Contraception practices among young unmarried women seeking abortion following unintended pregnancy in Ho Chi Minh City, Vietnam

Abstract

The aim of this study was to explore and describe contraception practices among young unmarried Vietnamese women seeking abortion after an unintended pregnancy. A qualitative study was conducted with voluntary participation of 42 women at a hospital in Ho Chi Minh City. Interview data were subjected to content analysis from which five categories were identified: (1) attitudes towards sexuality and contraception, (2) knowledge about contraception, (3) use of contraceptive methods, (4) cultural and traditional issues concerning sexuality and contraception, and (5) abortion as a solution to unwanted pregnancy. Prior to their abortion, women had viewed premarital sex as a means of maintaining a relationship with their boyfriends. Misconceptions, misbeliefs, fear of side effects and limited knowledge were reasons for not using contraception and, in case of unintended pregnancy, abortion was the solution. Boyfriends played an important role in influencing the use (or non-use) of contraceptives. Sexual and reproductive health education including counselling for gender equality, safer sex practices and the prevention of unintended pregnancy should be provided to both women and men in ways which combine traditional and modern views of sexuality. Intervention research to develop sexual and reproductive health education programmes, including contraception counselling, should be carried out.

Keywords:

• Contraception
• unintended pregnancy
• young unmarried women
• abortion
• Vietnam

Introduction

Sexual and reproductive health (SRH) problems, such as unintended pregnancy, have increased due to the unmet need for contraception in developing countries (Bearak et al. 2018). Premarital sex is increasingly prevalent among unmarried young adults in Vietnam (Gammeltoft 2002; Loan and Srisaeng 2014; Ministry of Health of Vietnam 2010). High-risk sexual preferences among young adults (e.g. early sexual debut, unprotected sexual intercourse, multiple partners, and sex with casual or unknown partners) have been reported (Janghorbani and Lam 2003). Premarital sex and high-risk sexual preferences can expose young adults not only to risk of unintended pregnancy and abortion but also to increased risk of negative consequences for health such as HIV and other sexually transmitted infections (Yip et al. 2013). Insufficient knowledge of sexual and reproductive health and insufficient access to contraception can lead to unplanned pregnancies (Hoang, Nguyen, and Duong 2018). However, good knowledge about contraceptives among young adults does not help if utilisation of contraceptives is low among those who are sexually active (Gammeltoft 2002; Wang et al. 2015). Factors responsible for unintended pregnancy include not planning to have sex, not being able to get pregnant, wishing to feel more natural when having sex, underestimating the risk of contraceptive failure, and having difficulty getting birth control prescriptions (Loan and Srisaeng 2014; Mensch, Clark, and Nguyen 2003; Ngo et al. 2012; Nguyen and Pham 2015).

Traditionally, Confucian culture in East and Southeast Asia has considered women to be subordinate to men (Gao et al. 2012). Family structures, values and norms are frequently rooted in Confucian philosophies of respect, hierarchy and collectivism. Men and women are expected to have distinct social roles (Bélanger and Barbieri 2009; Bryant 2002; Gao et al. 2012; Nguyen 2007; Schuler et al. 2006). In Vietnamese culture, men are usually the heads of households and responsible for important decision making while women are in charge of more minor decisions on the running of the household (Bélanger and Khuat 1999; Gammeltoft 2002). Confucianism, which has long governed the ways of life and the beliefs of Vietnamese people, continues to influence life in Vietnam (Bélanger and Barbieri 2009; Bryant 2002; Nguyen 2007; Schuler et al. 2006). Traditionally, a high value is placed on female virginity and open discussion of sexuality is seen as taboo (Bélanger and Khuat 1999; Khuat 2003). Premarital sex is strongly condemned (Nguyen and Pham 2015), and women are expected to retain their virginity until after marriage. In sexual activities, they are supposed to be submissive and less aggressive than men (Gao et al. 2012; Khuat 2003).

Since 1986, economic reforms in Vietnam have changed people’s lives economically and socially. Open door policy and economic development have brought about rapid and significant social change and increasing exposure to the mass media and the Western culture (Gammeltoft 2002; Nguyen 2007). Better access to the media and higher exposure to Western ideologies have influenced traditional cultures and ideologies (Bélanger and Barbieri 2009; Ghuman et al. 2006). People have more freedom to make their own choices, which has led to many changes in family relations and has undermined traditional social systems (Zhang and Locke 2002). Sexuality is expressed most strongly in urban areas in terms of fashion, pornography, romantic cuddling in parks and sex work (Drummond 2006). Young women in urban areas display a more liberal attitude toward sexual issues and engage increasingly in sexual activity before marriage (Horton and Rydstrom 2011; Martin 2010). Additionally, young educated Vietnamese women resist the power of traditional discourses on femininity and sexuality and want to exert agency and control within their sexual relationships (Quach 2008).

Unintended pregnancy and abortion among unmarried young women are serious public health problems (Bearak et al. 2018). The increased number of young unmarried people who are sexually active has led to an increased number of unwanted pregnancies (Gammeltoft 2002; Nguyen and Liamputtong 2007). Loan and Srisaeng (2014) found that only 10.5% of young unmarried Vietnamese women aged 18 to 24 years in Hanoi use contraceptives regularly instead of less reliable methods such as emergency contraception, withdrawal and periodic abstinence. Hoang et al. (2012) found that 45% of women of the same age group in Ho Chi Minh City (HCMC) who had an unintended pregnancy before marriage had had at least one prior abortion. Also, Ngo et al. (2014) found that about half the number of abortion-seeking women and one quarter of the number of unmarried such women had had at least one prior abortion. In a recent literature review, Nguyen and Pham (2015) identified a number of factors influencing unintended pregnancy and abortion among young people in Vietnam. These included liberal attitudes to premarital sex, lack of knowledge about contraception, a low sense of self-efficacy, and poor communication between partners as well as between parents and youth on issues related to sexuality. They also had less than adequate sexuality education in school and poor access to SRH services for youth. Other factors influencing women to seek abortion were related to finance, the timing of pregnancy and requests for abortion from a partner (Ngo et al. 2012).

With a population of more than eight million, HCMC is the largest city in Vietnam. Urbanisation has been rapid, and many inhabitants have come to the city from other provinces. As a result, many young adults have changed their lifestyles and live more independently from their families. Their attitudes towards sex and sexuality have become more open (Do and Fu 2010; Ghuman et al. 2006; Trang 2008). Previous studies in Vietnam have suggested that gender inequality, cultural norms and societal double standards seriously constrain young women’s capability to negotiate safer sex and exert influence over their sexual lives, which makes them vulnerable to sexual health risks (Bélanger and Khuat 1999; Gammeltoft 2002; Martin 2010; Mensch, Clark, and Nguyen 2003; Vu 2008). Social norms regarding the roles of women and men and their culturally assigned positions in society influence patterns of sexual behaviour and contraceptive use (Khuat 2003; Nguyen and Liamputtong 2007). Many Vietnamese women are no longer committed to leading traditional social lives, but traditional gender ideology and sexual values remain in society (Bui and Liamputtong 2018) and gender-specific discourses still discourage young women from engaging in premarital sex (Gammeltoft 2002; Quach 2008).

Against this background, it is important to gain more knowledge into the contraception practices among young unmarried Vietnamese women seeking abortion because of unintended pregnancy. Such knowledge may be used to influence the sexual and reproductive health-related knowledge and practices of health care providers and young adults in Vietnam.

Methods

A qualitative study was conducted with the approval and support of the University of Medicine and Pharmacy, HCMC. Data were collected in the family planning clinic of a women’s hospital in HCMC.

Participants

Forty-two young unmarried Vietnamese women seeking abortion because of unintended pregnancy, selected by means of purposive convenience sampling, participated voluntarily. The selection criteria were as follows: (1) aged 16 to 24 years, (2) unmarried, (3) seeking abortion because of unintended pregnancy, and (4) having given informed consent. All had a boyfriend. Some lived with their parents while others lived with friends. Twenty-seven were working. The others were studying at high school, college or university. Most were not religious, and their ages ranged from 20 to 24 years. Those who worked had incomes in between 959 and 2,398 USD per month, while those who studied received support from their parents of between 288 and 1,439 USD per month. The majority had used contraceptive methods. All had used emergency contraceptive pills at least four times a month, and 15 had used such pills 10 times a month or more. Gestational age when seeking abortion was between 8 and 15 weeks (Table 1).

Table 1. Demographic background of young unmarried Vietnamese women seeking abortion.

Demographic background	Young unmarried Vietnamese women
	n	%
Age (years)
19-20	15	35.7
21-22	17	43.6
23-24	10	23.8
Religion
Buddhist	4	9.5
Catholic	1	2.4
None	37	88.1
Education
High school	11	26.2
College	15	35.7
University	16	38.1
Occupation
Student	15	35.7
Seller	6	14.3
Accountant	9	21.4
Public officer	7	16.7
Worker	5	11.9
Income per month (USD)
<899	6	14.3
900-999	11	26.2
1000-1999	15	35.7
2000-2999	10	23.8
Contraceptive method (more than one method can be selected)
Withdrawal	17	43.6
Condom	8	19.0
Contraceptive pill	10	23.8
Emergency contraceptive pill	42	100.0
Had a previous abortion
No	31	73.8
Yes	11	26.2
Gestational age when seeking abortion
8-12 weeks	20	47.6
12-15 weeks	22	52.4

Data collection

Women participated in a semi-structured individual interview. The interview guide elicited demographic background and asked seven open-ended questions in Vietnamese as follows: (1) What is your opinion about sexuality in society? (2) What is your perspective on having sex with your boyfriend before marriage? (3) Have you used contraception to prevent pregnancy? If “yes”, what kinds of contraceptive methods have you used and why? If “no”, why haven’t you? (4) What did you think when you got pregnant as unmarried? (5) What factors influenced you to seek an abortion? (6) What did you feel when you sought an abortion? (7) Do you have something else to share?

The interview questions were pre-tested before use, but none of the questions needed follow-up adjustment. Individual interviews lasting 30 to 90 min were conducted in a room in the clinic of the hospital by the author with support from two Vietnamese colleagues from the University of Medicine and Pharmacy in Ho Chi Minh City with long experience in midwifery. While participants described their experiences, their facial expressions and gestures were observed and noted. Interviews were tape-recorded and the data collection continued until no new information emerged. After 42 interviews, saturation had been achieved with regard to the main topics. The recorded interviews were transcribed verbatim and translated from Vietnamese to English. The linguistic accuracy of the transcripts was checked by a language expert in Ho Chi Minh City.

Data analysis

Data from the translated interviews were subjected to qualitative content analysis involving the subjective interpretation of content by means of a systematic classification process (Burnard et al. 2008; Krippendorff 2013). Initially, the transcripts were read several times with reference to the aims of the study. Analysis then began by highlighting sentences of importance and dividing them into meaning units. Next, the meaning units were condensed and labelled using short codes. Then, these codes were compared to identify similarities and differences between them. Categories were then developed from the codes based on their manifest content. Finally, emerging categories were tested and revised by reference back to the interviews. Outcomes were then discussed with the two Vietnamese colleagues and modified to ensure reliability. Peer checking, validation of emerging codes and categories, and debriefing were used to enhance credibility. This was done with the aid of two colleagues, experts in the research methods and the subject, one from Vietnam and one from Sweden. Disagreements were discussed until consensus was reached (Krippendorff 2013).

Ethical considerations

The study was approved by an Ethics Committee of the University of Medicine and Pharmacy in Ho Chi Minh City (ID: 15/04/2011-HD/NCKH), and the study itself was conducted in line with the requirements outlined in the Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects. All participants were informed about the purpose of the study and assured of anonymity and confidentiality. They provided informed consent verbally and knew they could withdraw from the study at any time.

Results

Five principal categories relating to contraception and unintended pregnancy were developed: (1) attitudes towards sexuality and contraception, (2) knowledge about contraception, (3) the use of contraceptive methods, (4) cultural and traditional issues concerning sexuality and contraception, and (5) abortion as a solution to an unwanted pregnancy.

Attitudes towards sexuality and contraception

All participating women reported having had premarital sex with their boyfriends. They described how they found it natural to have sex in this way before marriage. Most (40/42) mentioned that they often used contraceptive methods but preferred withdrawal and periodic abstinence rather than contraception pills or emergency contraceptive pills. The reason was fear of long-term side effects and perceived health risks.

Sexuality as love and commitment

All women were influenced by Western culture and considered sex a way of keeping their boyfriends. They described how they and their friends followed a Western lifestyle even though they had been brought up traditionally by their parents. They believed that love and sex go together. Some (32/42) explained it was common to have sex with a boyfriend when they had come to know one another and they wanted to commit their love. Most (41/42) found it difficult to refuse their boyfriends sex or require the use of contraception. They did what their boyfriends preferred. However, they felt conflict in their minds about not preserving their virginity in line with Vietnamese culture.

I thought that if we had sex together, our love would last so that I could keep him with me longer. (College student, 20 years)

My boyfriend and I have had a sexual relationship while we have known each other for six months. We believe in our love … (University student, 21 years)

Sometimes I feel bad when I think about our cultural beliefs related to maintaining chastity … because I have sex with my boyfriend before getting married. (Accountant, 23 years)

Fear of side effects of using emergency contraceptive pills

All the women had experience using emergency contraceptive pills but were afraid of long-term side effects if they used this method too often. After using emergency contraceptive pills, more than half (28/42) had experienced short-term side effects such as dizziness, nausea, vomiting, abdominal pain, breast engorgement, menstrual disorders and fatigue, while the others had not. For some (19/42), the menstruation cycle became longer. They worried about infertility, cancer and haemorrhage, and also about the possible poor health of the baby if they became pregnant.

I am afraid of infertility in the future if I use Postinor® too often or more than twice per month. (Seller, 22 years)

If I use the pills (ECPs) many times per month after sexual intercourse, I believe that I will not be able to have a child in the future. (College student, 19 years)

Partner’s influence on choice of contraception

All the women were influenced by their boyfriends about contraception. They described how their boyfriends felt uncomfortable using condoms, and therefore they felt shy and embarrassed to ask them. They also said that their boyfriends were the first to mention and suggest the use of emergency contraceptive pills.

My boyfriend influenced my use of this pill (emergency contraceptive pill) and he told me how to use it. I was afraid of becoming pregnant, so I used it. (High-school student, 19 years)

The first time, my boyfriend bought the medicine for me at the drug store, but sometimes I have bought the same medicine myself at different drug stores. (Worker, 22 years)

Knowledge about contraception

All women had heard about contraceptive methods but had limited knowledge about their use. Many (39/42) had learned something about sex or contraception from their parents and/or at college or university. Others had the misconception that contraception should be used only by married couples.

Heard about emergency contraceptive pill but limited knowledge about its usage

The women had heard about emergency contraceptive pills. Some were able to accurately describe how to use them correctly, but others were not. First-time abortion seekers described how they had unclear ideas about the risk of pregnancy. Some thought that they could not get pregnant the first time they had sex. Others mentioned that their boyfriends had told them to use emergency contraceptive pills after intercourse to prevent pregnancy.

I heard about contraception and especially about emergency pills to prevent pregnancy after sex without protection. My boyfriend and I asked the drugstore seller how to use them. (University student, 21 years)

Sources of information

Women reported receiving information about contraception from several sources including pharmacists and friends. Other sources included magazines, the Internet, radio and television. Several mentioned they preferred to get information from the Internet because of the anonymity it afforded. A few had received information from a doctor or a midwife after an induced abortion.

I can ask for everything on the Internet. For example, I can go to Google and write “how to prevent pregnancy” or “what is a contraceptive pill?”. I can also chat with someone through the Internet and get answers to what I want to know. (University student, 22 years)

I got information about Postinor® and how to use this pill from my friends. I asked the pharmacist at the drugstore to tell me and I also read the instruction paper about how to use the pills. (Public officer, 24 years)

Use of contraceptive methods

All women had experience of a range of contraceptive methods. They strongly preferred the use of emergency contraceptive pills but did not always use them correctly. Some (18/42) mentioned how they had become pregnant and had had to go to hospital for an abortion despite using emergency contraceptive pills.

I took the first pill after intercourse, but I did not remember what the drug store seller had told me about taking the second tablet. I did not do it correctly, so I got pregnant. (Accountant, 21 years)

Last time I used the two tablets of the medicine, the first after intercourse and the second after 12 hours. I did not become pregnant… but this time I forgot to take the second tablet after 12 hours, so I got pregnant. (Worker, 20 years)

Cultural and traditional issues concerning sexuality and contraception

Women mentioned that according to Vietnamese culture and tradition they were not supposed to have sexual intercourse before marriage.

Feeling guilt and shame

Most women (40/42) described feeling guilt and shame when they went to buy contraceptives from the drug store. They also became anxious when thinking about the risk of pregnancy. If they became pregnant, they had strong feelings of shame and guilt about what had happened.

I did not want to have sexual intercourse with my boyfriend, but he wanted [to]. He bought pills for me to take. I felt guilty and worried. I was unhappy because I became pregnant. (University student, 20 years)

I felt guilt and shame when I got pregnant and came here to have abortion. I have just got a job and I and my boyfriend have no plan to get married. (Worker, 22 years)

Lack of comfort talking about sex and contraception

Many women (38/42) said that expressing their sexuality was taboo. This made them feel uncomfortable to talk about sex and contraception with others and, therefore, they rarely talked about these matters. They kept their use of contraceptives secret and did not want to be seen as sexually active. They explained that women should keep their chastity until marriage according to traditional Vietnamese cultural and social norms.

I have never talked with anyone. In my culture it is not good to have sex before marriage. If someone knew that I use this medicine (emergency contraceptive pills) it would not be good. If I were married already it would be ok. (Officer, 23 years)

In my culture we should not talk about having sex with boyfriends and using ECPs before marriage. So, I have not told or discussed this with anyone. (University student, 22 years)

Only a few informants (10/42) mentioned that they had discussed sexuality and the use of emergency contraceptive pills with their close friends.

I often talk together with my close girl friends about sex, boyfriend and use of medicine to prevent pregnancy. We share our experiences with each other and discuss our problems. (University student, 20 years)

Abortion as a solution

Seeking an abortion was the solution for the women who had an unwanted pregnancy. All of them mentioned that pregnancy was unthinkable when they were unmarried and either studied or worked, and abortion was a sensitive topic. Those who worked (27/42) said that they had sought abortion because they had to earn money and keep their careers. Those who studied (15/42) mentioned that their parents were unaware of their pregnancy because they could not tell them. They were receiving financial support from parents for their studies and living while their boyfriends, who also studied, had no income. They said they could not get pregnant when they were not married without going against the tenets of Vietnamese culture. Their parents believed that they had protected their virginity by not having premarital sex. Therefore, their only choice was an abortion.

I have not finished my studies and my parents send money to me every month, so I had no choice when I got pregnant. I and my boyfriend think that seeking abortion is good for us. (University student, 20 years)

When I knew that I got pregnant after sex with my boyfriend, I decided to have abortion because I had just got a job after my education. I would like to have a career. (Accountant, 23 years)

Many women (30/42) said that an abortion was dangerous for their health. However, they felt that an abortion was a necessary option when contraception including emergency contraceptive pills had failed. Some (11/42) with experience of previous abortions indicated that they had felt safe when abortion was induced at a hospital. Therefore, they had decided to seek an abortion in hospital again.

I experienced abortion before when I did not use ECPs after intercourse. Abortion was the option I and my boyfriend chose … I think it is safe[r] to do so at the hospital. (Seller, 22 years)

Discussion

Perspectives on sexuality and premarital sex

Young unmarried Vietnamese women in this study believed that having sexual intercourse before marriage was a way of maintaining a relationship with a boyfriend. This perspective may be due – at least in part - to the combined influence on women of modern lifestyles, Doi Moi, and the media. Previous studies (Bélanger and Khuat 1999; Gammeltoft 2002; Ghuman et al. 2006; Martin 2010; Vu 2008) support the view that premarital sex is increasingly seen as acceptable by young adults in Vietnam, where women struggle between modern-day individualism and liberal sexuality and conservative values and norms regarding women’s gender and sexual roles (Khuat 2003; Trang 2008).

Findings reveal that open discussion of sexuality is still taboo and abortion remains a sensitive topic in Vietnam. Women in this study did not want to be seen as sexually active and kept their sexuality a secret. Their sexual culture reflects changes in Vietnam (Horton and Rydstrom 2011; Martin 2010; Nguyen 2007; Schuler et al. 2006) in a context where gender inequality and cultural norms constrain young women’s capability to control their sexual activity (Phan 2008; Vu 2008). Women felt guilt and shame when buying emergency contraceptive pills or seeking abortion. Social and family pressure were barriers to the use of contraceptives and were associated with lack of education about sex and family planning (Nguyen and Pham 2015).

The preference of the women in this study for the Internet as a source of information about contraception is in accord with findings from other research showing that young women seek confidentiality when looking for information (Frost et al. 2016). The Internet and the media are among the most common sources of information on contraception for youth (Ngo, Ross, and Ratliff 2008). Good quality online sources allow women to seek accurate information privately.

Contraception - attitudes and knowledge

Young women having unprotected sex with their boyfriends because of misconceptions and limited knowledge is in accord with several studies (Bélanger and Khuat 1999; Do et al. 2014; Gammeltoft 2002; Khuat 2003; Nguyen and Pham 2015). Participating women in this study may have been influenced by traditional norms about virginity and the wish to avoid rejection by their boyfriends. In addition, boyfriends controlling the use of contraceptives is in accord with other studies (Bui et al. 2010; Nguyen and Pham 2015) and aligns with gender power imbalances prevalent in the Vietnamese culture.

Knowledge about reproductive health and contraception among young adults in Vietnam has been found to be poor (Do and Fu 2010; Gao et al. 2012; Phan 2008). Previous studies have shown that single women having abortions have often failed to use contraceptives because of poor knowledge and limited skills (Bélanger and Khuat 1999; Gammeltoft 2002; Khuat 2003; Loan and Srisaeng 2014; Nguyen, Liamputtong, and Murphy 2006). This study confirmed that even though young unmarried women has received information about sex and contraceptives some still had little knowledge about effective means of contraception, with some young women using emergency contraceptive pills incorrectly.

Abortion as a solution for unwanted pregnancy

Young unmarried women struggle with the conflict between traditional beliefs regarding virginity (Bélanger and Barbieri 2009; Martin 2010; Nguyen 2007; Nguyen and Liamputtong 2007; Schuler et al. 2006) and more modern ideas concerning sexuality (Drummond 2006; Horton and Rydstrom 2011; Nguyen and Pham 2015; Phan 2008) and premarital sex (Nguyen 2007). Abortion as an option for young women studying or working is consistent with other research (Do and Fu 2010; Loan and Srisaeng 2014; Ngo et al. 2014). To prevent unwanted pregnancy and reduce the future use of abortion, effective contraception should be adopted as a part of modern lifestyle. Pre-abortion counselling should promote safe sex practices and prevent repeated unplanned pregnancies (Nguyen et al. 2010). Discussion of sex and contraception with boyfriends should be encouraged.

Strengths and limitations of the study

With traditional Confucian culture as a background, insights have been gained concerning young unmarried Vietnamese women’s use of contraception and their perceptions and experiences of unintended pregnancy that can serve as a basis for further research. That said, although diverse, the sample does not represent all such women. In particular, it does not reflect the influence of age, ethnicity, education level and social standing on individual attitudes, values and practices. In addition, the study is limited by its small sample size, and some women may have felt it difficult to describe their perceptions and experiences. Yet, the in-depth interviews provide insight into women’s situation through their own words. The trustworthiness of the results was strengthened in several ways. The interviews were based on questions that had been pre-tested before use. The transcribed interviews were discussed with two colleagues with long experience in the area and with colleagues who were experts in the use of qualitative methods.

Conclusion

Findings from this study highlight aspects of premarital sexuality and contraceptive practices among young unmarried Vietnamese women seeking abortion. Women viewed premarital sex as a commitment to maintain a relationship with their boyfriends. Misconceptions, misbeliefs, fear of side effects, limited knowledge and boyfriends’ decisions were reasons for neglecting contraception, and its use was not always successful. Boyfriends play an important role in influencing contraceptive use. For women studying or at the start of a career, abortion was seen as the only solution in case of unintended pregnancy. Sexual and reproductive health education and counselling for gender equality, safer sex practices and prevention of unintended pregnancy should be given to both young women and young men. Such education should seek to combine traditional and modern ideas to enhance understanding of contraception, prevent unplanned pregnancies, and reduce the use of abortion. A reliable online forum could be helpful in providing an environment in which young women can anonymously discuss matters concerning reproductive health, sexuality and contraception. Counselling for unmarried young women seeking abortion should be offered both before and after abortion.

Acknowledgements

Thanks go to all the young women who participated in the study. I also thank Trieu Thi Ngoc Thu and Nguyen Thi Bao Hieu from the Department of Midwifery and Nguyen Thi Phoung Lan from the Department of Nursing at the University of Medicine and Pharmacy in Ho Chi Minh City, Vietnam. Thank you also to Clara Aarts from the Department of Public Health and Caring Sciences, Uppsala University, Sweden, for her help and support.

Disclosure statement

There are no conflicts of interest to declare.

Additional information

Funding

This study was supported by the Swedish Council for Higher Education through the Linnaeus-Palme exchange programme.