Supporting dialysis patients’ self-management through a nurse-led program: a single-group pre- and post-test intervention

Abstract

Background

Chronic kidney disease (CKD) is a growing health problem in Vietnam, affecting approximately 10% of the population, many of whom require hemodialysis. There is a limited intervention to support these patients, so a brief self-management intervention using the teach-back method has been developed. Therefore, this study aimed to investigate the impact of a health education program on hemodialysis patients.

Methods

A single-group pre- & post-test intervention design was used to recruit 100 dialysis patients aged ≥ 18. The intervention involved face-to-face education using the teach-back method and a dialysis care booklet. Linear mixed-effect models assessed the usefulness of kidney disease knowledge, arteriovenous shunt self-care, and hemodialysis self-management behaviors at Week 0 (baseline) and Week 12.

Results

All 100 participants (mean age = 43.8 years, 61% female) completed the study. After 12 weeks, significant improvements were observed in kidney disease knowledge, arteriovenous shunt self-care, and two self-management domains. However, problem-solving and emotional management domains did not significantly improve, warranting further educational content consolidation to improve these areas.

Conclusions

A brief and low-cost nurse-led self-management program successfully improves patients’ understanding of kidney disease and promotes self-management behaviors. Additional content focusing on problem-solving and emotional management is recommended to provide comprehensive support for individuals undergoing hemodialysis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-026-04871-8.

Background

Chronic kidney disease (CKD) is a significant health challenge in Vietnam, with over 10 million individuals affected, representing 10.1% of the country’s population [1]. The estimated population with end-stage kidney disease is about 800,000 people and has been increasing, with an annual tally of approximately 8,000–9,000 patients [1–3]. Alongside medical treatments, fostering self-management behaviors in people with CKD is vital for slowing CKD progression and preventing complications in CKD management guidelines [4]. Self-management in chronic disease involves individuals actively participating in their healthcare to optimise health, prevent complications, manage symptoms, and follow treatment plans [5].

Evidence shows self-management positively impacts critical biomarkers (urine protein, blood pressure, C-reactive protein level), exercise capacity, and mental health in people with CKD, potentially improving overall CKD care outcomes [6, 7]. Effective self-management requires individuals to understand their condition and take responsibility for their care [8]. However, many patients struggle with health literacy, with systematic reviews showing that 23–25% of people with CKD have inadequate health literacy [9, 10]. In Vietnam, a significant proportion of people with CKD, especially those with lower socioeconomic status, have deficits in multiple health literacy domains [11]. Health literacy is defined as an individual’s ability to access, understand, appraise, and use health information and services to make appropriate health decisions to promote and maintain good health and well-being for themselves and those around them [12]. Limited health literacy is strongly associated with lower self-management capacity and poorer outcomes in people with CKD [13]. Health literacy is important to the design of nurse-led educational interventions for people undergoing hemodialysis.

As a health literacy initiative, the teach-back method is recommended for healthcare providers to ensure patients understand complex health information, especially for those with low health literacy. This method involved explaining health information in simple terms and asking patients to repeat it in their own words, allowing clinicians to identify and address gaps in understanding. The teach-back method has positively affected disease-specific knowledge and self-management in various conditions, including diabetes, heart failure [14, 15], and CKD [16].

The COVID-19 pandemic has highlighted the challenges of limited health literacy on the patient’s self-management. A cross-sectional study in Vietnam found that 75% of chronic patients missed regular medical checkups during social distancing, 40% did not engage in daily physical activity, and nearly 25% did not adhere to dietary recommendations [17]. Strict social distancing measures halted both non-medical (work, sports, commercial areas) and medical activities (outpatient visits, home care, and non-urgent hospital admissions), exacerbating these challenges [18, 19]. Economic burdens, fear of infection, and treatment compliance issues further impeded self-management [20–22].

These struggles underscore the need for self-management education programs for people with CKD. Nurses are crucial in providing health-promoting knowledge and decision-making support, emphasizing patient autonomy [23]. Comprehensive self-management programs should cover CKD understanding, medication knowledge, lifestyle modifications, and health behavior changes (treatment adherence, complications control) [6]. Systematic reviews have shown that nurse-led programs effectively improve self-management and clinical outcomes [24–26]. For example, combining patient education with nurse-led follow-up services significantly improved adherence to hemodialysis, medication, and dietary recommendations [27]. Another study demonstrated improvements in proteinuria and estimated glomerular filtration rate with a 12-month nurse-led education program [28].

In Vietnam, few interventions have been implemented for people with CKD, focusing on people at pre-dialysis and hemodialysis stages [28, 29]. Routine patient education is often provided at discharge by renal teams, primarily by nephrologists, consisting of brief verbal information (e.g., instructions on taking medications, reducing salt intake, and avoiding smoking and alcohol consumption). Structured written materials are not often available for people to take home for reading or to use in patient education. This is the first study to develop a self-management program, enclosed in a hemodialysis booklet, customised for individuals with low health literacy who undergo hemodialysis. This paper reports the evaluation of the postitie impact of the program on hemodialysis patients.

Methods

Study design

A single-group pre- & post-test intervention design was conducted over a 12-week period.

Study population and setting

Participants were recruited from Hanoi Kidney Hospital, which is a hospital specializing in nephrology in Hanoi, Vietnam, equipped with 100 beds for hemodialysis patients and an outpatient clinic, serves individual from Hanoi and surrounding provinces. We recruited participants with CKD who had been on hemodialysis for over three months were invited to participate in the study. Other eligibility criteria included individuals aged ≥ 18 years, attending hemodialysis at the study site, being able to give informed consent, and having a mobile phone number for follow-up. Individuals who had cognitive impairments or critical conditions were excluded.

Sample size

The sample size was determined using G*Power software with a two-tailed test, an alpha level of 0.05, and a power of 0.95. An effect size of 0.48 was adopted, based on previous findings conduced in an intervention group evaluating the impact of health education programs on self-management among hemodialysis patients, assessed using the Hemodialysis Self-management Behavior Questionnaire [30]. After accounting for a 20% dropout rate, the required sample was estimated at 71 participants. Nevertheless, due to the urgent need of supporting dialysis patients during the COVID-19 pandemic, in consultation with the participating healthcare setting, the study ultimately enrolled 100 patients.

Participant recruitment

Patients who had undergone hemodialysis for at least three months were identified in collaboration with the renal medical practitioner. The dialysis nurse at the registration desk then distributed recruitment flyers to these eligible patients during the registration process. Patients were given time to review the flyers while undergoing dialysis.

At the end of the dialysis session, those willing to learn more about the study were referred by the dialysis nurse to the principal researcher, who was available in the waiting room adjacent to the dialysis unit. The principal researcher introduced the study, explained its purpose and procedures, and invited eligible patients to participate. Patients were provided with the Participant Information Sheet and were encouraged to ask questions. Written informed consent was obtained either immediately after understanding the study or at a subsequent dialysis visit, should patients wish to discuss the information further with family or friends. A total of 100 patients undergoing hemodialysis were included in this study. Participants were prospectively recruited from Hanoi Kidney Hospital between June to November 2022. A total of 100 adults with hemodialysis received the intervention (among 448 screened, 243 ineligible, 79 declined to participate because of the time requirements, 26 left clinic before receiving the intervention and were not contactable). There was no lost-to-follow up during 12 weeks, as these participants attended hemodialysis sessions weekly.

Study design

Participants who met eligibility criteria were invited to participate in this study which was a single-group pre- & post-test intervention design. The study duration was 12 weeks. Outcome assessment was conducted at Week 12.

Intervention

All participants received routine treatment and care at the study site, along with a 12-week self-management program delivered by two trained dialysis nurses. These two nurses were trained to deliver the intervention to 100 participants, ensuring workload was manageable. The fidelity of adhering to the intervention protocol was monitored by the chief inestigator ensuring as their delivery of intervention was consistent to each other. After giving consent and completing the baseline assessment, each participant received a booklet detailing self-care instructions and a one-hour individual face-to-face educational session with a dialysis nurse. The booklet content was synthesized from multiple sources, including a CKD booklet used in previous clinical research, dialysis guidelines from the Vietnam Ministry of Health [28], and guidelines from Hanoi Kidney Hospital [18, 28, 31, 32]. The educational content covered general knowledge about CKD and the dialysis stage, dialysis-related nutrition recommendations, and self-care of arteriovenous fistula (i.e., shunt). Given the COVID-19 pandemic, guidance on preventing virus transmission was also included. The booklet content was reviewed for relevance and accuracy by a group of eleven experts, including three nephrologists, two renal nurses, and six nurse academics.

This intervention was underpinned by the element “self-management support” of the Chronic Care Model [33], that patients’ lifestyle and healthcare behaviours are modifiable through actively learning about self-care and being supported by their healthcare providers and surrounding social network. The educational components were developed to purposefully integrate five key principles in chronic care self-management, including i/problem solving, ii/decision making, iii/resource utilization, iv/forming a patient/healthcare providers partnership and v/taking action [5]. The intervention was developed by the research team with two researchers, completed a doctoral study on the population, and mentored by a professor in kidney care in the consultations with clinicians. Patients were not involved in the intervention development, nor pilot test was conducted due to its urgency during COVID-19, however, previous interventions educating self-management for hemodialysis patients have demonstrated effectiveness [34, 35].

The teach-back method was used during the educational session to address potential difficulties participants might have in reading and understanding the information [36]. The nurse educator explained the content in plain language and small chunks of sentences and then asked participants to summarize the information in their own words. The educator re-explained as necessary until adequate understanding was achieved. The teach-back sessions provided an opportunity to build rapport between the patient and educator, allowing the patient to ask questions tailored to their individual learning needs; these questions are often overlooked in traditional didactic teaching methods. The teach-back has been used in previous interventional studies in CKD [16]. Each session lasted approximately 60 min, allowing participants to demonstrate their understanding and think about small daily changes they could make. Participants were instructed to self-monitor and record their renal clinical tests in the dialysis booklet at home.

In Week 1, participants were followed up with a research team member either in person at the study site, via a messaging application (Zalo), or by phone. The main purpose of this first follow-up was to reinforce the content delivered during Week 0. Between Weeks 2 and 11, each participant received at least one more follow-up session to encourage seeking family and social support for long-term behavioral changes, living well with CKD and dialysis, and preventing the COVID-19 infection. Participants could call the allocated dialysis nurse to address any issues related to the education support program.

The routine care consists of nurses performing clinical tasks and medication administration if any. Any routine therapeutic encounters do not involve self-management education given by nurses or other healthcare team members warranting there is a significant need for this intervention.

Data collection

Four research assistants collected data at Week 0 and Week 12 using self-reported questionnaires including (i) demographic information (Week 0 only) such as age, gender, marital status, individual and household income, level of education, and occupation and pathology results; and other data was collected in both occasions including (ii) kidney disease knowledge; (iii) hemodialysis self-management; and (iv) arteriovenous shunt self-care practices.

Measurements

The primary outcomes, including the Kidney Disease Questionnaire and the Hemodialysis Self-Management Instrument. Secondary outcomes, including blood pressures, body mass index (BMI), and arteriovenous shunt self-care practice, were measured. The data was collected at Week 0 and Week 12.

Primary outcomes

Kidney disease questionnaire (KDQ)

Dialysis-related knowledge was assessed using a modified version of the 26-item Kidney Disease Questionnaire [37]. First, the questionnaire was translated into Vietnamese using a forward-and backward translation process [38]. The Vietnamese version of the original 26-item KDQ divided into two forms of 13 items each and each form consisted of 13 multiple choice type questions. The original KDQ asked hemodialysis patients about eight fields of end-stage kidney disease under hemodialysis, including kidney anatomy, kidney function, hemodialysis, peritoneal dialysis, fluid intake, diet, transplantation, and medication. In this study, any differences between the forward and backward translation were discussed with the research team. Then, the final Vietnamese version of the original KDQ has undergone a content face validation process by a group of healthcare professionals (registered nurses and renal doctors). The health experts assessed its linguistic equivalence, cultural relevance, and the appropriateness of individual items for the study population. They indicated that the instrument consisted of some items with medical terms and others that asked for knowledge related to medical treatments, which were difficult for the Vietnamese patients to understand. These items were removed from the Vietnamese version. Moreover, recommendations from healthcare professionals led to the incorporation of additional questions, specifically focusing on hemodialysis, such as the indication and types of hemodialysis. Hence, the final Vietnamese version of the KDQ questionnaire had 15 items that measured participants’ knowledge related to kidney hemodialysis management [37]. The items are scored as follows: 1 = correct, 0 = incorrect/do not know. The mean score per item, ranging from 0 to 1, was calculated to assess the patients’ dialysis-related knowledge. A higher score indicates a greater understanding of kidney disease and dialysis among patients. The instrument demonstrates an acceptable Kuder-Richardson Formula 20 reliability coefficient of 0.6 in this sample.

Hemodialysis self-management instrument (HDSMI)

The Hemodialysis Self-management Instrument measures self-management among hemodialysis patients. The 20-item HDSMI was initially developed to measure the level of self-management in a Taiwanese population with hemodialysis [39]. The 20-item HDSMI was translated into Vietnamese using a forward translation process. The final Vietnamese version of 20-item HDSMI has undergone a content face validation process by a group of healthcare experts similar to the KDQ, who assessed its linguistic equivalence, cultural relevance, and the appropriateness of individual items for the study population. For this study, cultural and practical disparities between Vietnam and Taiwan led to slight language modifications (i.e., adding explanations or examples) and the removal of two items which are not normally done by patients in Vietnam (Item 11 “I will check the settings on the dialysis machine” and Item 14 “I will proactively let healthcare providers know my expectation for desired goals”). Hence, the health care professionals suggested omitting items 11 and 14 from the Vietnamese version of HDSMI. This resulted in a Vietnamese version of HDSMI having 18 items in four dimensions: partnership (2 items), self-care (7 items), problem‐solving (5 Items), and emotional management (4 Items). Respondents rated each item on a Likert scale of 1–4 (1 = Never to 4 = Always). The mean score per item, which ranged from 1 to 4, was calculated with a higher score indicating a higher level of self-management behavior in hemodialysis patients. The HDSMI demonstrates robust internal consistency, with a Cronbach’s alpha of 0.9 for the total scale.

Secondary outcomes

Renal and clinical data

Data obtained from patients’ medical records comprised blood pressure (BP), weight, and height (or body mass index - BMI). A manual BP cuff was used to measure BP at each clinic appointment. The result was routinely recorded in the medical record. Both systolic pressure (SBP) and diastolic pressure (DBP) in mmHg were obtained at Week 0 and at Week 12.

Arteriovenous shunt self-care practice

A self-administered questionnaire evaluated arteriovenous (AV) shunt self-care practice [40]. For this instrument, a 5-point Likert scale, ranging from 1- Never to 5- All the day, was used to help participants self-rate 4 items relating to 1- Sleep on the arm/side of the shunt, 2- Wear jewelry or tight slaves on the arm of the shunt, 3- Measure blood pressure or take a blood sample from the arm of the shunt, and 4- Carry heavy things by the arm of the shunt. The mean score per item of this scale varied between 1 and 5 and was used to assess patients’ AV shunt self-care practice. The AV shunt self-care practice was measured at Week 0 and Week 12 when the study ended.

Demographic questionnaire

This self-structured questionnaire comprises questions regarding age, gender, marital status, level of education, occupation, and length of dialysis. This information was collected at Week 0 only.

Statistical analysis

Data were analyzed using IBM-SPSS 21.0 software. All data were entered into an SPSS file, and the data was checked for missing data and outliers. Descriptive analysis described variables (means, standard deviations for the continuous and numbers, percentages for the categorical). The total scores of knowledge, hemodialysis self-management behavior, and AV shunt self-care were calculated. Pearson’s correlation test and independent T-test were used to examine the differences in knowledge, self-management behavior, and AV shunt self-care between demographic groups at the bivariate level (Supplementary Table 1). The variables that showed a significant association with the outcome (i.e., knowledge) were entered into a linear mixed-effects model to examine the intervention’s positive impact relative to baseline (Week 0) and Week 12. The models included variables including education (high school and lower, vocational training and above), occupation categories defined by the International Standard Classification of Occupations (high-skilled jobs such as officers and retired and low-skilled jobs including farmers, workers, free traders, housewives, and others [41] length of dialysis (≤ 3, > 3 years), and time point (Week 0, Week 12) were included in the models. The overall score of knowledge, AV shunt self-care, and self-management were used for multivariate models. Results were considered significant when the p ≤ 0.05.

Ethics considerations

Ethical approval was obtained from the Human Research Ethics Committee, Hanoi University of Public Health (approval no. 022–230/ DD-YTCC). An agreement for the study’s implementation was also granted by the study site. Potential participants received a written explanatory statement and signed an informed consent. The written informed consent was obtained from all study participants. The data were reported in an aggregate form to protect participants’ identities.

Results

Participant characteristics

A total of 100 CKD participants undergoing dialysis were involved in the intervention, of whom 61% were female. The majority of the participants were single, divorced, or widowed (79%), had completed high school level and lower (55%), and worked in low-skilled jobs (75.26%). The participants’ mean age was 43.80 years (SD = 11.60) and BMI was 23.80 (SD = 9.03).

Regarding clinical characteristics, 46% of patients had been on hemodialysis for less than 3 years The average systolic and diastolic blood pressures were 133.10 mmHg (SD = 21.42) and 82.75 mmHg (SD = 11.42), respectively. Table 1 displays the detailed characteristics of participants included in this study.

Table 1.

Participant demographic and clinical characteristics (n = 100)

Variables		Frequency (N)	Percentage (%)
Gender	Male	39	39
	Female	61	61
Marital status	Married	21	21
	Single/ Divorced/ Widowed	79	79
Education	High school and lower	55	55
	Vocational training and above	45	45
Occupation (n = 97)	High-skilled jobs	24	24.74
	Low-skilled jobs	73	75.26
Length of dialysis	≤ 3 years	46	46
	> 3 years	54	54
Age		Mean = 43.80 (SD = 11.60)
Systolic blood pressure		Mean = 133.10 (SD = 21.42)
Diastolic blood pressure		Mean = 82.75 (SD = 11.42)
BMI		Mean = 23.80 (SD = 9.03)

Abbreviation: BMI: Body mass index; SD: Standard deviation

Models testing changes in kidney disease knowledge and arteriovenous shunt self-care

At baseline, the mean knowledge and AV shunt self-care scores were 12.28 ± 1.89 and 8.40 ± 2.04, respectively. After three months, the patients’ kidney-related knowledge significantly improved (coefficient = 2.12, 95% CI: 1.70–2.55, p < 0.001). The level of AV shunt self-care also improved significantly compared to the baseline measurements (coefficient = 9.12, 95% CI: 8.62–9.62, p < 0.001).

Additionally, people with high-skill jobs had more knowledge than those with lower-skill employment (coefficient = 0.73, 95% CI: 0.29–1.16, p = 0.001); however, the difference between these two groups was not significant in AV shunt self-care (see Table 2).

Table 2.

Linear mixed-effect model testing the positive impact of kidney disease knowledge and AV shunt self-care (n = 100)

Variables	Knowledge			Arteriovenous shunt self-care
	Coef	95% CI	p	Coef	95% CI	p
Intercept	12.09	11.71–12.47	< 0.001*	8.35	7.92–8.78	< 0.001*
Occupation
High-skilled vs. Low-skilled jobs	0.73	0.29–1.16	0.001*	0.26	-0.29–0.81	0.35
Time
T1 vs. T0	2.12	1.70–2.55	< 0.001*	9.12	8.62–9.62	< 0.001*

*Significant p ≤ 0.05. Coef: Coefficient. CI: Confidence interval

Model testing changes in hemodialysis self-management

Patients had significantly increased scores in self-management (coefficient = 2.93, 95% CI: 0.68–5.17, p = 0.01) compared with baseline evaluation. Overall, patients who had hemodialysis for less than three years had significantly higher levels of self-management than those with longer hemodialysis duration (coefficient = 2.63, 95% CI: 0.33–4.92, p = 0.03) (see Table 3).

Table 3.

Linear mixed-effect model measuring the effect of the intervention program on hemodialysis self-management (n = 100)

Variables	Self-management
	Coefficient	95% Confidence interval	p
Intercept	49.63	47.46–51.79	< 0.001*
Education
Graduate and upper vs. High school and lower	2.03	-0.48 – -4.54	0.11
Occupation
High-skilled vs. Low-skilled jobs	1.80	-1.15–4.75	0.23
Length of dialysis
≤ 3 years vs. >3 years	2.63	0.33–4.92	0.03*
Time
T1 vs. T0	2.93	0.68–5.17	0.01*

*Significant p ≤ 0.05

Discussion

It was the first study delivering self-management education to individuals undergoing hemodialysis in Vietnam. The outcome assessments indicated improvement in knowledge, two self-management domains (partnership and self-care), and AV shunt care over a 3-month follow-up.

The educational intervention resulted in a significant increase in kidney knowledge at the post-test (mean score = 14.4 out of 15), noting that the baseline knowledge score was relatively high, as most participants had been on dialysis for years. This suggests that self-management education could be more beneficial for individuals who have just commenced hemodialysis and have a higher knowledge demand.

This intervention has demonstrated impacts on improving self-management in patients undergoing hemodialysis. Overall scores and those of two domains (partnership and self-care) significantly increased, but not those of the problem-solving or emotional management domains. Problem-solving requires higher cognitive abilities, indicating the need for further modifications to achieve comprehensive coverage of educational content. Overall, participants with higher education had higher problem-solving scores, and those within the first 3 years of dialysis practised more self-care than others. The self-care practice of AV fistula/shunt access also improved markedly after the intervention, increasing the mean score from 8.4 ± 2.04 at baseline to 17.54 ± 1.4 at Week 12. It implies that AV fistula is the primary focus for individuals on hemodialysis, and education can significantly enhance their knowledge and self-care practices by encouraging active participation in disease management.

Our education intervention utilised the teach-back method to foster deep understanding and long-term memorisation among patients. A recent systematic review found that the teach-back method can enhance knowledge, skills, and confidence in people with CKD, yet only six studies have applied this method to people with CKD, highlighting the need for its broader implementation in clinical practice [16]. Yangöz et al. (2021) emphasised that the face-to-face teach-back method can establish a close nurse-patient connection and can even improve fluid and dietary adherence in those on hemodialysis [42]. To further support our patients, we followed up with phone calls over the next 12 days, allowing us to monitor their progress and address any questions closely. In summary, our teach-back intervention and follow-up significantly improved CKD patients’ knowledge, confidence, self-management, and adherence to treatment. Self-management education is not part of routine nursing practice in Vietnam, due to high patient load and emphasis on hospital-based acute care in the health system. The improved self-management scores in those who received this intervention promise clinical significance when the intervention is upscaled in clinical settings, especially for patients who have just started hemodialysis. Self-management should also be integrated into professional development training for renal nurses, upskilling them to provide education and physical and emotional support to their recipients of care. This nurse-led intervention demonstrated that a low-cost brief intervention can benefit people undergoing hemodialysis and can be integrated into the routine practice of renal or dialysis nurses across multiple dialysis settings in Vietnam.

The study has limitations to be acknowledged. The first limitation was the short duration of the intervention period. Twelve weeks may have been insufficient to significantly affect the self-management behaviors of CKD patients receiving hemodialysis. Another limitation was the lack of a control group, which made it challenging to attribute the outcome improvement solely to the intervention. This intervention was implemented during the COVID-19 pandemic, with no control group, to ensure all participants had equitable access to self-management support in a timely manner. In the future, more comprehensive interventions with randomized controlled trial design, incorporating components from previous trials [43] are needed to support the CKD population in Vietnam.

Conclusion

The nurse-led self-management program was an effective and low-cost approach engaging dialysis patients in developing knowledge of kidney disease, AV shunt self-care, and hemodialysis self-management. Self-management education should be targeted at individuals in the early stage of hemodialysis. Further modifications of this intervention, with consolidated problem-solving strategies and emotional management, are needed to warrant more comprehensive impacts on hemodialysis self-management.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

VNU

Vietnam National University

CKD

Chronic kidney disease

BMI

Body mass index

KDQ

Kidney Disease Questionnaire

HDSMI

Hemodialysis Self-management Instrument

AV

Arteriovenous

Dr. Nguyet Thi Nguyen

has done her PhD in self-management program for people with chronic kidney disease at the School of Nursing, Queensland University of Technology since June 2018. Currently, she is a nurse lecture at University of Medicine and Pharmacy, Vietnam National University, and conducting several research projects for people with chronic kidney disease in Vietnam. She is interested in chronic disease management, particularly in self-management and chronic kidney disease/or multiple chronic diseases.

Author contributions

NTN and VLH conceptualized the study. NTN and VLH led the data collection process. TTHD and HTB conducted data analysis. NTN, VLH, TML, THP, and TTHD led the development of this manuscript. NTN, VLH, TML, THP, TTHD, and HTB conducted reviews and revisions of the manuscript. All authors read and approved the final manuscript.

Funding

This study received funding from the Australian Alumni Grants Fund (No. AAGF-R4-00068). However, the research team members had full authority regarding the final decision-making of the publication.

Data availability

Data are provided in the results of the manuscript. The raw data can be accessed by contacting the corresponding author within the specified confidentiality requirements.

Declarations

Ethics approval and consent to participate

The research was approved by the Human Research Ethics Committee, Hanoi University of Public Health (approval no. 022–230/ DD-YTCC). Before the intervention was implemented, the participants were given a written explanatory statement. The data were reported in aggregate form to protect participants’ identities. All authors declare adherence to the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.