Ethnic minority health in Vietnam: a review exposing horizontal inequity

Figures & data

Table 1. Inclusion and exclusion criteria for studies

Inclusion criteria	Exclusion criteria
•Studies published in English	•Studies in other languages than English
•Studies published from 1990 up until September 2011.	•Studies with no comparison between ethnic groups
•Qualitative studies aiming to explain differences in health between ethnic groups due to cultural and societal factors	•Studies with study population outside Vietnam
	•Reviews
•Quantitative studies measuring the impact of ethnicity on health outcomes	•Studies with no health related outcomes

Fig. 1.  Flow chart.

Table 2. Health care seeking and utilization

Author(s)	Title	Publication	Year	Main results	Study design and sample	The ethnicity variable
Castel P. 36	Vietnam Health Insurance: Use of Health Care Services by the Poor Efficiency and Equity Issues in the Province of Kon Tum.	Working papers series, Posted at SSRN April 6, 2011.	2011	Less expenditure on ethnic minorities (EM) compared to the non-poor, thus an equity problem in the provision of health care services. All received more expensive treatments when referred to hospital except EM. EM get less blood, fewer lab exams and less surgery (minor and major). EM mothers do not search particular health care support during pregnancy and delivery.	Comparison of individual's health insurance data of the Provincial Social Security Health Insurance and information collected for claim control	Kinh vs. Minority
Committee for Ethnic Minorities/UNICEF. 31	Reaching out for change: A qualitative assessment of government health care and education policies affecting the women and children of ethnic minorities.	Available at: www.unicef.org/vietnam	2003	Low awareness among ethnic minority groups about governmental programs was a major obstacle for policy implementation.	Observations, group discussions and in-depth and informal interviews	Ethnic minorities in priority communes.
Hong TK, Dibley MJ, Tuan T. 41	Factors affecting utilization of health care services by mothers of children ill with diarrhea in rural Vietnam.	Southeast Asian J Trop Med Public Health. 2003 Mar: 34 1:187–98.	2003	Low use of ORS among EM. EM less likely to seek care for children with diarrhea (OR 2.32 CI 1.08–5.00, adj for education, economy and disease severity). EM reported low levels of satisfaction with their local medical services.	Cross-sectional household survey between Nov 1998 and Jan 1999 in three provinces in the south. 1632 women with 1935 children under 5	Kinh vs. Minority
Malqvist M, Nga NT, Eriksson L, Wallin L, Hoa DP, Persson LA. 6	Ethnic inequity in neonatal survival: a case-referent study in northern Vietnam.	Acta Paediatr. 2011 Mar: 100 (3):340–6.	2011	Increased risk of neonatal mortality for ethnic minority mothers. The elevated risk was maintained even if the EM mothers went to hospital to deliver or if they attended ANC.	Case-referent study including 183 neonatal death cases and 599 referents	Kinh vs. Minority
Ministry of Health and Health Partnership Group. 39	Joint annual health review 2010 – Vietnam's health system on the threshold of the five-year plan 2011–2015	Available at http://www.jahr.org.vn	2010	Lower admission to inpatient care for ethnic minorities than for Kinh majority. Actively support ethnic minority students in medical training.	Vietnam Household and Living Standards Survey (VHLSS) 2002, 2004 and 2006	Delta/urban areas vs. mountains/ethnic minority areas
Ministry of Health and Health Partnership Group. 37	Joint annual health review 2009 – Human resources for health.	Available at http://www.jahr.org.vn	2009	Few health workers from ethnic minorities.	Cross-sectional survey	Kinh vs. Minority
Oosterhoff P, White J, Huong NT. 44	Family health consequences of modernisation programmes in Black Thai communities.	Cult Health Sex. 2011 Apr 1.	2011	Imposed governmental policies promoting patrilocality and health facility delivery resulted in increased vulnerability to HIV among Thai women. Highlighting the importance of policy-makers attempting to understand cultural institutions and their social function in their specific context.	Focus Group Discussions (FDGs) with men and women separately of mixed ages. In-depth interviews with 84 Thai women	Black Thai community in Dien Bien province
Rheinlander T, Samuelsen H, Dalsgaard A, Konradsen F. 42	Perspectives on child diarrhoea management and health service use among ethnic minority caregivers in Vietnam.	BMC Public Health. 2011 Sep 6; 11 (1):690	2011	Several obstacles for EM caregivers to seek health services were identified, including gender roles, long travelling distances, concerns about indirect costs and disrespectful treatment.	In-depth interviews of 43 caregivers, 3 Focus Group Discussions (FGDs) and 2 weeks of participatory observations at two Communal Health Stations	Four EMGs in Lao Cai province
Teerawichitchainan B, Phillips JF. 40	Ethnic differentials in parental health seeking for childhood illness in Vietnam.	Soc Sci Med. 2008 Mar: 66 (5):1118–30.	2008	EM mothers less likely to seek care when children were sick. EM parents less frequently reported illness.	VNHS 2001	Kinh/Chinese vs. Minority
Toan NV, Trong LN, Höjer B, Persson LA. 35	Public health services use in a mountainous area, Vietnam: implications for health for policy.	Scand J Public Health. 2002: 30 (2):86–93.	2002	EM used public health services less frequently than the majority group (24% vs. 43%). Distance to health facilities was not associated with ethnicity. Ethnic minority people reported more severe diseases (p=0.03). The under-use of health services by ethnic minorities was observed only when distance to the services was far. Failure of fee exemption; almost all EM (98%) had paid for services even though they should have been exempted.	Cross-sectional using four week diary and structured interview form. 1452 individuals from 300 households in three communes in northern Vietnam	Kinh vs. Minority
UNICEF Vietnam and Dien Bien Provincial People's Committee. 43	An analysis of the situation of children in Dien Bien.	Available at: http://www.un.org.vn/en/	2010	Ethnic minority mothers utilize healthcare services to a lesser extent. Explanations suggested are distance and cost, language barriers, the maintenance of traditional health care beliefs and a lack of knowledge.	FGDs and observational study	EM in Dien Bien Provence
Wagstaff A. 38	Estimating health insurance impacts under unobserved heterogeneity: the case of Vietnam's health care fund for the poor.	Health Econ. 2010 Feb: 19 (2):189–208	2010	EM less covered by Health Care Fund for the Poor (HCFP) unless they are poor even though they are eligible.	Official data from Vietnam Social Security (VSS) and household survey data from VHLSS 2002, 2004 and 2006, triple differencing with matching	Ethnic minorities eligible for HCFP

Table 3. Maternal, newborn and child health

Author(s)	Title	Publication/Agency	Year	Main results	Study design and sample	The ethnicity variable
Amin S, Teerawichitchainan B. 47	Ethnic fertility differentials in Vietnam and their proximate determinants.	Working Paper No 18, Population Council.	2009	Two major contributors to the higher fertility rate among ethnic minority groups are early childbearing and lower rates of abortion due to strong ideological opposition.	Vietnam National Health Survey (VNHS) 2001	Kinh-Chinese vs. Ethnic minority groups divided by region
Central population and housing census steering committee. 21	The 2009 Vietnam Population and Housing census: Major findings.	Available at http://www.gso.gov.vn	2010	Infant mortality rate higher in ethnic minority groups.	Cross-sectional	Kinh, Tay, Thai, Muong, Khme, Mong and Other
Ekman B, Axelson H, Ha DA, Nguyen LT. 50	Use of Maternal Health Care Services and Ethnicity: A Cross-Sectional Analysis of Vietnam.	Working papers series. Posted at SSRN June 15, 2007.	2007	The use of maternal health care services, including antenatal care, skilled assistance at birth and delivering at a clinic, is highly related to ethnicity such that ethnic minorities (EM) use significantly less of these services.	Cross-sectional using national survey data 2001/02	Kinh vs. Minority
Graner S, Klingberg-Allvin M, Phuc HD, Krantz G, Mogren I. 49	The panorama and outcomes of pregnancies within a well-defined population in rural Vietnam 1999–2004.	Int J Behav Med. 2009: 16 (3):269–77.	2009	Higher risk of stillbirth for EM, OR 6.34 CI 1.33–30.29). EM more likely to delivery outside a health care facility (OR 1.85 adjusted for area of residence, economy, education and marital status)	Population-based surveys 1999, 2001, 2003. All women who reported a pregnancy from 1999 up to 2004 were included (n=5845)	Kinh vs. Minority
Hoa DP, Nga NT, Malqvist M, Persson LA. 7	Persistent neonatal mortality despite improved under-five survival: a retrospective cohort study in northern Vietnam.	Acta Paediatr. 2008 Feb: 97 (2):166–70.	2008	Increased risk of neonatal mortality in ethnic minority groups, independent of economy and education. Increased risk o neonatal mortality over time.	Cross-sectional. Retrospective reproductive life stories were collected through interviews with 14329 women	Kinh vs. Minority
Knowles JC, Bales S, Cuong LQ, Oanh TTM, Luong DH. 59	Health equity in Viet Nam: A situation analysis focused on maternal and child mortality.	UNICEF, Hanoi. Available at: http://www.un.org.vn/en/	2009	Child survival related to Vietnamese or Chinese ethnicity. Infant mortality even stronger associated to ethnicity.	Surveys of Population Change and Family Planning 2005 and 2006	Kinh/ Chinese vs. Minority
Ministry of Planning and Investment. 52	Vietnam population and housing census 2009 – Sex ratio at birth in Vietnam: New evidence on patterns, trends and differentials	Available at: http://www.gso.gov.vn	2010	Data indicates that the SRB among minority (non-Kinh) women is relatively low at 105.9.	Cross-sectional survey	Kinh vs. Minority
Malqvist M, Nga NT, Eriksson L, Wallin L, Hoa DP, Persson LA. 6	Ethnic inequity in neonatal survival: a case-referent study in northern Vietnam.	Acta Paediatr. 2011 Mar: 100 (3):340–6.	2011	Increased risk of neonatal mortality for ethnic minority mothers. The elevated risk was maintained even if the EM mothers went to hospital to deliver or if they attended ANC.	Case-referent study including 183 neonatal death cases and 599 referents.	Kinh vs. Minority
Malqvist M. 58	Neonatal mortality: an invisible and marginalised trauma.	Glob Health Action. 2011 Mar 16: 4	2011	Increased risk of neonatal mortality for ethnic minority mothers, independent of distance, or place of delivery.	Case-referent study including 183 neonatal death cases and 599 referents.	Kinh vs. Minority
Malqvist M, Nga NT, Eriksson L, Wallin L, Ewald U, Persson LA. 53	Delivery care utilisation and care-seeking in the neonatal period: a population-based study in Vietnam.	Ann Trop Paediatr. 2008 Sep: 28 (3):191–8.	2008	Ethnic minority mothers less likely to seek care at time of delivery.	Cross-sectional. Registry data. 284 neonatal death cases.	Kinh vs. Minority
Sepehri A, Sarma S, Simpson W, Moshiri S. 54	How important are individual, household and commune characteristics in explaining utilization of maternal health services in Vietnam?	Soc Sci Med. 2008 Sep: 67 (6):1009–17.	2008	Kinh mothers are almost three times more likely to give birth at health facilities than EM women. While ethnicity has little influence on access to prenatal care it has a strong influence on a woman's decision on delivery location.	Cross-sectional using data from VNHS 2001, including 158 000 individuals in 36 000 households	Kinh vs. Minority
Teerawichitchainan B, Amin S. 46	The role of abortion in the last stage of fertility decline in Vietnam.	Int Perspect Sex Reprod Health. 2010 Jun: 36 (2):80–9.	2010	EM in northern uplands and central highlands had higher fertility rates, were less likely to use modern contraceptives and had a lower abortion rate.	VNHS 2001 including 27097 women 15–49 years	Five clusters of ethnic groups; Kinh/Chinese, Tay/Thai/Muong/Nung (TTMN), EM in the south, EM in northern uplands, EM in central highlands.
UNFPA. 57	Childbirth in ethnic minority communes – a qualitative study in Binh Dinh province	Available at: http://www.vietnam.unfpa.org	2008	Poor understanding and knowledge about ethnic minority birth practices among health workers. Existing reproductive health services are not relevant to local customs and practices.	In-depth interviews, FGDs and non-participatory observations among health workers in Binh Dinh province	EM in Binh Dinh province.
UNFPA. 56	Knowledge and behaviour of ethnic minorities on reproductive health	Available at: http://www.vietnam.unfpa.org	2007	Many ethnic minorities do not utilize delivery facilities due to a combination of complex rituals surrounding birth. Important not to attempt to explain complex situations with simple mono-causal factors.	Interviews and FGDs	EM in Ha Giang and Hoa Binh provinces
UNFPA. 48	Reproductive health of H'mong people in ha Giang province.	Available at: http://www.vietnam.unfpa.org	2008	Low rates of contraceptive use due to limited knowledge, fear of domestic violence, cultural taboos and time constraints.	Ethnographic interviews, FGDs, observations and case studies	H'mong in Ha Giang province
UNICEF Vietnam and Dien Bien Provincial People's Committee. 43	An analysis of the situation of children in Dien Bien.	Available at: http://www.un.org.vn/en/	2010	Ethnic minority mothers utilize healthcare services to a lesser extent. Explanations suggested are distance and cost, language barriers, the maintenance of traditional health care beliefs and a lack of knowledge.	FGDs and observational study	EM in Dien Bien Provence
UNICEF. 51	An analysis of the situation of children in Viet Nam 2010.	Available at: http://www.un.org.vn/en/	2010	Low overall awareness of reproductive health among ethnic minority women.	Multiple Indicator Cluster Survey (MICS) 2 2006	Kinh vs. Minority
Vo Van T, Hoat LN, Jan van Schie T. 55	Situation of the Kinh poor and minority women and their use of the Maternal Care and Family Planning Service in Nam Dong Mountainous District, Thuathien-Hue Province, Vietnam.	Rural Remote Health. 2004 Oct-Dec: 4 (4):255.	2004	Home delivery rate higher for EM (81%) compared to Kinh (19%). Illiteracy rate higher among EM. Language was a common barrier when Kinh health staff attempted to communicate with minority women. Most communication material at the health centre was written in Kinh.	Oral questionnaire. Random sample of 420 women with children under 5 in seven communes	Kinh vs. Minority
World Health Organization (WHO). 26	Health and ethnic minorities in Viet Nam.	Technical Series No. 1	2003	Most provinces with high infant and child mortality rates have high concentrations of EM.	Population Census 1999	Comparing 10 provinces with highest and lowest percentage of EM
World Health Organization (WHO). 45	Maternal mortality in Viet Nam 2000–2001: An in-depth analysis of causes and determinants.	Available at: http://dosei.who.int/	2005	Women in ethnic minority groups had a relative risk of maternal death 3.92 times higher than Kinh women.	Cross-sectional survey in seven provinces	Kinh vs. Minority

Table 4. Nutrition

Author(s)	Title	Publication	Year	Main results	Study design and sample	The ethnicity variable
Bui QT, Le Linh C, Rahman Z. 60	Child health status and maternal and child care in Quangtri Province, Vietnam.	Asia Pac J Public Health. 2008 Oct: 20 Suppl:228–35.	2008	Ethnicity associated with child malnutrition	Cross-sectional, FGDs and In-depth interviews. 400 mothers with children under 2. 27 mothers interviewed and 4 FGDs with total 38 participants	Kinh vs. Minority
Haughton D, Haughton J. (61)	Explaining Child Nutrition in Vietnam.	Economic Development and Cultural Change, Vol. 45, No. 3 (April 1997), pp. 541–556.	1997	Ethnic minorities (EM) more likely to be stunted (-0,2 SD), possibly due to geography	Vietnam Living Standard Survey (VLSS) 1992–93. 7046 children from 4800 households	Kinh vs. Minority
Thang NM, Popkin B. 64	Child malnutrition in Vietnam and its transition in an era of economic growth.	J Hum Nutr Diet. 2003 Aug: 16 (4):233–44.	2003	Minority populations living in rural areas were more likely to be stunted. Minority status not predictive for escaping stunting. Economy showing stronger association	Cross-sectional using data from VLSS 1992–93 and 1997–98. 4305 households and 4367 children	Kinh vs. Minority
Thang NM, Popkin BM. 63	Patterns of food consumption in Vietnam: effects on socioeconomic groups during an era of economic growth.	Eur J Clin Nutr. 2004 Jan: 58 (1):145–53.	2004	EM consumes 19.3 kcal/day less than Kinh population. EM populations not only eat less foods rich in proteins and lipids, but also less food rich in starches.	Cross-sectional using household from VLSS 1992–93 and individuals from VLSS 1997–98 23839 individuals (1992–93) and 28509 individuals (1997–98)	Kinh vs. Minority
Thang NM, Popkin BM. 62	In an era of economic growth, is inequity holding back reductions in child malnutrition in Vietnam?	Asia Pac J Clin Nutr. 2003: 12 (4):405–10.	2003	EM living in rural areas were 2.34 times more likely to be stunted. No difference only from minority status	Cross-sectional using data from VLSS 1997–98. 5309 children	Kinh vs. Minority
Trinh LT, Dibley M. 65	Anaemia in pregnant, postpartum and non-pregnant women in Lak district, Daklak province of Vietnam.	Asia Pac J Clin Nutr. 2007: 16 (2):310–5.	2007	Women of BoY, Ede and Koho minorities had an increased risk of anaemia compared to Kinh women (OR 2.7 CI 1.4–5.0). No difference between Kinh and M'nong overall, but pregnant M'nong women more likely to be anemic than Kinh (adjOR 2.1 CI 1.2–9.2)	Cross-sectional 2001 in a mountainous area. All pregnant and post pregnant women (up to 6 months after delivery) were included. An equal amount of non-pregnant women	M'nong (62%), Kinh (31%), BoY, Ede and Koho (7%)
UNICEF. 51	An analysis of the situation of children in Viet Nam 2010.	Available at: http://www.un.org.vn/en/	2010	Underweight malnutrition is considerably higher among ethnic minority children compared to Kinh (30 per cent versus 18 per cent)	Multiple Indicator Cluster Survey (MICS) 2 2006	Kinh vs. Minority

Table 5. Infectious diseases

Author(s)	Title	Publication	Year	Main results	Study design and sample	The ethnicity variable	Sub theme
Abe T, Honda S, Nakazawa S, Tuong TD, Thieu NQ, Hung le X, Thuan le K, Moji K, Takagi M, Yamamoto T. 71	Risk factors for malaria infection among ethnic minorities in Binh Phuoc, Vietnam.	Southeast Asian J Trop Med Public Health. 2009 Jan: 40 (1):18-29.	2009	Ethnic minority status not associated with malaria infection.	Cross-sectional study including 682 individuals in a village in Binh Phuoc province in southern Vietnam.	Kinh (20%) vs. Stieng (80%),	Malaria
Bui TD, Pham CK, Pham TH, Hoang LT, Nguyen TV, Vu TQ, Detels R. 69	Cross-sectional study of sexual behaviour and knowledge about HIV among urban, rural and minority residents in Viet Nam.	Bulletin of the World Health Organization, 2001; 79 (1):15–21.	2001	Lower awareness about HIV in areas with a large proportion of ethnic minorities.	Cross-sectional	Kinh vs. Minority	HIV/TB
Des Jarlais DC, Johnston P, Friedmann P, Kling R, Liu W, Ngu D, Chen Y, Hoang TV, Donghua M, Van LK, Tung ND, Binh KT, Hammett TM. 68	Patterns of HIV prevalence among injecting drug users in the cross-border area of Lang Son Province, Vietnam, and Ning Ming County, Guangxi Province, China.	BMC Public Health. 2005 Aug 24: 5:89..	2005	Ethnicity was not related to HIV status.	Cross-sectional survey of injecting drug users in Lan Son province in northern Vietnam. (n=348)	Kinh vs. Minority	HIV/TB
Hammett TM, Johnston P, Kling R, Liu W, Ngu D, Tung ND, Binh KT, Dong HV, Hoang TV, Van LK, Donghua M, Chen Y, Des Jarlais DC. 67	Correlates of HIV status among injection drug users in a border region of southern China and northern Vietnam.	J Acquir Immune Defic Syndr	2005	Ethnicity was not related to HIV status.	Cross-sectional survey of injecting drug users in Lan Son province in northern Vietnam. (n=348)	Kinh vs. Minority	HIV/TB
Huong NT, Vree M, Duong BD, Khanh VT, Loan VT, Co NV, Borgdorff MW, Cobelens FG. 15	Delays in the diagnosis and treatment of tuberculosis patients in Vietnam: a cross-sectional study.	BMC Public Health. 2007 Jun 13: 7:110.	2007	Patients’ delay longer in ethnic minority groups.	Cross-sectional survey of new TB patients at 70 randomly selected districts. (n=2093)	Kinh vs. Minority	HIV/TB
Schratz A, Pineda MF, Reforma LG, Fox NM, Le Anh T, Tommaso Cavalli-Sforza L, Henderson MK, Mendoza R, Utzinger J, Ehrenberg JP, Tee AS. 73	Neglected diseases and ethnic minorities in the Western Pacific Region exploring the links.	Adv Parasitol. 2010: 72:79–107.	2010	Coincidental report of high prevalence of soil transmitted helminth infections in areas with large ethnic minority populations.	Epidemiological data.	Kinh vs. Minority	Neglected diseases
Vach TH, Cuong ND. 66	Study on access to care, treatment, and support for children and women with HIV and AIDS among communities with higher numbers of ethnic minority people in Dien Bien, Kon Tum, and An Giang provinces.	UNICEF, Research Centre for Rural Population and Health and Ministry of Health; available at www.vaac.gov.vn	2010	Equitable and universal access among vulnerable groups, including ethnic minority children and women related to HIV/AIDS control and prevention has not been well addressed.	In-depth interviews and Focus Groups Discussions (FGDs).	Ethnic minorities (EM) in Dien Bien, Kon Tum and An Giang provinces	HIV/TB
Verle P, Kongs A, De NV, Thieu NQ, Depraetere K, Kim HTM, Dorny P. 74	Prevalence of intestinal parasitic infections in northern Vietnam.	Tropical Medicine & International Health 8(10) 1365–3156.	2003	Prevalence of nematode infections was high in all ethnic groups.	Cross-sectional study including 2686 individuals from 50 villages in the province of Hoa Binh.	Muong (64%), Kinh (11%), Dao (10%), Thai (6%), Tay (5%), Hmong (4%)	Neglected diseases

Table 6. Oral health and hygiene

Author(s)	Title	Publication	Year	Main results	Study design and sample	The ethnicity variable
Rheinländer T, Samuelsen H, Dalsgaard A, Konradsen F. 78	Hygiene and sanitation among ethnic minorities in Northern Vietnam: does government promotion match community priorities?	Soc Sci Med. 2010 Sep: 71 (5):994–1001.	2010	Cultural perceptions of hygiene and sanitation did not differ substantially and were similar to hygiene explanations found in the rural majority population elsewhere in Vietnam. However, in order to design effective sanitation programs, policy makers and program managers need to understand the underlying cultural and social factors that determine sanitation behaviour and priorities, for example, by allowing for a larger diversity of low-cost sanitation solutions.	Participatory observations in 4 villages and 20 case households over a period of six months (May-October 2008). In addition, 10 key informants and 60 household-members were interviewed and 4 focus group discussions conducted	Representatives from Giáy, Tày and Xá Phó (all lowland villages), and red Dao.
Uetani M, Jimba M, Kaku T, Ota K, Wakai S. 75	Oral health status of vulnerable groups in a village of the Central Highlands, southern Vietnam.	Int J Dent Hyg. 2006 May: 4 (2):72–6.	2006	The Co-Ho were less likely to have heard about oral health than the Kinh (OR: 6.0; 95%CI: 1.2–14; P=0.014). The younger group of the Kinh had more dental caries than the Co-Ho (OR: 1.8; 95%CI: 1.5–2.2; P=0.001).	195 participants from 56 households	Kinh vs. Co-Ho
UNICEF and Viet Nam Administration of Preventive Medicine. 76	A summary of national baseline survey on environmental sanitation and hygiene situation in Viet Nam.	Available at: http://www.un.org.vn/en/	2007	The probability of ethnic minority households to have hygienic latrines is 12 folds lower than for Kinh households.	Cross-sectional survey of 37 306 households	Kinh vs. Minority

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Thang NM, Popkin B. Child malnutrition in Vietnam and its transition in an era of economic growth. J Hum Nutr Diet. 2003; 16: 233–44.10.3402/gha.v6i0.19803.

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