporting healthcare satisfaction among four groups in both areas of residence and living regions for all kinds of healthcare facilities. Furthermore, to test our hypotheses raised in the introduction, i.e. whether health satisfaction rating varies by place of residence and living regions, and whether the evaluation of health care satisfaction among older people might be significantly different due to educational level and social insurance holding status, mtable and m lincom command (Long and Freese, 2014) was used for this purpose. The four selected groups for places of residence and living regions were described as follows: Group A: high education and social health insurance. Group B: low education and social health insurance. Group C: high education and without social health insurance. Group D: low education and without social health insurance. [Table 4 about here] The results presented in Table 4 show that, for those with the same characteristics in both places of residence and living regions, the probability of reporting health care satisfaction was lower for urban areas than rural ones across the four groups. For the living region, the probability of service satisfaction in the north was lower than those in the central and the south across groups A, B, and D. Notably, the probability of healthcare satisfaction was the lowest for group A with high education and insurance holder in both areas of residence and living region. In addition, health insurance holders decreased the probability of healthcare satisfaction across the four groups in both places of residence and living region. [Table 5 about here] The results in Table 5 show that differences in the probability of patient satisfaction were statistically significant across the paired-group comparisons, except comparisons of groups C and D for both places of residence and living regions, groups A and B for the Central region, and groups B and C for urban areas only. Thus, there were differences in healthcare satisfaction between the insured and uninsured patients for both rural-urban areas and different regions. Among the insured group, there were differences in service satisfaction between the higher education group and the lower education group in both areas of residence and living region, except for the Central region.Besides, the results (not shown here) show that differences in the probability of patient satisfaction were statistically significant with group A between the north and the south and group B between the central and the south. This confirms that there was a significant difference in older patients among living regions in reporting healthcare satisfaction. Discussion As demographic changes are driving huge demand for healthcare services in Vietnam, it is salient that more attention needs to be paid to assessing patient satisfaction of the older adults because it is an important measure of the quality of service received. This study, using a national representative sample found that about 83.2% of the older patients in Vietnam were satisfied with health care services. The finding from this study was higher than that reported in previous studies in both developed and developing countries in terms of overall satisfaction rate (Ali Mostafa et al., 2018 ; Chandra et al., 2019 ; Hospital, 2016 ; Yaya et al., 2017 ). This could be explained by the fact that more than half of older people in Vietnam had no schooling or incomplete primary school education and the probability of reporting satisfaction with healthcare services was significantly higher in the lower education group. Besides, although the rate of overall satisfaction level was high, the proportion of patients being highly satisfied with the healthcare service was significantly lower (8.9%). In addition, behavioral research has shown that older patients are less demanding and tend to suffer their fate. Thus, lower expectations and higher acceptance of their status may also influence overall satisfaction with healthcare services among older patients (Chumbler et al., 2016 ). The notable research findings indicate that there was a significant difference in healthcare satisfaction among three living regions based on groups of social health insurance holders. Specifically, for those with the same characteristics and having social health insurance, the probability of healthcare satisfaction in the North was lower than those in the Central and the South. In addition, the South-North difference in patient satisfaction in rural areas was much larger than that in urban areas. This could be explain by the fact that healthcare worker satisfaction plays a critical role in providing patient satisfaction (F.K. Yilmaz, S. Karakuş,. 2023). The satisfaction with the attitude and capacities of health professionals in the Northern region in Vietnam was moderately low (Thach Phuong et al.,2023). Notably, our findings showed that while insurance and socio-demographic factors played an important role in narrowing the North-South gaps, the type of facility factor showed a great deal of importance as they widened the North-South difference in patient satisfaction. This might be explained by the fact that there were large regional differences in the number of beds per capita, of which the Northern-Central region had much fewer beds per capita, and in particular fewer provincial beds than the South (Somanathan et al., 2014 ). To address this problem and other major issues, the Vietnam Ministry of Health is currently launching several long-term plans aimed at improving healthcare system delivery such as the Plan for People’s Health Protection, Care, and Improvement in the period 2016–2020 or the Healthcare for the older adults Project for the period 2017–2025 (Vietnam Ministry of Health & Health Partnership Group, 2018). Besides, our findings show that for those with the same characteristics, the probability of reporting satisfaction with healthcare services was higher for rural areas than urban ones. These findings are consistent with previous studies in Scotland that reported urban patients were generally less satisfied with healthcare services compared to rural residents (Farmer et al., 2005 ). Healthcare satisfaction was also found to significantly differ by social health insurance status. The insured patients in urban areas and the South were dissatisfied with the health care service received compared to the uninsured. This finding contrasted with that of relevant research in Gaza (Frimpong & Odonkor, 2019). According to the guidelines from the Ministry of Health, insured patients can only use health services from the registered facilities in the CHS or District hospitals, and must be referred to higher-level facilities. Insured patients who bypass lower-level facilities must pay a higher copayment rate, depending on the level at which they have a health check (e.g. district hospitals (30%), provincial hospitals (50%), and central hospitals (70%)). In practice, the referral mechanisms remain ineffective because of relatively poor quality at the primary level facilities (Somanathan et al., 2014 ). Therefore, a possible explanation for that finding might be the fact that those who had insurance but did not receive medical fee reductions were less satisfied compared to the uninsured. Furthermore, a previous study conducted in Vietnam showed that the major reason for the low level of satisfaction of those insured but not receiving medical fee reductions was the high costs (N. Le et al., 2018 a). Thus, health insurance schemes were likely to suffer from the adverse selection problem, which casts doubt on the sustainability of the health financing system and requires further reform (Ikumi et al., 2017 ). Among the other independent variables, educational attainment was found to be statistically associated with patient satisfaction. Notably, there were differences in healthcare satisfaction between the higher education group and the lower education group in both areas of residence and living region, except for the Central region. People with higher educational levels tend to have less satisfaction with healthcare services than those with lower educational levels. This is in line with the findings in the US (Chumbler et al., 2016 ). It is a fact that healthcare satisfaction used in this study had been self-reported so respondents might take either their experience or their demands, expectations, or perceptions into consideration before making judgments on healthcare services. Thus, this finding contributes to a growing body of behavioral research indicating that lower expectations and higher acceptance of their status may also influence overall satisfaction with health care among older patients. Although the majority of the older patients in rural areas had health visits at the district hospitals, older patients receiving services at the District Hospital in rural areas had a 0.19 times lower probability of reporting being satisfied with healthcare services than those who used health services at Central Hospital. Moreover, the patients having health treatment in the district hospitals had a 0.004 times lower probability of reporting healthcare satisfaction compared to those in the central hospital in the Southern region. A possible reason was that although Vietnam’s grassroots healthcare system with CHCs and district hospitals in rural areas provided remarkably equitable care, these facilities under-performed capacity, availability of drugs, and doctor experience for diagnoses and treatments (World Bank 2016). Thus, the policymaker should prioritize improving the quality of services of health facilities at district levels in rural areas. This approach can help address the challenges currently faced by the healthcare sector. We would like to note some strengths of this study. First, our study is one of the few that explored the geographic differences in patient satisfaction with healthcare services for older people. It is plausible that findings from our study have implications for improving quality and equality in health care services for older patients in both areas of residence and living regions within the same country. Second, the dataset was nationally representative and included a broad range of indicators in terms of socio-economic factors and all types of facilities in Vietnam. Thus, this study contributes to a growing body of behavioral research improving the fact that lower expectations and higher acceptance of their status may also influence overall healthcare satisfaction. Along with these, the findings of this study also add to the existing empirical evidence of socio-economic factors associated with the probability of reporting satisfaction among older people in socio-economic settings. In this study, several limitations that should be acknowledged. Firstly, the utilization of a cross-sectional design may impede the establishment of causal relationships. Second, the potential for omitted variable bias exists. In addition, the data collection method employed, involving interviewer administration, introduces the possibility of either over-reporting or under-reporting. Finally, the Vietnam National Aging Survey (VNAS) did not include data on health facility information and satisfaction with health workers among older people. These factors could be crucial in determining overall patient satisfaction. To address these limitations, we have contemplated the adoption of longitudinal data or the incorporation of updated local/regional-level data for healthcare provision indicators. However, the challenge persists due to the lack of available information on healthcare satisfaction or other related indicators in data. Conclusion In the present study, we attempted to explore the geographic variation in healthcare service satisfaction for older people in Vietnam. Our finding has revealed that there was a significant difference in healthcare satisfaction among older patients in three living regions, in which the probability of service satisfaction in the Northern was lower than those in the Central and Southern regions. Also, the probability of reporting satisfaction with healthcare services was higher for rural areas than urban ones. Notably, health care satisfaction was different due to educational level and social insurance holding status. Specifically, this study has shown that the insured patients in urban areas and the South were dissatisfied with the healthcare service received compared to the uninsured. There is a need to review the policies for older people aiming at different socio-demographic groups to address healthcare service inequalities between both places of residence and living regions. Thus, our study suggests that some national strategy policies should prioritize improving social insurance mechanisms and the quality of healthcare services at district levels in rural areas to achieve geographic equality in patient satisfaction with healthcare services. References Abdelhafez, M. A., Al Qurashi, L., Al Ziyadi, R., Kuwair, A., Shobki, M., & Mograbi, H. (2012). 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" Health insurance and patient satisfaction: Evidence from the poorest regions of Vietnam ," MERIT Working Papers 2018-040, United Nations University - Maastricht Economic and Social Research Institute on Innovation and Technology (MERIT). Le, P. T., & Fitzgerald, G. (2016). R E S E A RC H AR T I C LE A Study on Patient Satisfaction at Khanh Hoa Provincial General Hospital . January 2013 . Levinton, C., Veillard, J., Slutsky, A., & Brown, A. (2011). The importance of place of residence in patient satisfaction. International Journal for Quality in Health Care , 23 (5), 495–502. https://doi.org/10.1093/intqhc/mzr048 Long, J. S., & Freese, J. (2014). Regression models for categorical dependent variables using Stata (3rd ed.). Stata Press. Luan, N. T., Komonpaisarn, T., Sriratanaban, J., & Vy, H. A. T. (2018). Patient Satisfaction and Quality of Healthcare: Case of Hospitals in Ho Chi Minh City. PSAKU International Journal of Interdisciplinary Research , 3 (1), 77–92. https://doi.org/10.12778/235108618x15452373185318 Maślach, D., Karczewska, B., Szpak, A., Charkiewicz, A., & Krzyżak, M. (2020). Does place of residence affect patient satisfaction with hospital health care? Annals of Agricultural and Environmental Medicine , 27 (1), 86–90. https://doi.org/10.26444/aaem/116574 Mohamed, E. Y., Sami, W., Alotaibi, A., Alfarag, A., Almutairi, A., & Alanzi, F. (2015). Patients’ Satisfaction with Primary Health Care Centers’ Services, Majmaah, Kingdom of Saudi Arabia. International Journal of Health Sciences , 9 (2), 163–170. Nguyen, M. P., & Wilson, A. (2017). Perspective How Could Private Healthcare Better Contribute to Healthcare Coverage in Vietnam ? 6 (6), 305–308. https://doi.org/10.15171/ijhpm.2017.05 Nguyen, T. A., & Giang, L. T. (2020). Factors Associated with Regional Disparity in Utilization of Healthcare Services among the Vietnamese Older People. Journal of Population and Social Studies [JPSS], 29(-), 15–31. Retrieved from https://so03.tci-thaijo.org/index.php/jpss/article/view/240847 Nguyen TA, Giang LT. Factors Influencing the Vietnamese Older Persons in Choosing Healthcare Facilities. Health Serv Insights. 2021 Jun 9;14:11786329211017426. doi: 10.1177/11786329211017426. PMID: 34177269; PMCID: PMC8193656. Pregibon, D. (1980). Goodness of Link Tests for Generalized Linear Models. Applied Statistics , 29 (1), 15. https://doi.org/10.2307/2346405 Rechel, B., Doyle, Y., Grundy, E., & Mckee, M. (2009). How can health systems respond to population aging ? WHO Europe , 43. http://www.euro.who.int/__data/assets/pdf_file/0004/64966/E92560.pdf Somanathan, A., Tandon, A., Dao, H. L., Hurt, K. L., & Fuenzalida-Puelma, H. L. (2014). Moving toward Universal Coverage of Social Health Insurance in Vietnam: Assessment and Options. In Moving toward Universal Coverage of Social Health Insurance in Vietnam: Assessment and Options . https://doi.org/10.1596/978-1-4648-0261-4 Takashima, K., Wada, K., Tra, T. T., & Smith, D. R. (2017). A review of Vietnam’s healthcare reform through the Direction of Healthcare Activities (DOHA). Environmental Health and Preventive Medicine , 22 (1), 74. https://doi.org/10.1186/s12199-017-0682-z Thach Phuong, N., Vu Hoang, P., Mac Dang, T., Nguyen Thi Huyen, T., & Ngo Thi, T. (2023). Improving Hospital’s Quality of Service in Vietnam: The Patient Satisfaction Evaluation in Multiple Health Facilities. Hospital Topics , 101 (2), 73–83. https://doi.org/10.1080/00185868.2021.1969871 Thi Thu Ha, B., Mirzoev, T., & Morgan, R. (2015). Patient complaints in healthcare services in Vietnam’s health system. SAGE Open Medicine , 3 , 205031211561012. https://doi.org/10.1177/2050312115610127 Tran, B. X., Nguyen, L. H., Nong, V. M., & Nguyen, C. T. (2016). Health status and health service utilization in remote and mountainous areas in Vietnam. Health and Quality of Life Outcomes , 14 (1), 85. https://doi.org/10.1186/s12955-016-0485-8 Tran, N. L. T., Wassmer, R. W., & Lascher, E. L. (2017). The Health Insurance and Life Satisfaction Connection. Journal of Happiness Studies , 18 (2), 409–426. https://doi.org/10.1007/s10902-016-9729-x United Nations (2019). Department of Economic and Social Affairs, P. D. World Population Ageing 2019: Highlights (ST/ESA/SER.A/430) .Vietnam Women Union. (2012). Vietnam AgingAging Survey (VNAS) 2011: Key findings . Women Publishing House. Vuong, Q. H. (2018). Sociodemographic factors influencing Vietnamese patient satisfaction with healthcare services and some meaningful empirical thresholds. Iranian Journal of Public Health , 47 (1), 119–126. Wagstaff, A., & Lieberman, S. S. (2009). Health Financing and Delivery in Vietnam . The World Bank. https://doi.org/10.1596/978-0-8213-7782-6 World Health Organization. (2014). Global status report on noncommunicable diseases 2014 . World Health Organization. (2016). Viet Nam: Human Resources for Health–Country Profile. World Health Organization. World Health Organization. (2022). Aging and Health: Key facts . Available online https://www.who.int/news-room/fact-sheets/detail/ageing-and-health Yaya, S., Bishwajit, G., Ekholuenetale, M., Shah, V., Kadio, B., & Udenigwe, O. (2017). The urban-rural difference in satisfaction with primary healthcare services in Ghana. BMC Health Services Research , 17 (1), 1–9. https://doi.org/10.1186/s12913-017-2745-7 Tables Tables 1 to 5 are available in the Supplementary Files section Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4720983","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":325424039,"identity":"03a4d6f9-f546-45f0-bbb8-53be642d7230","order_by":0,"name":"Nguyen Anh Tuyet","email":"data:image/png;base64,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","orcid":"","institution":"osaka school of international public policy","correspondingAuthor":true,"prefix":"","firstName":"Nguyen","middleName":"Anh","lastName":"Tuyet","suffix":""},{"id":325424040,"identity":"92aae1ae-8aba-448e-a7e5-dd598c687782","order_by":1,"name":"Le Duc Dung","email":"","orcid":"","institution":"Waseda institute for advanced study","correspondingAuthor":false,"prefix":"","firstName":"Le","middleName":"Duc","lastName":"Dung","suffix":""},{"id":325424041,"identity":"881d9064-fd89-4f59-bba6-c60c7477aa21","order_by":2,"name":"Nguyen Tuan Anh","email":"","orcid":"","institution":"Department of Social and Economic Studies at the Institute for Southeast Asian Studies, Vietnam Academy of Social Sciences","correspondingAuthor":false,"prefix":"","firstName":"Nguyen","middleName":"Tuan","lastName":"Anh","suffix":""}],"badges":[],"createdAt":"2024-07-11 00:53:59","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4720983/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4720983/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60120640,"identity":"3bbebff4-268d-447f-b9ac-eba9bdba4e14","added_by":"auto","created_at":"2024-07-12 04:37:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":355216,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4720983/v1/6ca0cd31-bb53-4573-91a1-278fe6bb33ce.pdf"},{"id":60120128,"identity":"1e9f5c7d-610c-4596-9f60-8300b26cb4eb","added_by":"auto","created_at":"2024-07-12 04:29:21","extension":"doc","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":202752,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.doc","url":"https://assets-eu.researchsquare.com/files/rs-4720983/v1/e475eae7dded19ebd7caab82.doc"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eGeographical Difference in Patient Satisfaction with Healthcare Services for Older Adults in Vietnam\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePopulation aging, as one of the four global demographic \u0026lsquo;megatrends\u0026rsquo;, is projected to bring profound impacts on sustainable development (United Nations, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). As reported in the Global Status Report on Noncommunicable Diseases, older adults (defined as those aged 65 and over) are at higher risks of age-specific health problems compared to younger age groups in societies (WHO, 2014). Such circumstances have overburdened the healthcare delivery system (WHO, 2022). As a result, it poses huge socio-economic challenges to governments in developing countries, where the health care system for older adults has been underdeveloped.\u003c/p\u003e \u003cp\u003eVietnam is one of the most rapidly aging countries in the Asia-Pacific region due to increasing life expectancies and declining fertility rates (General Statistics Office of Vietnam, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; United Nations, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Giang et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In addition, various studies indicate that older adults in Vietnam are also more vulnerable to disability, health status, and non-communicable diseases (NCDs) (Dam et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Le, Leon-Gonzalez, Giang, \u0026amp; Nguyen, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Nguyen TA, Giang LT, 2021). Such a substantial change in demographic trends, along with increased risks of diseases due to age-specific health issues, are expected to put greater pressure on Vietnam\u0026rsquo;s healthcare system in the coming years.\u003c/p\u003e \u003cp\u003eThe Vietnamese healthcare system is now a mix of public and private facilities (Nguyen \u0026amp; Wilson, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The public healthcare facilities include commune health centers (CHCs), district hospitals, provincial hospitals, and central hospitals (World Health Organization, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). In terms of healthcare services, while affordable services for the general public who have a social health insurance (SHI), premium services for those who can afford and willing to pay for them out-of-pocket (Le, Groot, Tomini, \u0026amp; Tomini, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Differences between the two types of healthcare services in terms of facilities, costs, and services offered have also impact on satisfaction levels among patients. However, little is known about how the Vietnamese people in general, and older people in particular measure health care services in practice.\u003c/p\u003e \u003cp\u003eVietnam's shape resembles a rough \"S,\" extending approximately 1,650 kilometers from north to south. Its width from west to east varies, reaching a maximum of around 600 kilometers and narrowing to a minimum of about 50 kilometers (Glassman, Jim, 2015). Although Vietnam's healthcare system has significantly improved since Doi Moi in the late 1980s, regional differences existed in the utilization of healthcare services among older patients in Vietnam, with those residing in the Central region showing a higher tendency to seek healthcare compared to their counterparts in the Northern region (Nguyen TA, Giang LT, 2020). Also, inefficiencies and lack of quality are critical challenges in the healthcare system of Vietnam (Somanathan, Tandon, Dao, Hurt, \u0026amp; Fuenzalida-Puelma, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Wagstaff \u0026amp; Lieberman, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). One of the major reasons is an unequal distribution of health personnel and infrastructure systems between urban and rural areas or geographic regions in Vietnam. Specifically, socio-economic barriers to accessing to healthcare system in rural areas such as long - distance to healthcare stations, lack of facilities, poor service quality, and healthcare costs lead to differences in satisfaction levels between rural and urban people (Somanathan et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Takashima, Wada, Tra, \u0026amp; Smith, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn response to those challenges, the government of Vietnam issued the Vietnam National Action Program for the older adults for the period 2012\u0026ndash;2020 under Decision No.1781/QD-TTg in 2012, aiming to improve the quality of care for older persons. Most recently, the Vietnam Ministry of Health promulgated the Health Care for the older adults Project for the period 2017\u0026ndash;2025 according to Decision No.7618/QD-BYT in 2017, with the objective to meet older people\u0026rsquo;s needs for health care by population aging\u0026rdquo;. Given such existing programs, it is timely and essential to conduct studies on the evaluation of health care satisfaction among older people, aiming to provide informative evidence-based for policymakers.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this is the first study to examine the geographic difference in patient satisfaction with healthcare services for older people in Vietnam. Understanding and measuring health care satisfaction among older people would contribute considerably to formulating or reviewing national plans/policies that meet the specific needs of groups for older people. This study is therefore to examine the geographic difference in patient satisfaction with healthcare services for older people in Vietnam and explore whether the healthcare satisfaction varied due to educational attainment, and social insurance holding status in both places of residence and living regions.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eData source\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study used the 2011 Vietnam Ageing Survey (VNAS), a nationally representative survey on aging in Vietnam, as the data input. The objectives, sampling design, and methodologies of VNAS were presented elsewhere in detail\u0026nbsp;(Vietnam Women Union, 2012). In brief, the sample of VNAS was drawn using a multistage stratified random sampling method. Specifically, the probability proportional to size sampling method was used to select provinces, communes, and villages. Respondents were selected randomly in each selected village. At the household level, the survey collected information on income, assets, and housing conditions. Also, information on demographic characteristics (e.g., age, gender, marital status, place of residence, and region), socioeconomic status (e.g., education and employment status), and health were collected at the individual level. A total of 4,007 people aged 50 and older were interviewed. In this study, older people, defined as those who were 60 years of age and older, are of interest which results in a sample of 2,789 people. Furthermore, the sample for this study was restricted to those who used healthcare services in the last 12 months only. The final sample, thus, consisted of 878 older people.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVariable measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDependent variable\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe dependent variable in this study was healthcare service satisfaction, which was derived from the question “Overall, how satisfied were you with the healthcare services you received in the last 12 months?” and possible responses were: very satisfied (6.83%); satisfied (77.68%); neither satisfied nor dissatisfied (8.66%); dissatisfied (6.38%); and very dissatisfied (0.46%). Next, we dichotomized the dependent variable\u003ca href=\"#_ftn1\" name=\"_ftnref1\" title=\"\"\u003e[1]\u003c/a\u003e: satisfied and dissatisfied. Specifically, those who were satisfied or very satisfied with the healthcare services received were assigned to the satisfied group. Conversely, the dissatisfied group included the remaining three categories (e.g., neither satisfied nor dissatisfied; satisfied; and very satisfied).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIndependent variables\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, we controlled for a set of demographic characteristics and socioeconomic status. Specifically, the former set included: age (60-69=1; 70-79=2; and 80+=3); gender (man=0 and women=1); marital status (married=0 and unmarried=1); place of residence (rural=0 and urban=1); region of Vietnam (North=0; Center=1; and South=2); and location of healthcare facilities (Central hospitals=0; Provincial hospitals=1; District hospitals=2; Commune health centers=3; private hospitals/clinics=4; and others=5). The latter set included: education (no schooling/incomplete primary school=0; primary school=1; secondary school=2; and high school and above=3); employment status (non-working=0 and working=1); and social health insurance (no=0 and yes=1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe existing literature has demonstrated the importance of model specification to avoid biased and misleading estimates\u0026nbsp;(Deb et al., 2017; Pregibon, 1980). In this study, our dependent variable is binary so standard logistic or probit regression models (known as link functions) are appropriate here. We, however, used logistic regression models in this study. Next, we used Pregibon’s link test\u0026nbsp;(Pregibon, 1980)\u0026nbsp;to examine the specification of independent variables. The link test results indicated that the independent variables used here were well specified, as the prediction squared had no explanatory power when we regressed our dependent variable on the prediction and prediction squared\u0026nbsp;(Pregibon, 1980). Also, the variance inflation factor (VIF) was used to check for multicollinearity before we performed regression analysis. The VIF results showed that the VIF value of each dependent variable was smaller than 3, implying there was no evidence of near-perfect linear combinations of one another among independent variables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe first provided a descriptive analysis of respondents’ characteristics, disaggregated by place of residence and region of Vietnam. We used the chi-square test to examine the differences in socio-demographic variables concerning place of residence and region of Vietnam. Logistic regression models were used to determine the association between healthcare satisfaction and independent variables by the full sample and disaggregated by place of residence and region of Vietnam. To examine the association of each set of dependent variables with healthcare satisfaction, we constructed four nested logistic models for the full sample analysis. Specifically, we only controlled for the place of residence and region of Vietnam in \u003cstrong\u003eModel 1.\u003c/strong\u003e Socio-demographic characteristics were added to \u003cstrong\u003eModel 2.\u003c/strong\u003e Next, we controlled for social health insurance in \u003cstrong\u003eModel 3\u003c/strong\u003e and types of health facilities in \u003cstrong\u003eModel 4\u003c/strong\u003e. In all calculations, we used survey data commands (svy) to account for complex survey designs (e.g., sampling weights and clustering). The results of regression analyses were reported as odds ratio (OR). All statistical analyses used in this study and the significance levels were set at \u003cem\u003ep\u003c/em\u003e\u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003eTo answer our research question and examine the hypotheses, i.e. whether health satisfaction rating varies by place of residence and living regions, and whether the evaluation of health care satisfaction among older people might be significantly different due to educational level and social insurance holding status we created four groups (please see Tables 4 and 5 for more details). In the next step, we computed the predicted probability of reporting satisfaction with healthcare services in each hypothetical group by Long and Freese (2014). Furthermore, we examined whether the predicted probabilities among the hypothetical groups showed statistically significant differences using the relevant statistical techniques, as also developed by Long and Freese..\u0026nbsp;\u003c/p\u003e\n\u003cdiv id=\"ftn1\"\u003e\n \u003cp\u003e\u003ca href=\"#_ftnref1\" name=\"_ftn1\" title=\"\"\u003e[1]\u003c/a\u003eWe tested the proportional odds assumption to determine whether ordered logistic/probit regression was appropriate. The result of the likelihood ratio chi-square value ha p\u0026lt;0.000, indicating that ordered logistic/probit regression was not appropriate here.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e[Table 1 about here]\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive analyses for the full sample and rural-urban stratification and three regions were presented inTable 1\u003cstrong\u003e.\u003c/strong\u003e The results of rural-urban stratification from columns 1 and 2 show that the majority of patients were generally satisfied with the health services received (83.24%), and that there was no difference in healthcare satisfaction between urban and rural older patients. However,\u0026nbsp;educational levels\u0026nbsp;and types of health facilities used were significantly difference between rural and urban areas. Specifically,\u0026nbsp;while education in rural and urban areas shares its similarity in the percentage of those with the lowest education, it differs from the proportion of those with the highest education, i.e., the proportion of those with the highest education in urban areas is more than doubled as compared to their counterparts in rural areas.\u0026nbsp;High educational attainment was therefore more prevalent in the urban areas.\u0026nbsp;Overall, more than a quarter of respondents (27.91%) used health services at\u0026nbsp;District\u0026nbsp;hospitals,\u0026nbsp;followed by Provincial hospitals (22.65%),\u0026nbsp;Central\u0026nbsp;hospitals\u0026nbsp;(14.84%), private hospitals\u0026nbsp;(12.13%), and CHCs\u0026nbsp;(8.81%).\u0026nbsp;The results\u0026nbsp;also show that healthcare utilization at District and CHC facilities was more prevalent in rural than urban areas, while\u0026nbsp;Central\u0026nbsp;hospitals, Provincial hospitals, and private healthcare services were more utilized by urban residents than their counterparts in rural areas.\u003c/p\u003e\n\u003cp\u003eColumns 3, 4, and 5 summarize the descriptive results disaggregated by living regions, which show significant differences in healthcare satisfaction among the three regions. Out of the three regions, older people living in Northern had the lowest satisfaction rates with health care services. In addition, distributions of\u0026nbsp;educational level,\u0026nbsp;employment status,\u0026nbsp;and types of health facilities used differ significantly among the three living regions. Specifically, older people living in the north were more likely to be educated, not working, and having health treatment in District Hospitals and Central Hospitals compared to those in the South and Central.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e[Table 2 about here]\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe multiple logistic regression results for the full sample are presented in Table 2. Model 1 (controlled for place\u0026nbsp;of residence\u0026nbsp;and living\u0026nbsp;region\u0026nbsp;only), shows that older patients living in Southern Vietnam had 3.66 times higher odds of reporting satisfaction with healthcare services than those living in the Northern region, whereas older patients in urban areas had 0.24 times lower probability than rural older patients in reporting healthcare services satisfaction. Adjusting for socio-demographic factors, Model 2, substantially reduced the Southern – the Northern gap by 0.83 times and the urban-rural gap by 0.13 times. Gender and educational level were positively and significantly associated with healthcare satisfaction. Upon the introduction of social health insurance in Model 3, the difference in healthcare satisfaction between Southern and Northern regions was further narrowed (from 2.83 to 2.57 times). Interestingly, controlling for types of facilities factors in Model 4, the Southern - Northern difference in healthcare satisfaction was further widened (from 2.57 to 2.94 times), and remained statistically significant and favored the South. Also, the urban-rural gap in healthcare satisfaction was further widened 0.15 times. These results show that the differences in the distribution of gender, insurance, education and type of facilities can explain a significant degree of the Southern–Northern differences in healthcare satisfaction\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e[Table 3 about here]\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Chow test results (not shown here) show that the differences in regression coefficients estimated for urban and rural areas were statistically significant at p-value \u0026lt; 0.01, which implies that the null hypothesis (e.g., the regression coefficients estimated for urban and rural areas were identical) was rejected. Following this, to identify factors associated with the probability of reporting service satisfaction between older people in urban-rural areas and living regions, we estimated separate logistic models in Table 3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eColumns 1 and 2 of Table 3 show factors associated with healthcare satisfaction among older people in urban-rural areas. The results show that social health insurance, employment status, and education level were significantly associated with healthcare satisfaction in urban areas, while types of health facility, marital status, educational level, and living region were the determinants of healthcare satisfaction in rural areas. Specifically, those with higher levels of education were less likely to report satisfaction with healthcare services than lower-educated groups in both places of residence. Besides, in urban areas, people who had social health insurance, working, and more educated had 0.03 times, 0.13 times, and 0.22 times, respectively, lower probability of reporting satisfaction with healthcare services than their counterparts in corresponding reference groups. In rural areas, older patients in the South were 4.19 times more likely to be satisfied with healthcare services than their counterparts in the North. In addition, older people who used health services at District Hospital had a 0.19 times lower probability of reporting being satisfied with healthcare services than those who used health services at Central Hospital.\u003c/p\u003e\n\u003cp\u003eColumns 3, 4, and 5 identify factors associated with the healthcare satisfaction of older people among three living regions. The results show that gender and educational level were significantly correlated with healthcare satisfaction for older people living in three regions. Notably, the types of health facilities and social insurance were significantly associated with health care satisfaction used for older patients living in Southern areas. Specifically, in the Southern region, respondents having health insurance were 0.04 times less likely to get satisfied when compared to uninsured. Moreover, the older patients who received health treatment at provincial hospitals and district hospitals had 0.01 times and 0.004 times respectively lower probability of reporting healthcare satisfaction compared to those coming to central hospitals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProbability of reporting healthcare satisfaction among selected groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVietnam is a lower middle-income country and\u0026nbsp;the healthcare sector faces a number of obstacles, however, the percentage of overall patients satisfied with healthcare services in Vietnam was higher than that reported in previous studies in both developed and developing countries\u0026nbsp;(Yaya et al., 2017; Ali Mostafa et al., 2018; Chandra et al., 2019). Besides, the results from Table 2 indicate that education, social health insurance, and living regions were associated with healthcare satisfaction in both\u0026nbsp;places of residence and\u0026nbsp;living regions. In addition, the majority of older people in Vietnam had\u0026nbsp;no schooling and incomplete primary school due to the War in the past.\u0026nbsp;The question remains whether the probability of health care satisfaction was higher in the lower educational attainment, and social insurance holding status in both\u0026nbsp;places of residence and\u0026nbsp;living regions. To shed light on this issue, Table 4 shows the results from the probability of reporting healthcare satisfaction\u0026nbsp;among four groups in both\u0026nbsp;areas of residence and\u0026nbsp;living regions for all kinds of healthcare facilities. Furthermore, to test our hypotheses raised in the introduction, i.e. whether health satisfaction rating varies by place of residence and living regions, and whether the evaluation of health care satisfaction among older people might be significantly different due to educational level and social insurance holding status,\u0026nbsp;\u003cem\u003emtable and m\u003c/em\u003e\u003cem\u003elincom\u003c/em\u003e command (Long and Freese, 2014)\u0026nbsp;was used for this purpose.\u003c/p\u003e\n\u003cp\u003eThe four selected groups for places of residence and living regions were described as follows:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGroup A: high education and social health insurance.\u003c/p\u003e\n\u003cp\u003eGroup B: low education and social health insurance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGroup C: high education and without social health insurance.\u003c/p\u003e\n\u003cp\u003eGroup D: low education and without social health insurance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e[Table 4 about here]\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results presented in Table 4 show that, for those with the same characteristics in both places\u0026nbsp;of residence and\u0026nbsp;living regions, the probability of reporting health care satisfaction was lower for urban areas than rural ones across the four groups. For the\u0026nbsp;living region,\u0026nbsp;the probability of service satisfaction in the north was lower than those in the central and the south across groups A, B, and D. Notably, the probability of healthcare satisfaction was the lowest for group A with high education and insurance holder in both\u0026nbsp;areas of residence and\u0026nbsp;living region. In addition, health insurance holders decreased the probability of healthcare satisfaction across the four groups in both\u0026nbsp;places of residence and\u0026nbsp;living region.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e[Table 5 about here]\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results in Table 5 show that differences in the probability of patient satisfaction were statistically significant across the paired-group comparisons, except comparisons of groups C and D for both\u0026nbsp;places of residence and\u0026nbsp;living regions, groups A and B for the Central region, and groups B and C for urban areas only. Thus, there were differences in healthcare satisfaction between the insured and uninsured patients for both rural-urban areas and different regions. Among the insured group, there were differences in service satisfaction between the higher education group and the lower education group in both\u0026nbsp;areas of residence and\u0026nbsp;living region,\u0026nbsp;except for the Central region.Besides, the results (not shown here) show that differences in the probability of patient satisfaction were statistically significant with group A between the north and the south and group B between the central and the south. This confirms that there was a significant difference in older patients among living regions in reporting healthcare satisfaction.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs demographic changes are driving huge demand for healthcare services in Vietnam, it is salient that more attention needs to be paid to assessing patient satisfaction of the older adults because it is an important measure of the quality of service received. This study, using a national representative sample found that about 83.2% of the older patients in Vietnam were satisfied with health care services. The finding from this study was higher than that reported in previous studies in both developed and developing countries in terms of overall satisfaction rate (Ali Mostafa et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Chandra et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Hospital, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Yaya et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This could be explained by the fact that more than half of older people in Vietnam had no schooling or incomplete primary school education and the probability of reporting satisfaction with healthcare services was significantly higher in the lower education group. Besides, although the rate of overall satisfaction level was high, the proportion of patients being highly satisfied with the healthcare service was significantly lower (8.9%). In addition, behavioral research has shown that older patients are less demanding and tend to suffer their fate. Thus, lower expectations and higher acceptance of their status may also influence overall satisfaction with healthcare services among older patients (Chumbler et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe notable research findings indicate that there was a significant difference in healthcare satisfaction among three living regions based on groups of social health insurance holders. Specifically, for those with the same characteristics and having social health insurance, the probability of healthcare satisfaction in the North was lower than those in the Central and the South. In addition, the South-North difference in patient satisfaction in rural areas was much larger than that in urban areas. This could be explain by the fact that healthcare worker satisfaction plays a critical role in providing patient satisfaction (F.K. Yilmaz, S. Karakuş,. 2023). The satisfaction with the attitude and capacities of health professionals in the Northern region in Vietnam was moderately low (Thach Phuong et al.,2023). Notably, our findings showed that while insurance and socio-demographic factors played an important role in narrowing the North-South gaps, the type of facility factor showed a great deal of importance as they widened the North-South difference in patient satisfaction. This might be explained by the fact that there were large regional differences in the number of beds per capita, of which the Northern-Central region had much fewer beds per capita, and in particular fewer provincial beds than the South (Somanathan et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). To address this problem and other major issues, the Vietnam Ministry of Health is currently launching several long-term plans aimed at improving healthcare system delivery such as the Plan for People\u0026rsquo;s Health Protection, Care, and Improvement in the period 2016\u0026ndash;2020 or the Healthcare for the older adults Project for the period 2017\u0026ndash;2025 (Vietnam Ministry of Health \u0026amp; Health Partnership Group, 2018). Besides, our findings show that for those with the same characteristics, the probability of reporting satisfaction with healthcare services was higher for rural areas than urban ones. These findings are consistent with previous studies in Scotland that reported urban patients were generally less satisfied with healthcare services compared to rural residents (Farmer et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2005\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealthcare satisfaction was also found to significantly differ by social health insurance status. The insured patients in urban areas and the South were dissatisfied with the health care service received compared to the uninsured. This finding contrasted with that of relevant research in Gaza (Frimpong \u0026amp; Odonkor, 2019). According to the guidelines from the Ministry of Health, insured patients can only use health services from the registered facilities in the CHS or District hospitals, and must be referred to higher-level facilities. Insured patients who bypass lower-level facilities must pay a higher copayment rate, depending on the level at which they have a health check (e.g. district hospitals (30%), provincial hospitals (50%), and central hospitals (70%)). In practice, the referral mechanisms remain ineffective because of relatively poor quality at the primary level facilities (Somanathan et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Therefore, a possible explanation for that finding might be the fact that those who had insurance but did not receive medical fee reductions were less satisfied compared to the uninsured. Furthermore, a previous study conducted in Vietnam showed that the major reason for the low level of satisfaction of those insured but not receiving medical fee reductions was the high costs (N. Le et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2018\u003c/span\u003ea). Thus, health insurance schemes were likely to suffer from the adverse selection problem, which casts doubt on the sustainability of the health financing system and requires further reform (Ikumi et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong the other independent variables, educational attainment was found to be statistically associated with patient satisfaction. Notably, there were differences in healthcare satisfaction between the higher education group and the lower education group in both areas of residence and living region, except for the Central region. People with higher educational levels tend to have less satisfaction with healthcare services than those with lower educational levels. This is in line with the findings in the US (Chumbler et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). It is a fact that healthcare satisfaction used in this study had been self-reported so respondents might take either their experience or their demands, expectations, or perceptions into consideration before making judgments on healthcare services. Thus, this finding contributes to a growing body of behavioral research indicating that lower expectations and higher acceptance of their status may also influence overall satisfaction with health care among older patients.\u003c/p\u003e \u003cp\u003eAlthough the majority of the older patients in rural areas had health visits at the district hospitals, older patients receiving services at the District Hospital in rural areas had a 0.19 times lower probability of reporting being satisfied with healthcare services than those who used health services at Central Hospital. Moreover, the patients having health treatment in the district hospitals had a 0.004 times lower probability of reporting healthcare satisfaction compared to those in the central hospital in the Southern region. A possible reason was that although Vietnam\u0026rsquo;s grassroots healthcare system with CHCs and district hospitals in rural areas provided remarkably equitable care, these facilities under-performed capacity, availability of drugs, and doctor experience for diagnoses and treatments (World Bank 2016). Thus, the policymaker should prioritize improving the quality of services of health facilities at district levels in rural areas. This approach can help address the challenges currently faced by the healthcare sector.\u003c/p\u003e \u003cp\u003eWe would like to note some strengths of this study. First, our study is one of the few that explored the geographic differences in patient satisfaction with healthcare services for older people. It is plausible that findings from our study have implications for improving quality and equality in health care services for older patients in both areas of residence and living regions within the same country. Second, the dataset was nationally representative and included a broad range of indicators in terms of socio-economic factors and all types of facilities in Vietnam. Thus, this study contributes to a growing body of behavioral research improving the fact that lower expectations and higher acceptance of their status may also influence overall healthcare satisfaction. Along with these, the findings of this study also add to the existing empirical evidence of socio-economic factors associated with the probability of reporting satisfaction among older people in socio-economic settings.\u003c/p\u003e \u003cp\u003eIn this study, several limitations that should be acknowledged. Firstly, the utilization of a cross-sectional design may impede the establishment of causal relationships. Second, the potential for omitted variable bias exists. In addition, the data collection method employed, involving interviewer administration, introduces the possibility of either over-reporting or under-reporting. Finally, the Vietnam National Aging Survey (VNAS) did not include data on health facility information and satisfaction with health workers among older people. These factors could be crucial in determining overall patient satisfaction. To address these limitations, we have contemplated the adoption of longitudinal data or the incorporation of updated local/regional-level data for healthcare provision indicators. However, the challenge persists due to the lack of available information on healthcare satisfaction or other related indicators in data.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn the present study, we attempted to explore the geographic variation in healthcare service satisfaction for older people in Vietnam. Our finding has revealed that there was a significant difference in healthcare satisfaction among older patients in three living regions, in which the probability of service satisfaction in the Northern was lower than those in the Central and Southern regions. Also, the probability of reporting satisfaction with healthcare services was higher for rural areas than urban ones. Notably, health care satisfaction was different due to educational level and social insurance holding status. Specifically, this study has shown that the insured patients in urban areas and the South were dissatisfied with the healthcare service received compared to the uninsured. There is a need to review the policies for older people aiming at different socio-demographic groups to address healthcare service inequalities between both places of residence and living regions. Thus, our study suggests that some national strategy policies should prioritize improving social insurance mechanisms and the quality of healthcare services at district levels in rural areas to achieve geographic equality in patient satisfaction with healthcare services.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAbdelhafez, M. A., Al Qurashi, L., Al Ziyadi, R., Kuwair, A., Shobki, M., \u0026amp; Mograbi, H. (2012). Analysis of Factors Affecting the Satisfaction Levels of Patients Toward Food Services at General Hospitals in Makkah, Saudi Arabia. \u003cem\u003eAmerican Journal of Medicine and Medical Sciences\u003c/em\u003e, \u003cem\u003e2\u003c/em\u003e(6), 123\u0026ndash;130. https://doi.org/10.5923/j.ajmms.20120206.03\u003c/li\u003e\n \u003cli\u003eAkbar, F. H., \u0026amp; Ayuandyka, U. (2018). 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(2020).\u003cem\u003e\u0026nbsp;Factors Associated with Regional Disparity in Utilization of Healthcare Services among the Vietnamese Older People. Journal of Population and Social Studies [JPSS], 29(-), 15\u0026ndash;31. Retrieved from https://so03.tci-thaijo.org/index.php/jpss/article/view/240847\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003eNguyen TA, Giang LT. \u003cem\u003eFactors Influencing the Vietnamese Older Persons in Choosing Healthcare Facilities. Health Serv Insights.\u0026nbsp;\u003c/em\u003e2021 Jun 9;14:11786329211017426. doi: 10.1177/11786329211017426. PMID: 34177269; PMCID: PMC8193656.\u003c/li\u003e\n \u003cli\u003ePregibon, D. (1980). Goodness of Link Tests for Generalized Linear Models. \u003cem\u003eApplied Statistics\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(1), 15. https://doi.org/10.2307/2346405\u003c/li\u003e\n \u003cli\u003eRechel, B., Doyle, Y., Grundy, E., \u0026amp; Mckee, M. (2009). 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(2016).\u0026nbsp;\u003cem\u003eViet Nam: Human Resources for Health\u0026ndash;Country Profile.\u0026nbsp;\u003c/em\u003eWorld Health Organization.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2022). \u003cem\u003eAging and Health: Key facts\u003c/em\u003e. Available online\u0026nbsp;https://www.who.int/news-room/fact-sheets/detail/ageing-and-health\u003c/li\u003e\n \u003cli\u003eYaya, S., Bishwajit, G., Ekholuenetale, M., Shah, V., Kadio, B., \u0026amp; Udenigwe, O. (2017). The urban-rural difference in satisfaction with primary healthcare services in Ghana. \u003cem\u003eBMC Health Services Research\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(1), 1\u0026ndash;9. https://doi.org/10.1186/s12913-017-2745-7\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Osaka University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Geographical difference, patient satisfaction, healthcare, older adults, Vietnam","lastPublishedDoi":"10.21203/rs.3.rs-4720983/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4720983/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAs economic growth and a rapidly aging population drive substantial demand for healthcare services in Vietnam, it is salient that more attention be paid to assessing patient satisfaction among older adults. Specifically, the study aims to shed light on the critical aspect of patient satisfaction among older adults, which has not been extensively explored in previous research conducted within the country. By utilizing national data from the Vietnam Aging Survey, our analysis showed that approximately 83.2% of older patients were satisfied with healthcare services. Notably, there were significant differences in healthcare service satisfaction between the Northern and Southern regions. Furthermore, healthcare satisfaction varied based on educational levels and social insurance holding status. While insurance coverage and socio-demographic factors played important roles in narrowing the gap between the Northern and Southern regions, the type of facility widened the regional difference in healthcare satisfaction. In light of these results, our study underscores the importance of national policies prioritizing enhancing social insurance mechanisms and improving the quality of healthcare services at the district level in rural areas. These measures are crucial for achieving geographic equity in patient satisfaction with healthcare services in Vietnam.\u003c/p\u003e","manuscriptTitle":"Geographical Difference in Patient Satisfaction with Healthcare Services for Older Adults in Vietnam","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 04:29:16","doi":"10.21203/rs.3.rs-4720983/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"09bacf6a-d949-4f52-a921-09dc62e4227c","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":34486702,"name":"Geriatrics \u0026 Gerontology"}],"tags":[],"updatedAt":"2024-07-12T04:29:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-12 04:29:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4720983","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4720983","identity":"rs-4720983","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}