Perceived Barriers to Care Among People Who Use Drugs in Vietnam

Abstract

Introduction:

Understanding how health literacy, depressive symptoms and family support for people who use drugs (PWUD) influence the perceived barriers to care is essential to helping them navigate healthcare challenges. Our study aims to explore this complex relationship among PWUD in Vietnam.

Methods:

We utilised baseline data from an intervention trial conducted in three provinces of Vietnam. Multiple linear regression models were used to explore the relationships between health literacy, depressive symptoms, family support and perceived barriers to care. We also conducted interaction terms and the Wald test follow-up to investigate the effect of health literacy on the association between depressive symptoms, family support and barriers to care.

Results:

Among 690 PWUD, depressive symptom level was positively associated with perceived barriers (β = 0.273; SE = 0.049; p < 0.001), while family support for care (β = −0.116; SE = 0.060; p = 0.001) and health literacy level (β = −0.237; SE = 0.078; p < 0.001) were negatively associated with perceived barriers. The association between family support for care and perceived barriers was significantly stronger among PWUD with low health literacy compared to those with high health literacy levels (p = 0.024).

Discussion and Conclusions:

This study underscores the importance of developing an intervention that integrates mental health support, family involvement and health literacy training to ensure effective care, especially among PWUD with limited health literacy.

1 |. Introduction

Substance use disorder (SUD) is associated with a range of health-related harms, such as overdose-related morbidity and mortality, infectious disease transmission (e.g., HIV, hepatitis C) and drug-related mental health [1, 2]. Therefore, timely access to healthcare services is essential for people who use drugs (PWUD) to reduce risks for morbidity and mortality and enhance their health status in general. Despite complex health challenges and the importance of accessing care services correctly, PWUD are facing significant barriers to seeking and accessing healthcare services [3, 4]. Seeking care involves actions by individuals who feel unwell to find a remedy, influenced by decision-making, household dynamics and community norms [5], while accessing care refers to the ability of individuals to obtain and utilise necessary healthcare services [6]. Barriers in care are multifaceted, encompassing individual, interpersonal and systemic challenges [7]. As a result, understanding these barriers in both seeking and accessing aspects is crucial for developing effective strategies to overcome difficulties and improve overall health outcomes for people with SUDs.

Prior studies examining the perceived barriers to care services among PWUD have shown some of their characteristics associated with barriers, such as gender, age, education level, health insurance and socio-economic status [3, 4]. Apart from those, evidence from research has shown that depressive symptoms and limited health literacy are crucial factors associated with perceived barriers to care, particularly among PWUD [7–11]. Family support for care has been recognised as an important facilitator of healthcare engagement among PWUD. Several studies have found that strong family networks can promote earlier and more consistent healthcare utilisation by offering emotional encouragement, financial assistance and logistical help, such as transportation and appointment scheduling [12, 13]. Given that depressive symptoms, family support for care and health literacy have been studied well separately with barriers to care, we hypothesised that all three aspects could be interrelated and may jointly influence PWUD’s seeking and accessing care.

In the context of Vietnam, the healthcare system is hierarchically established with four levels: national level, provincial level, district level and community level [14]. To enhance accessibility, lessen stigma and provide more holistic support that promotes long-term reintegration, addiction treatment has recently been decentralised, moving services into the community level [15, 16]. Nevertheless, as the population of PWUD continues to rise, the demand for healthcare services and support is also increasing [17, 18]. In Vietnam, a family-oriented, middle-income country with limited resources, PWUD often face significant barriers to care, including inadequate healthcare services’ infrastructure and fear of discrimination from family members [19, 20]. However, to the best of our knowledge, there are few studies investigating the impact of PWUDs’ mental health, health literacy and their perspective on family support on their barriers to care in Vietnam. Our study aimed to explore the impact of depressive symptoms, family support and health literacy on perceived barriers to care among PWUD in Vietnam. By examining these three factors, we can better understand the challenges PWUD encounter when finding and approaching healthcare services.

2 |. Methods

2.1 |. Participants and Data Collection

This study utilised the data collected at the baseline of an ongoing randomised controlled intervention trial in Vietnam [21]. Data collection was conducted from April to July 2024 across 58 communities of three provinces: Ninh Binh, Da Nang and Can Tho. Participants were Vietnamese PWUD and lived in these communities. To be eligible for the study, participants had to meet the following criteria: (i) be aged 18 or older; (ii) have a history of drug use; (iii) disclose their drug-using status to at least one family member and invite that family member to participate; (iv) currently reside in the selected areas; and (v) provide informed consent. With a participation rate of approximately 85%, a total of 690 participants were included in our study.

Before data collection, all participants provided written informed consent. They completed assessment questionnaires in a private office at a local community health centre or a chosen location. Trained interviewers conducted one-on-one, face-to-face interviews using a Computer-Assisted Personal Interview method and recorded answers directly on laptops. All questions were asked in Vietnamese, and each participant spent about 45 min on the assessment. Participants received 230,000 Vietnamese dong (VND) (around $8.86) as compensation for their time and effort.

2.2 |. Measures

Perceived barriers to care reported by PWUD were assessed using an adapted version of the Barriers to Access to Care Evaluation, developed by Clement and colleagues [22]. This instrument was previously validated in our previous study conducted in Vietnam [23]. A modified 12-item version of the scale was utilised to evaluate PWUDs’ perception of how a PWUD experienced barriers, such as financial, knowledge and psychological barriers, when seeking healthcare services. The sample questions included ‘Being unsure about where to go to get professional care’, ‘Not being able to afford the financial costs involved’, ‘Thinking that treatment probably would not help’, ‘Having experience of unfair treatment previously’, ‘Having been treated as an inferior because of your diseases’ and ‘Feeling embarrassed to seek health care’. Participants assessed each item using a 4-point Likert scale, where 1 signifies ‘not at all’ and 4 indicates ‘a lot’. A score of perceived barriers to care (range: 12–48) was generated by summing all 12 items. Higher total scores indicate greater perceived barriers (Cronbach’s α = 0.84).

Depressive symptoms of PWUD were measured using a short form of the Zung Self-Rating Depression Scale (ZSDS) from the original 20-item instrument, which includes six items assessing how often the participants feel a specific symptom of depression [24, 25]. Example items included ‘You feel downhearted and blue’, ‘You get tired for no reason’ and ‘You are more irritable than usual’. For each item, participants were asked to rate how often they encounter each depressive symptom on a 5-point Likert scale from 1 = none of the time to 5 = all the time. A score of depressive symptoms (range: 6–26) was generated by summing all six items. A high score indicated a higher level of depressive symptoms (Cronbach’s α = 0.76).

Family support for care was evaluated with revised items from the Multidimensional Scale of Perceived Social Support (MSPSS), which was originally developed by Dahlem with colleagues [26], and it was validated with PWUD in China [27]. The original scale consists of 12 questions; we selected five questions most relevant to our research purpose and study population. Participants were requested to rate how true each statement was from 1 (strongly disagree) to 5 (strongly agree), with higher total scores (ranging from 5 to 25) demonstrating a high level of family support for care (Cronbach’s α = 0.94). Questions included: ‘Your family members really try to help you with your treatment and health care’, ‘You get the emotional support from your family members for your health and treatment issues’, ‘You can talk about your treatment problems with your family members’, ‘Your family members are willing to help you to stay in treatment and care’ and ‘Your family members always encourage you to stay in treatment and care’.

Health literacy of PWUD was evaluated using screening validated questions for limited health literacy, which were developed by Chew et al. [28, 29]. A modified 3-item scale relevant to our research purpose and study population was used to assess how often a PWUD experiences difficulties related to health literacy. Participants were asked to rate how often they encounter each obstacle stated in the questionnaire on a 5-point Likert scale from 1 = always to 5 = never. A score of health literacy (range: 3–15) was generated by summing all three items, and a high score indicated better health literacy (Cronbach’s α = 0.80).

We also collected data on participants’ background characteristics, including gender (male vs. female), age, years of education, marital status (married/living with partners vs. no), current job status (yes vs. no), annual family income (million VND), type of substances ever used, polysubstance use status, seeking healthcare services in the last 3 months (yes vs. no) and healthcare bills covered by insurance (yes vs. no).

2.3 |. Data Analysis

Descriptive statistics were used to summarise participants’ characteristics as well as scores of four scales: perceived barriers in seeking healthcare, depressive symptoms, family support for care and health literacy, with categorical variables reported as frequencies (n) and percentages (%) and continuous variables presented as means and standard deviations (SDs). We conducted multiple linear regression models to explore the association between depressive symptoms, family support for care, health literacy and perceived barriers, controlling for gender, age, years of education, marital status, current job status, annual family income, seeking healthcare in the last 3 months and healthcare covered by insurance. Estimated regression coefficient (β), standard error (SE) and p value were presented (the statistically significant level was set at α = 0.05).

To determine whether there was complex interplay among depressive symptoms, family support for care and health literacy on the dependent variable or not, we included interaction terms in our multiple linear regression models: We tested the interaction between health literacy and each of the two variables—family support for care and depressive symptoms—to examine whether the relationship between these predictors and perceived barriers to care varied by levels of health literacy (dichotomous variable). The levels of health literacy were divided into two groups according to the 25th quartile of the score distribution: low (score ≤ 12; n (%): 177 (25.7%)) and high (score > 12; n (%): 513 (74.3%)). The Wald test was utilised to perform pairwise comparisons and test for significant differences in marginal effects (slopes) after models with interaction terms between groups defined by health literacy levels (the statistically significant level was p ≤ 0.05). All statistical analyses were performed with STATA software, version 17.1 MP (StataCorp LLC, College Station, TX, USA).

3 |. Results

The characteristics of participants in our study are described in Table 1. Among 690 eligible PWUD, most of them were male (96.8%), had a secondary-school education level (45.9%), were currently working (78.6%) and their family annual income was below 120 million VND (approximately $4614) (47.1%). The majority of participants reported lifetime opioid use (94.1%), followed by sedatives or sleeping pills (7.4%) and amphetamine-type stimulants (6.9%). The percentage of people seeking healthcare services in the last 3 months was 28.3%. The mean score of perceived barriers to care among PWUD was 17.4 (SD = 4.9).

TABLE 1 |.

Participants' characteristics (n = 690).

Characteristics	n or Mean (SD)	%
Gender
Male	668	96.8
Female	22	3.2
Age, years	42.2 (8.8)
18–35	144	20.9
36–45	338	49.0
46 and more	208	30.1
Years of education	8.8 (3.3)
5 years of fewer	99	14.4
6–9 years	317	45.9
10–12 years	227	32.9
More than 12 years	47	6.8
Married/living with partners	399	57.8
Currently having job	542	78.6
Annual family income (million VND)	140 (176.4)
< 120	325	47.1
≥ 120 to < 180	188	27.3
≥180	177	25.6
Seeking healthcare services for the last 3 months	195	28.3
Healthcare covered by insurance	445	64.5
Perceived barriers to care	17.4 (4.9)
Health literacy	13.5 (2.3)
Depressive symptoms	9.6 (3.6)
Family support for care	21.4 (2.9)

Table 2 demonstrates the results of two multivariate regression models exploring factors related to perceived barriers to care among PWUD. The result from Model 1 shows that high education level was positively associated with low levels of perceiving barriers to care (β = −0.095; SE = 0.057; p = 0.014), and PWUD who sought healthcare in the last 3 months were more likely reported a higher level of barriers compared to others who did not seek healthcare (β = 0.118; SE = 0.421; p = 0.003). After controlling for participants’ characteristics, Model 2 shows that depressive symptom scores were positively associated with perceived barrier scores (β = 0.273; SE = 0.049; p < 0.001), while family support for care (β = −0.116; SE = 0.060; p = 0.001) and health literacy scores (β = −0.237; SE = 0.078; p < 0.001) were negatively associated with perceived barrier scores. In addition, seeking healthcare past 3 months was not significantly associated with barriers to care in this model.

TABLE 2.

I Factors related to perceived barriers to care among participants (n = 690).

Factors	Model 1		Model 2
	β (SE)	p	β (SE)	p
Being female (vs. male)	0.023 (1.047)	0.545	0.005 (0.958)	0.895
Age	−0.047 (0.022)	0.248	−0.054 (0.020)	0.147
Years of education	−0.095 (0.057)	0.014	−0.028 (0.054)	0.454
Married/living with partners (vs. no)	−0.051 (0.391)	0.200	−0.009 (0.363)	0.811
Currently having job (vs. no)	−0.019 (0.459)	0.621	−0.008 (0.418)	0.828
Annual family income	−0.068 (0.001)	0.085	−0.062 (0.001)	0.081
Seeking healthcare last 3 months (vs. no)	0.118 (0.421)	0.003	0.045 (0.391)	0.217
Healthcare covered by insurance (vs. no)	−0.071 (0.395)	0.069	−0.045 (0.369)	0.205
Health literacy			−0.237 (0.078)	< 0.001
Depressive symptoms			0.273 (0.049)	< 0.001
Family support for care			−0.116 (0.060)	0.001

Abbreviations: β, standardised coefficient; SE, standard error.

Figure 1 illustrates the interaction effects between health literacy and two other factors (family support for care and depressive symptoms) on perceived barriers to care, derived from multiple linear regression models including interaction terms. Less family support for care was associated with higher perceived barriers, with a significantly stronger effect observed among people with low health literacy than those with high health literacy (p = 0.024). There was no significant effect of health literacy level on the association between depressive symptoms and perceived barriers to care (p = 0.050).

FIGURE 1 |.

Interaction effects of health literacy on the relationship between the perceived barriers to care and (1) family support for care and (2) depressive symptoms.

4 |. Discussion

In this study, we found that there was an association between health literacy, depressive symptoms, family support for care and perceived barriers to care among PWUD in Vietnam. We also observed the role of health literacy in the relationship between family support for care and perceived barriers. These findings underscore the complex relationship and the importance of addressing health literacy, depressive symptoms and family support for care in perceiving barriers to care. It is thus helpful to create a supportive environment that encourages PWUD to seek or access the care they need, ultimately leading to better health outcomes.

These findings reveal a significant positive association between depressive symptoms and perceived barriers, reinforcing the results of earlier research [8, 9, 30]. Depressive symptoms can significantly affect how PWUD perceive and navigate barriers to accessing care. PWUD with depressive symptoms often feel persistent sadness, have low energy and have reduced motivation; they might hesitate to seek or access care [31]. The norms in Vietnamese society related to substance use could be another explanation for the impact of depressive symptoms on perceived barriers to care among PWUD. Drug use is seen as a violation of traditional values and is often labelled as a ‘dangerous social disease’ or ‘social evil’ [32]. PWUD experience shame, fear of stigma and social isolation [19]. These experiences can be more detrimental among PWUD with depressive symptoms and potentially lead them to report having more barriers than others. It is necessary to pay attention to PWUD with depressive symptoms in supporting them to overcome difficulties in seeking/accessing healthcare services.

Our results indicated a relationship between family support for care and perceived barriers to care. This finding contributes to the existing literature on the role of family in supporting care for PWUD [33–35]. Family support plays a vital role in SUD recovery by providing emotional encouragement and practical help, which may strengthen motivation to seek/access treatment for a successful recovery [35]. Another possible reason is that Asian culture, as well as Vietnamese culture, is deeply family-oriented, with parents assuming central roles in decision-making [36, 37]. Because most PWUD live with their families, if parents disagree with each other, regardless of the need and method of PWUDs’ treatment, it can shape barriers for PWUD when deciding to approach or use healthcare services [38]. This result implies the importance of integrating family-based approaches in supporting PWUD in resolving barriers to care.

In this study, people with limited health literacy had a higher chance of reporting higher levels of perceived barriers to care. Health literacy is essential for using healthcare services effectively, but PWUD often face added socioeconomic challenges and struggle with low health literacy, making it hard to understand medical information and navigate the system when they have health problems [10, 39–41]. We also found that the negative association between family support for care and perceived barriers to care was stronger among PWUD with limited health literacy than among others. As people with lower health literacy find it hard to understand health information, communicate needs to family members/healthcare providers and navigate care systems, this may exacerbate their perceived barriers to care [10, 42]. PWUD with limited literacy also feel more vulnerable due to fear of judgement in healthcare settings or lower quality of life and mental health, which can increase their reliance on family support to help navigate care barriers compared to those with higher health literacy [10, 43]. Improving health literacy among PWUD is thus crucial for better health outcomes and navigating care, emphasising the importance of targeted interventions that enhance family support for those with SUD and limited literacy.

Our study findings should be interpreted considering some potential limitations. First, due to the study’s cross-sectional design, we cannot make causal inferences between health literacy, depressive symptoms and family support for care, which are associated with perceived barriers to care. Second, we used a scale to measure health literacy and manually divided PWUD into two groups based on the distribution of the score, not a test to diagnose limited health literacy. Third, the study did not include details on how people use drugs—their patterns and duration—which limited our ability to explore how specific drug use relates to barriers to care or to compare experiences between current and former users. Despite these limitations, the study highlights the individual association and interactions of health literacy, depressive symptoms and family support for care on PWUD’s ability to utilise healthcare services. Future interventions should address all three aspects: literacy, mental health and support from family members to encourage PWUD to seek or access the appropriate care. Since we did not observe a significant association between seeking healthcare in the past 3 months and reported barriers to care, factors such as PWUD’s experiences during care-seeking, their reasons for seeking care and the specific challenges encountered may need to be collected and warrant further investigation. Exploring these aspects may provide deeper insights into how barriers operate and inform strategies to create supportive, non-stigmatising healthcare environments that promote sustained care engagement.

5 |. Conclusion

Our findings revealed the relationship between health literacy, depressive symptoms and family support for care on PWUDs’ perceived barriers to care. It is necessary to create a multi-approach intervention that combines mental health and family-based support with health literacy training to provide effective support, especially among PWUD with limited health literacy.

Summary.

• Health literacy, depressive symptoms and family sup-port influenced barriers to care.

• The association between low family support and care barriers was stronger in people who use drugs with low health literacy.

• Integrating mental health and family support for people who use drugs with low health literacy is essential to minimise perceived barriers to care.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.