We incorporated the three delay model into our analysis as follows. For seeking care we gathered data beginning with the scene of the crash including the process whereby the patient or their care-givers realised that hospital treatments were required. Our reaching care data described the events experienced by patients until they reached the first hospital. Receiving care data included problems arising after the patients had been admitted to a hospital and transferral between hospitals. For each of the three delays, we described socio-cultural and system factors that contributed to delays. Major themes identified were summarised in Table 2 .
Table 2 Major themes identified from the findings listed based on the three delay model Seeking care
Many patients delayed seeking care because they were wary of hospitals and their treatment regimes. Their fears were based on previous experiences or stories that included an inter-play of personal, social and financial concerns. Indeed, sociocultural issues were identified by almost all interviewees and included ideas, beliefs and reinforced by their families. As was the case with Kim. She fractured her patella when she tripped on a bumpy road but refused to go to the hospital until her brother, a doctor forced her to go. He explained that:
First, she is frightened of surgery and of dying; then she is scared that she had to share a room with other people and worried that the service would not be good. So I have to assure her that she would get a private room for herself [...] I also called my contacts here and they operated on her immediately as we got to the hospital. (Case 24, Kim’s brother).
Another interviewee reported having a comminuted fracture forcing him to go to the hospital.
I have a comminuted fracture so I have to go to the hospital. If it was a simple fracture I would have gone to the traditional healers instead. They [traditional healers] use herbs so it does not affect my health. This hospital uses antibiotics which make my leg shrink. The antibiotics are really bad for your health. (Case 36, Male, 30s, calcaneus fracture).
It is noteworthy that patients were generally sceptical of hospital treatments and some of the believe was based on sociocultural experiences. Illustrating financial anxieties, many patients used the popular proverb – “Tiền mất, tật mang” [literally: losing money, sustaining disability] to describe going to hospital as a wasted effort with more monetary loss than health gain.
Building on other concerns, the trip to hospital was often postponed because patients misjudged the severity of their injury, preferring to self-treat because it was cheaper and more convenient. One patient, Hong (M, 50s, clavicle dislocation) reported that he only went to hospital the day after traffic crash when the pain became unbearable and medicinal oil that he had applied did not seem to have much effects.
I did not think the injury was so serious. I thought it was just swollen from all the bruises. I thought to myself to do an X-ray just in case. It turned out that the clavicular joint was dislocated and the doctor said I need surgery to fix that. (Hong, Male, 50s, clavicular dislocation).
Another major reason for delay was that the patients preferred to wait for friends or family to arrive at the scene to take charge of their belongings. Motorbikes are the most common form of private transport with riders highly prone to traffic related injuries. For many Vietnamese people, a motorbike is not only their most valuable asset but also a means of making a living. Thus, patients were reluctant to leave their motorbike at the crash scene for fear of it being stolen. Leaving a vehicle with a stranger required more trust than most people had. For example, Chinh explained that he would rather wait 30 min for his friend to arrive rather than accepting the assistance of a bystander.
I am very wary of swindlers. They are very cruel; they have no morals. I am worried that my bike would be stolen. So the moment I fell on the ground, I immediately tried to pick up the bike and took out the keys. (Chinh, 20s, male, construction worker, torn ligaments).
The same sentiments were echoed by others, irrespective of socio-economic status or location, although it reflects the general poor economic status of the country.
Reaching care
Experiences and decisions about reaching care also exemplified a complex mix of sociocultural and economic considerations, including the difficulties of travel in Vietnam and cost. In contrast to economically developed Western countries, ambulances are rarely used in Vietnam with only two patients out of 40 in our sample transported to the hospital in one. Ambulances were distrusted or only used for life threatening conditions.
You only call [the ambulance] if you are very sick; if you cannot breathe and need support such as ventilation, the ambulance has those equipments. For my wife’s case, it was relatively simple so we just used a taxi. (Case 10, the patient’s husband, the patient suffered from a compound fracture of the tibia).
Because they were so rarely used, many patients and their family did not know about the official ambulance service (115Footnote 1 EMS) while others might have known it but expressed cynicism and disbelief in the service.
No, definitely not [consider calling the 115 Ambulance Service]. You never know [what will happen]. (Case 5, the patient’s friend).
In Vietnam, the main mode of transport to hospital, usually a taxi or motorbike, reflected the patient’s socioeconomic status rather than their injury severity. Generally, patients believed that it was cheaper, faster and more convenient to call a taxi than an ambulance, especially if the site was far away – “If I cannot even call a taxi, why would an ambulance be any different!” One of the patients used to work as a driver for the official 115 Ambulance Service, yet he preferred a taxi over an ambulance for the same reasons. Another patient who had used the ambulance service previously concluded that it was better to employ a taxi.
I named the ambulance service “Taxi 115” because they are just transporting service. They are twice or even triple the price of a normal taxi, and with a taxi, I can negotiate. [I noticed that] the ambulance would take at least 15 min while a taxi was there immediately. (Case 26, Male, 50s, metatarsal fracture).
Local newspapers often reported that taxis in Vietnam refused to transport injured patients to the hospital for fear of misfortune, troubles, or blood contamination [14,15,16] but we found that was not common. One patient reported how a taxi driver had gone above and beyond to help:
First I called my family to inform them of the accident. Then I waved down a taxi. The driver helped bring my motorcycle to a nearby office then personally carried me to the car. He asked me which hospital [I would like to go to], I told him just brought me to the nearest and the best hospital. (Case 33, Male, 60s, tibial fracture).
Some patients reported paying the taxi extra for a “cleaning fee”. However, it should be noted that in all the cases when the patients were transported by taxi, they were either conscious or were accompanied by a family member. In one case where the patient was semi-lucid with heavy bleeding, the patient reported that the taxi driver refused to transport him initially but later “complied” because of a police presence.
The non-uniform policeman called taxi to bring me to the hospital. At first the taxi driver refused because he could see that there was lots of blood. Then the policeman told him his rank and made the taxi driver do it. (Case 10, Male, 30s, toe fracture).
Apart from transport difficulties other delay in reaching care occurred as patients detoured to nearby health facility for professional opinion and first-aid treatment; as well hoping to avoid going to the hospital. However, these places could offer limited support as this patient demonstrates.
So I went to a pharmacy which was only a few blocks away but they said they cannot do anything. [The bystanders] then told me to go to the community clinic as I felt that the injury was not too bad. When I got there, the nurse had a look [at the injury] and told me to go to the hospital. They did not wrap it up or anything, but at that point, the bleeding has somewhat stopped and the hospital is only 15 min away. (Case 11, male, 70s, compound phalangeal fracture).
Receiving care
There were hurdles that patients needed to overcome to receive care at a hospital that reflected lack of infrastructure and resources in the health care system. Consequently, finding a suitable hospital could be time-consuming process. For example, in a truck collision, Long (M, 70s) injured his head and was left unconscious. A kind bystander promptly brought him to a nearby clinic where he regained consciousness and called his family who took him to Hospital 1. However, the CT Scanner of Hospital 1 was not working and they moved him to Hospital 2 where they took a CT scan. He was then taken to a third hospital for long-term recovery. During this ordeal, the only treatment he had was ‘a piece of cotton wool in his ears to stop the bleeding’ (Long’s daughter). The overall trip took 2 h and 30 min.
Hospitals did not always provide appropriate treatment. Huong (F, 30s, broken arms) fell off her motorbike and was unconscious when her family took her to a small but expensive private hospital. The hospital treated her head wound but missed her broken arm and discharged her. At home, the pain in Huong’s arm became so unbearable that she had to go to another hospital. There, Huong was put into a queue with other ‘cold/flu patients’. She ‘lay on the bench holding onto [her] broken arm for half a day’ because the hospital had no protocol to identify patients’ needs.
Mai (F, 20s) had similar experience as she was admitted to a nearby hospital promptly following a crash. Her dislocated shoulder was treated but they misdiagnosed the pain in her leg as ‘just swelling and bruising’. As the pain did not improve she visited another hospital a few days later where she was diagnosed with a torn ligament and recommended surgery costing ‘80 million dong’ (~ 4000 AUD), an equivalent to 20 months of an average Vietnamese salary, because Mai did not have insurance. Mai had the operation 5 months later after she had purchased insurance.
Patients and their families were aware of these problems and take into consideration the hospital reputation, service and location before making any decision. While some would rather travel long distance for a reputable hospital, others opted to go to the nearest place first for initial management and later request a transfer to a more suitable location. The rationale for the latter was that if there is no ambulance to bring a trained technician to help, the patient should go to the nearest place that offered immediate first aid treatment.
The first hospital was about 15 min away from the accident site. The doctors at that hospital were quite good. Although we (the patient and the other party) did not have any money and had to wait for my family to come over to pay, they let me take an X-Ray in the meantime anyway. The X-Ray showed a radial fracture that required surgical fix. I called my aunt who is a nurse at this hospital and she told me to come here instead as it is better and safer here. (Case 9, male, 20s, radial fracture).
Although transferring is common, the process is cumbersome and potential conflicts frequently arise between family and hospital. Unless the patient was formally transferred from a facility that had its own ambulance, they depend on a private vehicle to get to the next hospital. The patient’s family may discharge the patient and take them to another hospital but without a hospital referral letter, the patient might be rejected and be returned to the original hospital. Even when a hospital authorised the transfer, patients might still be required to repeat tests. This process is expensive and takes valuable time needed for treatment.
I want to transfer him [the patient] to a level 1 hospital but this hospital does not authorize the transfer. They told me if I want to move him I can go ahead by my own means […] The hospital has an ambulance but we are not allowed to use it (Case 7’s daughter, patient was 70s Male with head injury).
Throughout these examples (detailed above), the important of family in first response is evident and may be the cause of great delay and inappropriate choice of medical care as family’s decisions may depend on non medical as well as medical variables.