Insights into Barriers Affecting Access to Hepatitis C Care in Viet Nam

Insights into Barriers Affecting Access to Hepatitis C Care in Viet Nam | 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 Insights into Barriers Affecting Access to Hepatitis C Care in Viet Nam Brian Do, Cam Huong Nguyen Thi, Thanh Kim, Bethany Holt, Doan Dao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7708476/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 Introduction: As of 2024 the Ministry of Health of Viet Nam has approved social health insurance reimbursement for testing and treatment for hepatitis C (HCV) at district hospitals to reduce barriers to access to care. However, a significant portion of patients still choose to access medical services at tertiary hospitals. This study sought to understand the barriers to hepatitis access to healthcare faced by adults who tested positive for HCV-RNA at the University Medical Center (UMC) at Ho Chi Minh City, Viet Nam, and to examine attitudes associated with seeking hepatitis care at district hospitals. Methodology: We conducted a cross-sectional study, consecutively recruiting 75 patients aged 18 and over who tested positive for HCV-RNA at the UMC outpatient liver clinic between February 2024 to April 2024. Participants were surveyed about the barriers they faced related to the diagnosis and treatment of HCV, their reasons for seeking care at tertiary hospitals instead of district hospitals, and the distance traveled and wait times to receive hepatitis care. Sociodemographic information, as well as social and behavioral factors, were also documented. The social-ecological model was then applied to understand the barriers to linkage to treatment at the individual, community, environmental, organizational, and political levels. Findings: Seventy five participants with complete data were included in the analysis. Among these participants, 10.7% refused treatment for various reasons, despite physician consultation. The primary barriers to hepatitis C treatment included financial constraints (45.3%), geographical distance (65.3%), and time limitations (57.3%). Conversely, a lack of understanding of their results (18.7%) and fear of side effects (18.7%) were perceived as less significant barriers. When surveying patients on why they chose to seek hepatitis healthcare at tertiary hospitals instead of their district hospitals, the results indicated that 82.7% believed they would receive better hepatitis treatment at tertiary hospitals, 73.3% thought they would receive better overall hepatitis healthcare at tertiary hospitals, 53.3% believed that the tertiary hospital had more comprehensive testing, 45.3% did not trust the hepatitis treatment at their district hospital, and 30.7% were unaware that they could seek treatment at their district hospital. The average wait time at the tertiary clinic was 4.53 hours, and the average distance traveled to seek hepatitis care was 163.79 km. However, 37.3% of patients expressed that they would be open to seeking hepatitis healthcare and treatment at their district hospitals if they could provide the same standard of care as tertiary hospitals. Conclusion Our interviews and surveys reveal that financial constraints, time, and travel distance are the main barriers to seeking hepatitis C treatment at tertiary hospitals. However, a significant minority of patients expressed a willingness to utilize district hospitals, provided these facilities offer comparable standards of care to tertiary hospitals. Our results support the application of decentralization of hepatitis healthcare in Vietnam, which is critical for reaching the targeted goals of HCV elimination. hepatitis C hepatitis C antibody Viet Nam decentralization district hospitals tertiary hospitals elimination goals Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Hepatitis C is a chronic liver disease caused by the hepatitis C virus (HCV). Since hepatitis C often presents with no apparent clinical symptoms, many patients may not realize they are infected, which can lead to continued transmission of the virus and delays in seeking medical treatment. This contributes to the rate of diagnosis and treatment for hepatitis C remaining low. Chronic hepatitis C can progress to end-stage liver diseases such as cirrhosis and liver cancer. One of the most significant barriers to eliminating hepatitis C, even if it is identified through screening, appears to be the lack of effective linkage to care and treatment. Vietnam is one of 11 countries accounting for half of the global burden of chronic viral hepatitis ( 1 ). With the availability of direct-acting antiviral drugs (DAAs), which have cure rates of up to 95%, Viet Nam now has a chance to eliminate HCV. In a study on HCV prevalence and related health services in Ho Chi Minh City, the "Conquering Hepatitis via Micro-Elimination for Vietnam" (C.H.I.M.E.) project, led by the Vietnam Viral Hepatitis Alliance, 118 patients tested positive for HCV-RNA and required treatment ( 2 ). However, 74.5% of these patients were not linked to care and treatment. Furthermore, in a different study conducted by the same team, it was found that six months after receiving screening results and free coupons, only 14.3% (16/112) of individuals with positive HBsAg and/or positive anti-HCV Ab utilized the coupons to receive free clinical evaluations for HBV or HCV infection ( 3 ). Therefore, the results from this pilot study convey that there are barriers beyond cost alone that considerably prevent people from seeking hepatitis healthcare. To advance Viet Nam's hepatitis C elimination goals, it is essential to understand the barriers faced by patients affected by hepatitis C to improve access to their hepatitis healthcare and treatment. Overview of Viet Nam’s Public Health Care System: Viet Nam has a highly organized and centralized health care system formed with a hierarchy of tiers (Table 1): central/tertiary hospitals, provincial hospitals, district hospitals and outpatient departments, and commune health stations ( 6 ). District hospitals and commune health stations comprise primary care network and are the point of contact with the health system for most people in Vietnam. District hospitals have primary care clinics, i.e., outpatient departments staffed by generalist physicians (OPD). District hospitals provide a range of primary health care services – including management of chronic conditions, prevention, and health promotion programs – to a local catchment area ranging from 20,000 to 200,000 people. The district hospital OPDs are generally used for diagnosis and management of acute and chronic illnesses and, in line with the national social health insurance (SHI) scheme, charge a small co-payment fee to patients (ranging from 5% to 20% of total cost) who are registered for SHI at that facility. The commune health stations generally provide free preventive public health-oriented services, including vaccination, antenatal care, and community health education to a local community catchment ranging from 5,000 to 30,000 people ( 7 ). Commune health stations are generally bypassed for clinical diagnosis and care and are viewed as being more limited in health services and less trusted for medical care than the district hospital OPDs or higher level tertiary care ( 4 ). Table 1. Overview of Vietnam’s health service delivery system, including the primary care network Hierarchal Level Healthcare facilities Central/National National general and specialized hospitals, Research institutes, Medical public health universities City/Provincial Provincial general and specialized hospitals, regional hospitals, medical colleges District District hospitals with OPDs (outpatient departments) Ward/Commune Commune health clinics Hepatitis C treatment rates in Viet Nam also remain low due to barriers to accessing affordable DAAs. The average cost of 12 and 24 weeks of DAA treatment in Viet Nam is US $ 300 and US $ 600, respectively. To obtain these DAAs, patients must travel to tertiary hospitals in urban areas. These challenges are further compounded for individuals living in rural or remote areas who must invest more time, money, and effort to access these hospitals ( 4 ). People in rural or remote areas also tend to have lower-than-average incomes compared to those living in city or capital cities, which makes it more difficult for them to afford costly hepatitis treatment and services upfront. Since January 1st, 2019, Viet Nam's SHI scheme has provided a 50% reimbursement for DAAs to treat hepatitis C. In addition, as of 2024 the Ministry of Health of Viet Nam has approved testing and treatment for hepatitis C at district hospitals. These efforts by the Vietnamese government aim to reduce barriers to hepatitis access to healthcare, especially for those in rural or remote areas who are disproportionately affected ( 5 ). Despite these efforts, most patients prefer hepatitis C care at tertiary hospitals over district hospitals. To better understand the barriers to hepatitis C treatment in Viet Nam, we conducted a cross-sectional study on adults who tested positive for HCV-RNA at UMC in Ho Chi Minh City. We then utilized the Social-Ecological Model (SEM) to interpret the barriers identified in our study. We identified strategies and actionable insights to address these barriers and improve hepatitis C district hospital care in Viet Nam. METHODS This is a cross-sectional study with ethical approval by the Institutional Review Board at the University of Medicine and Pharmacy at Ho Chi Minh City (UMP-HCMC), with 1243/HDDD-DHYD, signed on 12/14/2023. UMC is a teaching hospital of UMP-HCMC. Our research involves collecting identifiable private data, and human subjects are not readily identified. Clinical Setting The University Medical Center at Ho Chi Minh City (UMC) was selected for the study due to its high volume of patients seeking comprehensive hepatitis C screening, diagnosis, and treatment. UMC caters to the general population of Southern Viet Nam, with a diverse range of patients from both within the city and neighboring provinces seeking specialized care. The hospital serves an average of 2 million outpatient visits annually, equating to about 7,000 people daily. In Viet Nam, some patients can access specialized care at tertiary hospitals without needing government-aided insurance referrals from district or commune-level hospitals, if they have the funds. UMC is a referral center for complex cases and a primary point of contact for patients with viral hepatitis. Patients cannot register their SHI directly at UMC to receive full benefits; instead, they must obtain a referral from their primary care clinic to access care for the lowest level of co-pay that they are eligible to receive. Patients entering the UMC liver clinic and other tertiary hospitals are first screened for hepatitis C antibodies. If the antibody results are positive, patients are then recommended to undergo HCV-RNA testing to determine if treatment is necessary for their hepatitis C. Survey development We developed our survey based on a informal, exploratory qualitative interviews with patients, to identify common trends and barriers to seeking care. Using these insights, we designed the survey to understand the prevalence and impact of these barriers and determine the most significant challenges. We then applied the socio-ecological model to categorize the barriers and identify targeted interventions at the individual, community, organizational/health system, and policy levels. Study Procedures Information from 75 HCV-RNA-positive patients was retrieved through in-person interviews at UMC. All recruited patients had tested positive for HCV-RNA at UMC and were at various stages of treatment, ranging from newly diagnosed and offered treatment to those who had completed treatment and were undergoing liver health monitoring. All recruited patients were defined to have been linked to care as they completed confirmatory testing (anti-HCV and/or HCV-RNA) and had at least one consultation with a physician regarding hepatitis status and potential treatment options. We determined that a sample size of 75 participants would meet our desired confidence levels and be feasible for patient recruitment. Interviews were conducted in Vietnamese and took place from February 2024 to April 2024. The patients were all 18 years or older and came from various provinces across Viet Nam. The purpose of the interviews is to survey currently infected patients and ask about the barriers they face when seeking care and treatment for hepatitis C. The participants had no prior relationship with the individuals conducting the interviews. UMP IRB approved this research study. Written informed consent was obtained from all participants prior to their participation in the study. Participation in the survey required about 5–10 minutes of their time. Data collection and Analysis using the Social-Ecological Model When the patients met the physician at UMC, they were provided with information and the purpose of the study. Patients were surveyed about socio-demographic characteristics (6 questions), the need for linkage of care and treatment (3 questions), and barriers associated with diagnosis and treatment for hepatitis C care (8 questions). Following this, patients were surveyed about their decisions regarding seeking treatment, barriers related to time constraints, the distance they traveled and time required to access medical services, their reasons for not seeking care for hepatitis at their district-level hospital (9 questions), and their openness to seeking care for hepatitis at the district-level hospital if their barriers to seeking care were addressed (2 questions). Patients who chose not to undergo treatment for their positive HCV-RNA diagnosis were asked to share their reasons for declining and whether they required any assistance with obtaining government-aided insurance. Research and interview data were collected and analyzed using Excel and SPSS version 25.0. The Social-Ecological Model (SEM) was used to provide a comprehensive, layered approach by examining factors at the individual, interpersonal, community, organizational, and policy levels ( 8 ). This model is well-suited for decentralized healthcare settings, where barriers often span multiple levels. For example, SEM allows us to identify and analyze the relationships between factors influencing access to hepatitis C treatment, such as individual beliefs, experiences with healthcare systems, and social or physical environments (see Fig. 1 ). Research shows that understanding these relationships through SEM can improve intervention strategies, making them more effective and sustainable in addressing access to healthcare barriers ( 9 ). In our study, we used to the SEM model to interpret and categorize our survey results across four levels of SEM to identify the most significant factors affecting access to hepatitis healthcare. RESULTS Demographics Seventy-eight study participants with complete data were included in the analysis. The characteristics of the study participants, insurance usage for HCV healthcare, type of liver disease, and treatment status were recorded in Table 2 . The study population consisted of a majority of female participants (62.7%), the median age was 60.9, and 64.2% did not have a graduation level higher than middle school. About half of the participants (48.7%) have sought healthcare within the last year, and only 16.7% of patients were able to use their government-aided insurance for their hepatitis healthcare. We found that 30.8% of our patients have cirrhosis, and 10.7% of patients refused to initiate treatment for HCV despite physician consultation. Table 2 Population Characteristics (n = 75) Characteristics n (%) Age (mean ± SD) 60.9 ± 13.1 Gender Male 28 (37.3) Female 47 (62.7) Education Level (n = 67) Primary 26 (38.8) Middle 17 (25.4) Highschool 19 (28.4) University or above 5 (7.5) Yearly check-up Yes 35 (46.7) No 40 (53.3) Insurance Usage for HCV healthcare Yes 7 (9.3) No 68 (90.7) Chronic liver disease stage Liver Cirrhosis 24 (30.8) HCC 1 (1.3) Chronic hepatitis 53 (67.9) HCV treatment status Treated 67 (89.3) Untreated 8 (10.7) Table 3 Barriers to Hepatitis Linkage to Care (n = 75) Barriers n (%) Transportation and distance 49 (65.3) Not enough time 43 (57.3) No symptoms 35 (46.7) Not enough funds 35 (45.3) Does not understand HCV results 14 (18.7) Side effects 14 (18.7) Lack of insurance 7 (9.3) Lack of acute or advanced symptoms a 4 (5.3) a The lack of acute or advanced symptoms may serve as a barrier to hepatitis linkage to treatment when the patient deprioritizes treatment due to a perception that their diagnosis does not require immediate medical care. Table 4 Reasons why people did not go to district hospitals for hepatitis C care (n = 75) Reasons n (%) Perceived increased quality of treatment at tertiary hospital 62 (82.7) Perceived increased quality of care at tertiary hospital 55 (73.3) Do not believe local clinics that can provide comprehensive care for HCV 40 (53.3) Do not believe/trust local clinics to treat HCV 34 (45.3) Did not know that the local clinics can treat HCV 23 (30.7) Because HCV is a difficult disease to treat 20 (26.7) Local clinic referred me to specialist clinic for treatment 9 ( 12 ) Individual Level Factors Our survey identified several individual-level factors that act as barriers to seeking hepatitis C treatment and accessing care at district hospitals, including patients' knowledge and beliefs, as summarized in Table 3 . The most significant individual-level barriers to accessing hepatitis C treatment were a lack of symptoms (46.7%) and limited understanding of hepatitis C test results (18.7%). Additionally, we identified four key reasons why patients chose not to access hepatitis C care at district hospitals, as detailed in Table 4 . Primary reasons included a belief that tertiary clinics provide more comprehensive hepatitis C care (53.3%), a lack of trust in the treatment available at district hospitals (45.3%), and the perception that hepatitis C is difficult to treat (26.7%). Lastly, 30.7% of patients were unaware they could receive treatment at their district hospital. Figure 2 shows the distribution of patients from various provinces seeking hepatitis care. The UMC outpatient liver clinic, where this study was conducted, primarily serves patients outside Ho Chi Minh City. Figure 3 highlights the long distances patients travel from their provinces to receive hepatitis care at UMC. Community and Environmental Level Factors We categorized factors related to the physical and social environment as community-level factors. The most significant barrier to accessing hepatitis treatment was the long distance and transportation required, as reported by 65.3% of participants (Table 3 ). This challenge was further highlighted by the average distance patients traveled to seek treatment, which was 163.8 km (101.8 miles) (see Fig. 3 ). While many patients lived locally in Ho Chi Minh City to access UMC for hepatitis care, 91.5% came from distant provinces such as Ben Tre, Vinh Long, Binh Duong, Kien Giang, An Giang, and Tien Giang (see Fig. 2 ). Overall, our study found that community and environmental level factors presented one of the largest barriers to accessing hepatitis treatment and was the primary reason why people did not seek hepatitis care at district hospitals. Organizational/Health System Factors At the organizational health system level, our assessment of barriers to HCV treatment identified significant challenges within the healthcare system and its operations. Our survey found that limited funding for treatment (45.3%) and insufficient time to seek care (57.3%) were among the most reported barriers, as detailed in Table 3 . The time constraint was further emphasized by an average wait time at the tertiary clinic of 4.53 hours ± 2.39 hours. This duration does not include the time patients travel an average distance of 163.8 km ± 161.5 km (approximately 101.8 miles) to access treatment (see Fig. 3 ). Additionally, organizational barriers at district hospitals included the referral of 12% of patients to tertiary care due to the lack of hepatitis C treatment services, as detailed in Table 4 . Policy Level Factors We surveyed patients at the UMC tertiary hospital, where social health insurance is not accepted for those who register directly. Despite this limitation, these tertiary hospitals remain the primary locations for individuals seeking hepatitis C care. At the policy level, we have identified that patients' inability to use their social health insurance for hepatitis healthcare (90.7%) directly at UMC is a significant issue, as detailed in Table 2 . This restriction, combined with barriers to accessing care at district hospitals, contributes to financial challenges and a lack of funds for hepatitis C treatment (45.3%), particularly among those of low socioeconomic status (Table 3 ). DISCUSSION Our study aimed to identify barriers to accessing HCV treatment and explore attitudes toward HCV care and treatment at district hospitals in Vietnam. The results aim to inform national HCV elimination efforts by identifying key barriers patients face to access existing HCV healthcare and support Viet Nam’s effort to decentralize HCV care. We conducted our study at the University Medical Center at Ho Chi Minh City, one of the largest hospitals where patients seek HCV care. In our discussion, we further describe factors that might be considered when implementing HCV care decentralization as an effective strategy to address these barriers and how effectively doing so requires gaining the public’s trust. The average age of participants seeking HCV care in our study was 61. We found that 61.3% of participants were born in the 1945–1964 birth cohort, known for its distinctively high HCV prevalence ( 10 ). Additionally, 64.2% of participants had an education level no higher than middle school. To improve HCV care decentralization, outreach programs for patients and training programs for healthcare workers may be tailored to serve those over 60 and people with lower education levels so that they can understand and trust services. Our surveys indicate that health system and insurance policy barriers at the organizational level contribute to the financial constraints faced when seeking HCV treatment. Although the Vietnamese government's SHI scheme began offering 50% coverage of DAAs in 2019, most patients still cannot access these subsidized medications at tertiary hospitals, where they typically seek HCV care (only 9.3%, or 7 out of 75 patients, received coverage). This contributes to the continued high out-of-pocket costs for healthcare despite Vietnam’s health insurance reform ( 11 ). The rate of full out-of-pocket payment observed in our study is even higher than in previous studies in Vietnam, which reported approximately 50% of patients were able to access subsidized medications ( 4 ). While surveying patients about their decision to refuse, pursue, or continue treatment, we observed that patients who could not afford the upfront cost of DAA treatment often borrowed money from family and friends, a common strategy for managing high healthcare expenses ( 12 ). Fortunately, people in Viet Nam can reduce costs associated with HCV care by at least initially seeking treatment within the public primary care sector (district hospital OPDs), where SHI is accepted and/or referral can be made if indicated for complex cases. Nonetheless, most primary health facilities lack the training of healthcare workers and accreditation required by the SHI scheme needed to provide HCV care ( 13 ). Our results underscore the need for national investment to decentralize HCV care. In doing so, patients could use their SHI and alleviate the significant financial barrier they encounter when seeking DAA treatment by immediately seeking care at tertiary facilities. The most significant barrier to seeking HCV treatment was reported to be the extensive time, transportation, and travel distance required, which occur at both the provincial and community levels. In Viet Nam, patients living in provinces outside urban centers typically must set aside both money and an entire day to travel to the city and back by bus for healthcare. This highlights the average distance of 163.79 km ± 161.54 km that patients travel to access treatment. Upon arriving at tertiary hospitals in urban centers, patients wait an average of 4.53 hours before seeing a physician for HCV care. These findings align with previous research identifying the distance to healthcare facilities as a key determinant of the frequency of visits for HCV treatment ( 14 ). Our survey shows that most patients seeking hepatitis care came from southern provinces outside Ho Chi Minh City (91.5%). Importantly, most people in these provinces live within reasonable travel time of a primary healthcare facility comprised of district hospital OPDs ( 15 ). Accessing tertiary facilities can require an entire day of bus travel, along with the associated effort and costs. Therefore, expanding decentralized HCV care would reduce barriers for most current patients who expend considerable time, effort, and money traveling to urban centers for HCV care. Individuals from lower socioeconomic backgrounds living outside urban centers are more likely to delay seeking healthcare unless they present symptoms, prioritizing providing for their families instead. This partly explains why 91.5% of our patients traveled from outside Ho Chi Minh City, with 53.3% presenting symptoms and 32% having liver cirrhosis. This poses a challenge for patients unaware they have HCV or who delay seeking healthcare until symptoms secondary to decompensated cirrhosis and/or liver cancer appear. When HCV symptoms and cirrhosis are present, treatment becomes more difficult ( 16 ). Evidence suggests that HCV can be detected and treated at the primary healthcare level before it becomes harder to manage ( 17 ). Improving HCV healthcare decentralization in Viet Nam would enable individuals, especially those outside urban centers and from lower socioeconomic backgrounds, to detect and treat HCV more effectively before liver disease progresses. In low-income areas of Viet Nam, primary healthcare facilities can be ill-equipped to treat complex conditions. Patients in Viet Nam are not required to go through their primary healthcare provider to access specialist care at tertiary hospitals, however, they are incentivized to do so with financial penalties (higher co-pays) for bypassing primary care. Consequently, people frequently go directly to tertiary hospitals in urban centers for comprehensive care when complex conditions arise. This helps explain the limited confidence in district hospitals' ability to treat HCV among 45.3% of patients and the belief that district hospitals do not offer comprehensive HCV care among 53.3% of patients. Similarly, 82.7% of patients reported avoiding district hospitals because they perceive tertiary hospitals as providing higher-quality treatment, and 73.3% believe they would receive superior overall care at tertiary facilities. This perception of higher-quality HCV treatment and care at tertiary hospitals can be attributed to the current lack of accredited Hepatitis Treatment Units (HTUs) ( 13 ). Historically, hepatitis care was restricted to tertiary hospitals; however, healthcare facilities at any level can now establish an HTU and receive SHI reimbursement if they meet accreditation standards. Accreditation requires rigorous criteria in human resources, infrastructure, equipment, and management systems ( 18 ). The absence of locally accredited HTUs, combined with our findings, helps explain why patients are willing to overcome significant barriers to seek HCV care at tertiary hospitals. Therefore, creating or modifying public policy at the community, district, and provincial levels should focus on improving healthcare workers' education, training, and skills and the quality of care and treatment at district hospitals in an effort for these facilities to meet HTU accreditation ( 19 ). This would help shift the public perception of treatment and healthcare quality between district and tertiary hospitals and reduce Viet Nam’s HCV burden. At the community level, efforts should focus on educating the public about the risks of delayed hepatitis C diagnosis and treatment, and importance of screening even if asymptomatic. This outreach should extend beyond the target population and their immediate contacts to include community leaders ( 19 ). Doing so would help address the 18.7% of patients who lack an understanding of their test results, as well as the individual-level barriers, where 30.7% were unaware they could receive treatment at their district hospital, and 26.7% believe that hepatitis C is too difficult to treat at the district hospital level. These targeted interventions at the individual level could shift perceptions and enhance patients' self-efficacy. By combining community, organizational, and policy efforts, we can better address individual factors influencing patients’ decisions to seek hepatitis care and treatment at district hospitals. A limitation of this study is that the patients interviewed are already seeking care at tertiary hospitals, making them more likely to have a greater distrust of district hospital treatment and healthcare for hepatitis C. A strength of our study is that the barriers faced by the patients we surveyed are fewer than those encountered by individuals who are unable to access medical services for hepatitis in the first place. This is because the patients we interviewed have the resources and knowledge to access medical services and treatment for hepatitis C at UMC. In contrast, most patients who are unable to overcome these barriers would generally remain undiagnosed and untreated. In conclusion, our interviews and surveys reveal that financial constraints, time, and travel distance are the primary barriers to seeking hepatitis C treatment at tertiary hospitals. To address these challenges and improve HCV treatment rates, local stakeholders should invest in decentralizing healthcare to the district hospital level, enabling these hospitals to become accredited HTUs capable of providing high quality care, and eligible for SHI reimbursement to reduce costs for patients. This requires enhancing comprehensive care, treatment services, healthcare worker training, and raising awareness about hepatitis care in district hospitals across Vietnam. Our findings show that a significant minority of patients are willing to access medical services at their district hospitals if they provide the same standard of care as tertiary hospitals. Ultimately, our results strengthen the case for decentralizing hepatitis healthcare in Viet Nam—an essential step toward achieving the country's HCV elimination goals. Abbreviations HCV Hepatitis C Virus DAAs Direct-Acting Antiviral Drugs OPD Outpatient Departments SEM Social-Ecological Model HTU Hepatitis Treatment Unit Declarations Ethics approval and consent to participate This study received ethical approval by the Institutional Review Board at the University of Medicine and Pharmacy at Ho Chi Minh City (UMP-HCMC), with 1243/HDDD-DHYD, signed on 12/14/2023. Our research involves collecting identifiable private data, and human subjects are not readily identified. This study was conducted in accordance with Declaration of Helsinki. Clinical Trial Clinical Trial number: not applicable Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Funding This research project was funded by the United States Fulbright Program, which aims to build mutual understanding between nations, advance knowledge across communities, and improve lives worldwide. Author Contribution The paper was conceptualized by B.D., N.T.C.H., and D.Y.D. B.D. and N.T.C.H. led the data collection and analysis, with support from T.K., D.Y.D., and B.H.. All authors contributed to the validation, analysis, and interpretation of the findings. B.D. and N.T.C.H. drafted the initial manuscript, which was subsequently revised by Thanh Kim, D.Y.D., and B.H.. All authors approved the final version for publication. 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1","display":"","copyAsset":false,"role":"figure","size":77730,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7708476/v1/7aebde0ee4371c1e0c62d6ca.png"},{"id":97299644,"identity":"0264d7b1-7d30-4a3f-b970-43feac7797e3","added_by":"auto","created_at":"2025-12-03 00:52:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":31052,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7708476/v1/a4d0756a21b96bcbc98d0786.png"},{"id":97299640,"identity":"28ea2f33-9d1c-4b3e-add1-8c918cd4004d","added_by":"auto","created_at":"2025-12-03 00:52:17","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":19972,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7708476/v1/fddbbd29bfc4e47465f6c7d3.png"},{"id":104421842,"identity":"0355cfa0-31f1-492f-be04-036ce39da6a6","added_by":"auto","created_at":"2026-03-11 13:59:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":707904,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7708476/v1/ade45fc6-746e-431c-8d5d-e69177178ef6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Insights into Barriers Affecting Access to Hepatitis C Care in Viet Nam","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eHepatitis C is a chronic liver disease caused by the hepatitis C virus (HCV). Since hepatitis C often presents with no apparent clinical symptoms, many patients may not realize they are infected, which can lead to continued transmission of the virus and delays in seeking medical treatment. This contributes to the rate of diagnosis and treatment for hepatitis C remaining low. Chronic hepatitis C can progress to end-stage liver diseases such as cirrhosis and liver cancer. One of the most significant barriers to eliminating hepatitis C, even if it is identified through screening, appears to be the lack of effective linkage to care and treatment.\u003c/p\u003e\n\u003cp\u003eVietnam is one of 11 countries accounting for half of the global burden of chronic viral hepatitis (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e). With the availability of direct-acting antiviral drugs (DAAs), which have cure rates of up to 95%, Viet Nam now has a chance to eliminate HCV. In a study on HCV prevalence and related health services in Ho Chi Minh City, the \u0026quot;Conquering Hepatitis via Micro-Elimination for Vietnam\u0026quot; (C.H.I.M.E.) project, led by the Vietnam Viral Hepatitis Alliance, 118 patients tested positive for HCV-RNA and required treatment (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e). However, 74.5% of these patients were not linked to care and treatment. Furthermore, in a different study conducted by the same team, it was found that six months after receiving screening results and free coupons, only 14.3% (16/112) of individuals with positive HBsAg and/or positive anti-HCV Ab utilized the coupons to receive free clinical evaluations for HBV or HCV infection (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e). Therefore, the results from this pilot study convey that there are barriers beyond cost alone that considerably prevent people from seeking hepatitis healthcare. To advance Viet Nam\u0026apos;s hepatitis C elimination goals, it is essential to understand the barriers faced by patients affected by hepatitis C to improve access to their hepatitis healthcare and treatment.\u003c/p\u003e\n\u003cp\u003eOverview of Viet Nam\u0026rsquo;s Public Health Care System:\u003c/p\u003e\n\u003cp\u003eViet Nam has a highly organized and centralized health care system formed with a hierarchy of tiers (Table\u0026nbsp;1): central/tertiary hospitals, provincial hospitals, district hospitals and outpatient departments, and commune health stations (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). District hospitals and commune health stations comprise primary care network and are the point of contact with the health system for most people in Vietnam. District hospitals have primary care clinics, i.e., outpatient departments staffed by generalist physicians (OPD). District hospitals provide a range of primary health care services \u0026ndash; including management of chronic conditions, prevention, and health promotion programs \u0026ndash; to a local catchment area ranging from 20,000 to 200,000 people. The district hospital OPDs are generally used for diagnosis and management of acute and chronic illnesses and, in line with the national social health insurance (SHI) scheme, charge a small co-payment fee to patients (ranging from 5% to 20% of total cost) who are registered for SHI at that facility. The commune health stations generally provide free preventive public health-oriented services, including vaccination, antenatal care, and community health education to a local community catchment ranging from 5,000 to 30,000 people (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e). Commune health stations are generally bypassed for clinical diagnosis and care and are viewed as being more limited in health services and less trusted for medical care than the district hospital OPDs or higher level tertiary care (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Overview of Vietnam\u0026rsquo;s health service delivery system, including the primary care network\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"564\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHierarchal Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare facilities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eCentral/National\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003eNational general and specialized hospitals, Research institutes,\u003c/p\u003e\n \u003cp\u003eMedical public health universities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eCity/Provincial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003eProvincial general and specialized hospitals, regional hospitals,\u003c/p\u003e\n \u003cp\u003emedical colleges\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eDistrict\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003eDistrict hospitals with OPDs (outpatient departments)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eWard/Commune\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003eCommune health clinics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHepatitis C treatment rates in Viet Nam also remain low due to barriers to accessing affordable DAAs. The average cost of 12 and 24 weeks of DAA treatment in Viet Nam is US \u003cspan\u003e$\u003c/span\u003e300 and US \u003cspan\u003e$\u003c/span\u003e600, respectively. To obtain these DAAs, patients must travel to tertiary hospitals in urban areas. These challenges are further compounded for individuals living in rural or remote areas who must invest more time, money, and effort to access these hospitals (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e). People in rural or remote areas also tend to have lower-than-average incomes compared to those living in city or capital cities, which makes it more difficult for them to afford costly hepatitis treatment and services upfront. Since January 1st, 2019, Viet Nam\u0026apos;s SHI scheme has provided a 50% reimbursement for DAAs to treat hepatitis C. In addition, as of 2024 the Ministry of Health of Viet Nam has approved testing and treatment for hepatitis C at district hospitals. These efforts by the Vietnamese government aim to reduce barriers to hepatitis access to healthcare, especially for those in rural or remote areas who are disproportionately affected (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e). Despite these efforts, most patients prefer hepatitis C care at tertiary hospitals over district hospitals.\u003c/p\u003e\n\u003cp\u003eTo better understand the barriers to hepatitis C treatment in Viet Nam, we conducted a cross-sectional study on adults who tested positive for HCV-RNA at UMC in Ho Chi Minh City. We then utilized the Social-Ecological Model (SEM) to interpret the barriers identified in our study. We identified strategies and actionable insights to address these barriers and improve hepatitis C district hospital care in Viet Nam.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e This is a cross-sectional study with ethical approval by the Institutional Review Board at the University of Medicine and Pharmacy at Ho Chi Minh City (UMP-HCMC), with 1243/HDDD-DHYD, signed on 12/14/2023. UMC is a teaching hospital of UMP-HCMC. Our research involves collecting identifiable private data, and human subjects are not readily identified.\u003c/p\u003e\u003cp\u003eClinical Setting\u003c/p\u003e\u003cp\u003eThe University Medical Center at Ho Chi Minh City (UMC) was selected for the study due to its high volume of patients seeking comprehensive hepatitis C screening, diagnosis, and treatment. UMC caters to the general population of Southern Viet Nam, with a diverse range of patients from both within the city and neighboring provinces seeking specialized care. The hospital serves an average of 2\u0026nbsp;million outpatient visits annually, equating to about 7,000 people daily.\u003c/p\u003e\u003cp\u003eIn Viet Nam, some patients can access specialized care at tertiary hospitals without needing government-aided insurance referrals from district or commune-level hospitals, if they have the funds. UMC is a referral center for complex cases and a primary point of contact for patients with viral hepatitis. Patients cannot register their SHI directly at UMC to receive full benefits; instead, they must obtain a referral from their primary care clinic to access care for the lowest level of co-pay that they are eligible to receive. Patients entering the UMC liver clinic and other tertiary hospitals are first screened for hepatitis C antibodies. If the antibody results are positive, patients are then recommended to undergo HCV-RNA testing to determine if treatment is necessary for their hepatitis C.\u003c/p\u003e\u003cp\u003eSurvey development\u003c/p\u003e\u003cp\u003eWe developed our survey based on a informal, exploratory qualitative interviews with patients, to identify common trends and barriers to seeking care. Using these insights, we designed the survey to understand the prevalence and impact of these barriers and determine the most significant challenges. We then applied the socio-ecological model to categorize the barriers and identify targeted interventions at the individual, community, organizational/health system, and policy levels.\u003c/p\u003e\u003cp\u003eStudy Procedures\u003c/p\u003e\u003cp\u003eInformation from 75 HCV-RNA-positive patients was retrieved through in-person interviews at UMC. All recruited patients had tested positive for HCV-RNA at UMC and were at various stages of treatment, ranging from newly diagnosed and offered treatment to those who had completed treatment and were undergoing liver health monitoring. All recruited patients were defined to have been linked to care as they completed confirmatory testing (anti-HCV and/or HCV-RNA) and had at least one consultation with a physician regarding hepatitis status and potential treatment options. We determined that a sample size of 75 participants would meet our desired confidence levels and be feasible for patient recruitment. Interviews were conducted in Vietnamese and took place from February 2024 to April 2024. The patients were all 18 years or older and came from various provinces across Viet Nam. The purpose of the interviews is to survey currently infected patients and ask about the barriers they face when seeking care and treatment for hepatitis C.\u003c/p\u003e\u003cp\u003e The participants had no prior relationship with the individuals conducting the interviews. UMP IRB approved this research study. Written informed consent was obtained from all participants prior to their participation in the study. Participation in the survey required about 5\u0026ndash;10 minutes of their time.\u003c/p\u003e\u003cp\u003eData collection and Analysis using the Social-Ecological Model\u003c/p\u003e\u003cp\u003eWhen the patients met the physician at UMC, they were provided with information and the purpose of the study. Patients were surveyed about socio-demographic characteristics (6 questions), the need for linkage of care and treatment (3 questions), and barriers associated with diagnosis and treatment for hepatitis C care (8 questions). Following this, patients were surveyed about their decisions regarding seeking treatment, barriers related to time constraints, the distance they traveled and time required to access medical services, their reasons for not seeking care for hepatitis at their district-level hospital (9 questions), and their openness to seeking care for hepatitis at the district-level hospital if their barriers to seeking care were addressed (2 questions). Patients who chose not to undergo treatment for their positive HCV-RNA diagnosis were asked to share their reasons for declining and whether they required any assistance with obtaining government-aided insurance. Research and interview data were collected and analyzed using Excel and SPSS version 25.0.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe Social-Ecological Model (SEM) was used to provide a comprehensive, layered approach by examining factors at the individual, interpersonal, community, organizational, and policy levels (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This model is well-suited for decentralized healthcare settings, where barriers often span multiple levels. For example, SEM allows us to identify and analyze the relationships between factors influencing access to hepatitis C treatment, such as individual beliefs, experiences with healthcare systems, and social or physical environments (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Research shows that understanding these relationships through SEM can improve intervention strategies, making them more effective and sustainable in addressing access to healthcare barriers (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In our study, we used to the SEM model to interpret and categorize our survey results across four levels of SEM to identify the most significant factors affecting access to hepatitis healthcare.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eDemographics\u003c/h2\u003e\u003cp\u003eSeventy-eight study participants with complete data were included in the analysis. The characteristics of the study participants, insurance usage for HCV healthcare, type of liver disease, and treatment status were recorded in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The study population consisted of a majority of female participants (62.7%), the median age was 60.9, and 64.2% did not have a graduation level higher than middle school. About half of the participants (48.7%) have sought healthcare within the last year, and only 16.7% of patients were able to use their government-aided insurance for their hepatitis healthcare. We found that 30.8% of our patients have cirrhosis, and 10.7% of patients refused to initiate treatment for HCV despite physician consultation.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePopulation Characteristics (n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60.9\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28 (37.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47 (62.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eEducation Level (n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26 (38.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMiddle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17 (25.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHighschool\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19 (28.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUniversity or above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5 (7.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eYearly check-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35 (46.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40 (53.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eInsurance Usage for HCV healthcare\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (9.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68 (90.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eChronic liver disease stage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLiver Cirrhosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e24 (30.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHCC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChronic hepatitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e53 (67.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHCV treatment status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67 (89.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUntreated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8 (10.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBarriers to Hepatitis Linkage to Care (n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBarriers\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransportation and distance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e49 (65.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot enough time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43 (57.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e35 (46.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot enough funds\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e35 (45.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDoes not understand HCV results\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14 (18.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSide effects\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14 (18.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLack of insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7 (9.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLack of acute or advanced symptoms\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (5.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e\u003c/h3\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e The lack of acute or advanced symptoms may serve as a barrier to hepatitis linkage to treatment when the patient deprioritizes treatment due to a perception that their diagnosis does not require immediate medical care.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eReasons why people did not go to district hospitals for hepatitis C care (n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReasons\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived increased quality of treatment at tertiary hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62 (82.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived increased quality of care at tertiary hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55 (73.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDo not believe local clinics that can provide comprehensive care for HCV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u0026nbsp; (53.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDo not believe/trust local clinics to treat HCV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34 (45.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDid not know that the local clinics can treat HCV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23 (30.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBecause HCV is a difficult disease to treat\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (26.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLocal clinic referred me to specialist clinic for treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eIndividual Level Factors\u003c/h3\u003e\n\u003cp\u003eOur survey identified several individual-level factors that act as barriers to seeking hepatitis C treatment and accessing care at district hospitals, including patients' knowledge and beliefs, as summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The most significant individual-level barriers to accessing hepatitis C treatment were a lack of symptoms (46.7%) and limited understanding of hepatitis C test results (18.7%). Additionally, we identified four key reasons why patients chose not to access hepatitis C care at district hospitals, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Primary reasons included a belief that tertiary clinics provide more comprehensive hepatitis C care (53.3%), a lack of trust in the treatment available at district hospitals (45.3%), and the perception that hepatitis C is difficult to treat (26.7%). Lastly, 30.7% of patients were unaware they could receive treatment at their district hospital.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the distribution of patients from various provinces seeking hepatitis care. The UMC outpatient liver clinic, where this study was conducted, primarily serves patients outside Ho Chi Minh City.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e highlights the long distances patients travel from their provinces to receive hepatitis care at UMC.\u003c/p\u003e\n\u003ch3\u003eCommunity and Environmental Level Factors\u003c/h3\u003e\n\u003cp\u003eWe categorized factors related to the physical and social environment as community-level factors. The most significant barrier to accessing hepatitis treatment was the long distance and transportation required, as reported by 65.3% of participants (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e). This challenge was further highlighted by the average distance patients traveled to seek treatment, which was 163.8 km (101.8 miles) (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). While many patients lived locally in Ho Chi Minh City to access UMC for hepatitis care, 91.5% came from distant provinces such as Ben Tre, Vinh Long, Binh Duong, Kien Giang, An Giang, and Tien Giang (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Overall, our study found that community and environmental level factors presented one of the largest barriers to accessing hepatitis treatment and was the primary reason why people did not seek hepatitis care at district hospitals.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eOrganizational/Health System Factors\u003c/h2\u003e\u003cp\u003eAt the organizational health system level, our assessment of barriers to HCV treatment identified significant challenges within the healthcare system and its operations. Our survey found that limited funding for treatment (45.3%) and insufficient time to seek care (57.3%) were among the most reported barriers, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The time constraint was further emphasized by an average wait time at the tertiary clinic of 4.53 hours\u0026thinsp;\u0026plusmn;\u0026thinsp;2.39 hours. This duration does not include the time patients travel an average distance of 163.8 km\u0026thinsp;\u0026plusmn;\u0026thinsp;161.5 km (approximately 101.8 miles) to access treatment (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Additionally, organizational barriers at district hospitals included the referral of 12% of patients to tertiary care due to the lack of hepatitis C treatment services, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePolicy Level Factors\u003c/h3\u003e\n\u003cp\u003eWe surveyed patients at the UMC tertiary hospital, where social health insurance is not accepted for those who register directly. Despite this limitation, these tertiary hospitals remain the primary locations for individuals seeking hepatitis C care. At the policy level, we have identified that patients' inability to use their social health insurance for hepatitis healthcare (90.7%) directly at UMC is a significant issue, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e. This restriction, combined with barriers to accessing care at district hospitals, contributes to financial challenges and a lack of funds for hepatitis C treatment (45.3%), particularly among those of low socioeconomic status (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e Our study aimed to identify barriers to accessing HCV treatment and explore attitudes toward HCV care and treatment at district hospitals in Vietnam. The results aim to inform national HCV elimination efforts by identifying key barriers patients face to access existing HCV healthcare and support Viet Nam\u0026rsquo;s effort to decentralize HCV care. We conducted our study at the University Medical Center at Ho Chi Minh City, one of the largest hospitals where patients seek HCV care. In our discussion, we further describe factors that might be considered when implementing HCV care decentralization as an effective strategy to address these barriers and how effectively doing so requires gaining the public\u0026rsquo;s trust.\u003c/p\u003e\u003cp\u003eThe average age of participants seeking HCV care in our study was 61. We found that 61.3% of participants were born in the 1945\u0026ndash;1964 birth cohort, known for its distinctively high HCV prevalence (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Additionally, 64.2% of participants had an education level no higher than middle school. To improve HCV care decentralization, outreach programs for patients and training programs for healthcare workers may be tailored to serve those over 60 and people with lower education levels so that they can understand and trust services.\u003c/p\u003e\u003cp\u003eOur surveys indicate that health system and insurance policy barriers at the organizational level contribute to the financial constraints faced when seeking HCV treatment. Although the Vietnamese government's SHI scheme began offering 50% coverage of DAAs in 2019, most patients still cannot access these subsidized medications at tertiary hospitals, where they typically seek HCV care (only 9.3%, or 7 out of 75 patients, received coverage). This contributes to the continued high out-of-pocket costs for healthcare despite Vietnam\u0026rsquo;s health insurance reform (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The rate of full out-of-pocket payment observed in our study is even higher than in previous studies in Vietnam, which reported approximately 50% of patients were able to access subsidized medications (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). While surveying patients about their decision to refuse, pursue, or continue treatment, we observed that patients who could not afford the upfront cost of DAA treatment often borrowed money from family and friends, a common strategy for managing high healthcare expenses (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Fortunately, people in Viet Nam can reduce costs associated with HCV care by at least initially seeking treatment within the public primary care sector (district hospital OPDs), where SHI is accepted and/or referral can be made if indicated for complex cases. Nonetheless, most primary health facilities lack the training of healthcare workers and accreditation required by the SHI scheme needed to provide HCV care (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Our results underscore the need for national investment to decentralize HCV care. In doing so, patients could use their SHI and alleviate the significant financial barrier they encounter when seeking DAA treatment by immediately seeking care at tertiary facilities.\u003c/p\u003e\u003cp\u003eThe most significant barrier to seeking HCV treatment was reported to be the extensive time, transportation, and travel distance required, which occur at both the provincial and community levels. In Viet Nam, patients living in provinces outside urban centers typically must set aside both money and an entire day to travel to the city and back by bus for healthcare. This highlights the average distance of 163.79 km\u0026thinsp;\u0026plusmn;\u0026thinsp;161.54 km that patients travel to access treatment. Upon arriving at tertiary hospitals in urban centers, patients wait an average of 4.53 hours before seeing a physician for HCV care. These findings align with previous research identifying the distance to healthcare facilities as a key determinant of the frequency of visits for HCV treatment (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Our survey shows that most patients seeking hepatitis care came from southern provinces outside Ho Chi Minh City (91.5%). Importantly, most people in these provinces live within reasonable travel time of a primary healthcare facility comprised of district hospital OPDs (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Accessing tertiary facilities can require an entire day of bus travel, along with the associated effort and costs. Therefore, expanding decentralized HCV care would reduce barriers for most current patients who expend considerable time, effort, and money traveling to urban centers for HCV care.\u003c/p\u003e\u003cp\u003eIndividuals from lower socioeconomic backgrounds living outside urban centers are more likely to delay seeking healthcare unless they present symptoms, prioritizing providing for their families instead. This partly explains why 91.5% of our patients traveled from outside Ho Chi Minh City, with 53.3% presenting symptoms and 32% having liver cirrhosis. This poses a challenge for patients unaware they have HCV or who delay seeking healthcare until symptoms secondary to decompensated cirrhosis and/or liver cancer appear. When HCV symptoms and cirrhosis are present, treatment becomes more difficult (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Evidence suggests that HCV can be detected and treated at the primary healthcare level before it becomes harder to manage (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Improving HCV healthcare decentralization in Viet Nam would enable individuals, especially those outside urban centers and from lower socioeconomic backgrounds, to detect and treat HCV more effectively before liver disease progresses.\u003c/p\u003e\u003cp\u003eIn low-income areas of Viet Nam, primary healthcare facilities can be ill-equipped to treat complex conditions. Patients in Viet Nam are not required to go through their primary healthcare provider to access specialist care at tertiary hospitals, however, they are incentivized to do so with financial penalties (higher co-pays) for bypassing primary care. Consequently, people frequently go directly to tertiary hospitals in urban centers for comprehensive care when complex conditions arise. This helps explain the limited confidence in district hospitals' ability to treat HCV among 45.3% of patients and the belief that district hospitals do not offer comprehensive HCV care among 53.3% of patients. Similarly, 82.7% of patients reported avoiding district hospitals because they perceive tertiary hospitals as providing higher-quality treatment, and 73.3% believe they would receive superior overall care at tertiary facilities. This perception of higher-quality HCV treatment and care at tertiary hospitals can be attributed to the current lack of accredited Hepatitis Treatment Units (HTUs) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Historically, hepatitis care was restricted to tertiary hospitals; however, healthcare facilities at any level can now establish an HTU and receive SHI reimbursement if they meet accreditation standards. Accreditation requires rigorous criteria in human resources, infrastructure, equipment, and management systems (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The absence of locally accredited HTUs, combined with our findings, helps explain why patients are willing to overcome significant barriers to seek HCV care at tertiary hospitals. Therefore, creating or modifying public policy at the community, district, and provincial levels should focus on improving healthcare workers' education, training, and skills and the quality of care and treatment at district hospitals in an effort for these facilities to meet HTU accreditation (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This would help shift the public perception of treatment and healthcare quality between district and tertiary hospitals and reduce Viet Nam\u0026rsquo;s HCV burden.\u003c/p\u003e\u003cp\u003eAt the community level, efforts should focus on educating the public about the risks of delayed hepatitis C diagnosis and treatment, and importance of screening even if asymptomatic. This outreach should extend beyond the target population and their immediate contacts to include community leaders (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Doing so would help address the 18.7% of patients who lack an understanding of their test results, as well as the individual-level barriers, where 30.7% were unaware they could receive treatment at their district hospital, and 26.7% believe that hepatitis C is too difficult to treat at the district hospital level. These targeted interventions at the individual level could shift perceptions and enhance patients' self-efficacy. By combining community, organizational, and policy efforts, we can better address individual factors influencing patients\u0026rsquo; decisions to seek hepatitis care and treatment at district hospitals.\u003c/p\u003e\u003cp\u003eA limitation of this study is that the patients interviewed are already seeking care at tertiary hospitals, making them more likely to have a greater distrust of district hospital treatment and healthcare for hepatitis C. A strength of our study is that the barriers faced by the patients we surveyed are fewer than those encountered by individuals who are unable to access medical services for hepatitis in the first place. This is because the patients we interviewed have the resources and knowledge to access medical services and treatment for hepatitis C at UMC. In contrast, most patients who are unable to overcome these barriers would generally remain undiagnosed and untreated.\u003c/p\u003e\u003cp\u003eIn conclusion, our interviews and surveys reveal that financial constraints, time, and travel distance are the primary barriers to seeking hepatitis C treatment at tertiary hospitals. To address these challenges and improve HCV treatment rates, local stakeholders should invest in decentralizing healthcare to the district hospital level, enabling these hospitals to become accredited HTUs capable of providing high quality care, and eligible for SHI reimbursement to reduce costs for patients. This requires enhancing comprehensive care, treatment services, healthcare worker training, and raising awareness about hepatitis care in district hospitals across Vietnam. Our findings show that a significant minority of patients are willing to access medical services at their district hospitals if they provide the same standard of care as tertiary hospitals. Ultimately, our results strengthen the case for decentralizing hepatitis healthcare in Viet Nam\u0026mdash;an essential step toward achieving the country's HCV elimination goals.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHCV Hepatitis C Virus\u003c/p\u003e\u003cp\u003eDAAs Direct-Acting Antiviral Drugs\u003c/p\u003e\u003cp\u003eOPD Outpatient Departments\u003c/p\u003e\u003cp\u003eSEM Social-Ecological Model\u003c/p\u003e\u003cp\u003eHTU Hepatitis Treatment Unit\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e This study received ethical approval by the Institutional Review Board at the University of Medicine and Pharmacy at Ho Chi Minh City (UMP-HCMC), with 1243/HDDD-DHYD, signed on 12/14/2023. Our research involves collecting identifiable private data, and human subjects are not readily identified. This study was conducted in accordance with Declaration of Helsinki.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003ch2\u003eClinical Trial\u003c/h2\u003e\u003cp\u003eClinical Trial number: not applicable\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003ch2\u003eConsent for publication\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research project was funded by the United States Fulbright Program, which aims to build mutual understanding between nations, advance knowledge across communities, and improve lives worldwide.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThe paper was conceptualized by B.D., N.T.C.H., and D.Y.D. B.D. and N.T.C.H. led the data collection and analysis, with support from T.K., D.Y.D., and B.H.. All authors contributed to the validation, analysis, and interpretation of the findings. B.D. and N.T.C.H. drafted the initial manuscript, which was subsequently revised by Thanh Kim, D.Y.D., and B.H.. All authors approved the final version for publication.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO. 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J Gen Intern Med. 2022;37(13):3435\u0026ndash;43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11606-022-07628-9\u003c/span\u003e\u003c/span\u003e. Epub 2022 Apr 28. PMID: 35484367; PMCID: PMC9551010.\u003c/li\u003e\n\u003cli\u003eHolt B, Fernandez M, Nguyen D, Delima D, Duy LD, Gaspar M, Hamoy G, Le BN, Llevado J, Manlutac JMD, Mendoza J, Mercado T, Nguyen H, Nguyen HT, Ong J, Rombaoa MC, Florendo J, Dela Cruz JM, Pham T, Thai PN, Truong PX, Pollack T, Duong D. Embedding viral hepatitis into primary healthcare: results of a strategic landscape analysis in Vietnam and the Philippines. Lancet Reg Health West Pac. 2023;44:100990. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.lanwpc.2023.100990\u003c/span\u003e\u003c/span\u003e. PMID: 38204496; PMCID: PMC10777101.\u003c/li\u003e\n\u003cli\u003eGolden SD, Earp JAL. Social Ecological Approaches to Individuals and Their Contexts: Twenty Years of Health Education \u0026amp; Behavior Health Promotion Interventions. Health Educ Behav. 2012;39(3):364\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1090198111418634\u003c/span\u003e\u003c/span\u003e.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","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":"hepatitis C, hepatitis C antibody, Viet Nam, decentralization, district hospitals, tertiary hospitals, elimination goals","lastPublishedDoi":"10.21203/rs.3.rs-7708476/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7708476/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAs of 2024 the Ministry of Health of Viet Nam has approved social health insurance reimbursement for testing and treatment for hepatitis C (HCV) at district hospitals to reduce barriers to access to care. However, a significant portion of patients still choose to access medical services at tertiary hospitals. This study sought to understand the barriers to hepatitis access to healthcare faced by adults who tested positive for HCV-RNA at the University Medical Center (UMC) at Ho Chi Minh City, Viet Nam, and to examine attitudes associated with seeking hepatitis care at district hospitals.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethodology:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe conducted a cross-sectional study, consecutively recruiting 75 patients aged 18 and over who tested positive for HCV-RNA at the UMC outpatient liver clinic between February 2024 to April 2024. Participants were surveyed about the barriers they faced related to the diagnosis and treatment of HCV, their reasons for seeking care at tertiary hospitals instead of district hospitals, and the distance traveled and wait times to receive hepatitis care. Sociodemographic information, as well as social and behavioral factors, were also documented. The social-ecological model was then applied to understand the barriers to linkage to treatment at the individual, community, environmental, organizational, and political levels.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFindings:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSeventy five participants with complete data were included in the analysis. Among these participants, 10.7% refused treatment for various reasons, despite physician consultation. The primary barriers to hepatitis C treatment included financial constraints (45.3%), geographical distance (65.3%), and time limitations (57.3%). Conversely, a lack of understanding of their results (18.7%) and fear of side effects (18.7%) were perceived as less significant barriers. When surveying patients on why they chose to seek hepatitis healthcare at tertiary hospitals instead of their district hospitals, the results indicated that 82.7% believed they would receive better hepatitis treatment at tertiary hospitals, 73.3% thought they would receive better overall hepatitis healthcare at tertiary hospitals, 53.3% believed that the tertiary hospital had more comprehensive testing, 45.3% did not trust the hepatitis treatment at their district hospital, and 30.7% were unaware that they could seek treatment at their district hospital. The average wait time at the tertiary clinic was 4.53 hours, and the average distance traveled to seek hepatitis care was 163.79 km. However, 37.3% of patients expressed that they would be open to seeking hepatitis healthcare and treatment at their district hospitals if they could provide the same standard of care as tertiary hospitals.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOur interviews and surveys reveal that financial constraints, time, and travel distance are the main barriers to seeking hepatitis C treatment at tertiary hospitals. However, a significant minority of patients expressed a willingness to utilize district hospitals, provided these facilities offer comparable standards of care to tertiary hospitals. Our results support the application of decentralization of hepatitis healthcare in Vietnam, which is critical for reaching the targeted goals of HCV elimination.\u003c/p\u003e","manuscriptTitle":"Insights into Barriers Affecting Access to Hepatitis C Care in Viet Nam","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-03 00:52:12","doi":"10.21203/rs.3.rs-7708476/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":"1a6e4bfa-49ac-4e38-b3c7-8d2772e083a9","owner":[],"postedDate":"December 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-11T13:58:00+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-03 00:52:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7708476","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7708476","identity":"rs-7708476","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}