Attempts to dissect healthcare service expenditures as part of some behavioural trends are often obscured by the fact that individual behaviours occur under specific conditions and with private information and assessment. This study looks into the data of a specific healthcare spending: general health examinations (GHE). While it seems rational to regularly check one’s health to timely deal with the onset of an unexpected illness, the practice of periodic GHE is a rather modern phenomenon. The beginning of GHE could be traced back to the British physician Horace Dobell in 1861 when he sought a measure to monitor the health status of patients with tuberculosis (Dobell, 1961). Over the past two centuries, despite our intuition that regular health screenings could help prevent certain illnesses, studies have shown mixed results about their effects (Mehrotra and Prochazka, 2015; Ponka, 2014; Himmelstein and Phillips, 2016). The existing literature on the topic has also skewed toward Western practice of GHE, its limitations and benefits, and in turn, leaves an unfilled gap for research on this matter in developing countries such as Vietnam. This paper examines the case of Vietnam, an emerging economy where about 80% of its population of nearly 100 million have health insurance (Vietnam Plus, 2017). The analysis focuses on the sensitivity of Vietnamese healthcare consumers’ willing payments for GHE against two groups of factors, namely demographic and socioeconomic-cognitive, as this service is not covered by Vietnam’s health insurance (International Cooperation Department, 2017). Although the study is limited in its geographical scope, it nonetheless seeks to shed light on the behaviours of healthcare consumers in general when thinking about measures to minimise future risks.

Literature review

This section will look into the controversial nature of periodic GHE, the literature in developing countries and in Asia, the reason why Vietnam is chosen for the study, and the framework for identifying factors affecting consumer health behaviour.

On periodic GHE

Studies objecting to periodic GHE often point to (i) its high costs, (ii) the resulting wasted time and resources, (iii) its inconclusive support for reducing morbidity or mortality, and (iv) non-evidence-based approach (Kast et al., 2004; Merenstein, Daumit and Powe, 2006; Krogsbøll et al., 2012; Howard-Tripp (2011); Coffield et al., 2001; Thrall, 2009; Schäfer et al., 2012; Trogdon and Hylands, 2008; Yarnall et al., 2003). One of the most long-standing studies on routine general checkups is carried out in Canada where the practice has been discouraged and even abandoned since 1979 due to poor evidence on its effectiveness (Canadian Medical Association, 1979; MacMillan, MacMillan and Offord, 1993; Thombs, Lewin, and Tonelli, 2017).

Although it is worth noting that resources could be allocated to higher-quality medical services instead of the periodic GHE (Hayward et al., 1991; US Public Health Service (1994)), there are proven benefits to this kind of health screening. First, regular check-ups help facilitate patient-physician relationship, raising mutual trust and potentially contributing to positive health outcomes (Ponka, 2014; Kelley et al., 2014). Second, the service may assist marginalised groups that would otherwise miss out on regular health screening (Ponka, 2014). Third, it reduces patient anxiety and provides physicians with evidence-based preventive measures, such as early detection of risk factors and a more updated patient profile over time (Fletcher, 2007; Lin et al., 2011; Duerksen, Dubey and Iglar, 2012; Kermott et al., 2012). Another outcome often attributed to routine health check-ups is higher rates of cervical cancer screening, faecal occult blood testing, and cholesterol screening (Boulware et al., 2007), as well as new diagnoses that could have been missed or delayed (Himmelstein and Phillips, 2016).

Regular health screening in developing countries and Asia

In recent years research on periodic health screening has also emerged in developing countries and in Asia, with many studies analysing factors influencing consumer health behaviour. Participation in regular health exams among Brazilian women was linked to four factors, namely being younger than 40 years old, having higher educational level, having private health insurance and being married (Leal et al., 2005). Meanwhile, in Saudi Arabia where healthcare is free of charge, six factors were found to increase the likelihood of receiving periodic GHE, including high age, education, being married, daily consumption of fruits and vegetables, diagnoses of diabetes, and a clinic/hospital visit for injury/illness within the past two years (El Bcheraoui et al., 2015). A study on health screening behaviour among Singaporeans similarly named low education and income levels as two factors associated with low uptake of periodic GHE (Wong et al., 2015). The results were also confirmed in a study in South Korea, such that both demographic (gender, age) and socioeconomic attributes (education, income, health status, living habits) are strongly linked to the willingness to take a physical exam (Yeo and Jeong, 2012). In terms of occupation, Chinese civil servants and retired government officials were reported to have more frequent annual physical exams than farmers, especially the elderly, due to their better health knowledge (Sun et al., 2014). In South Korea, a recent study found workers at enterprises with more than 300 employees are more likely to participate in the national GHE than those at enterprises with fewer than 50 employees (Kang et al., 2017).

Another line of research in Asia looks for the impacts of a periodic checkup, such as improved healthcare utilisation in the short term in Japan (Ren, Okubo and Takahashi, 1994), increased surgical treatment for uterine fibroids in Chinese women (Wu, Yang and Zhou, 2010), higher hepatitis B vaccine uptake in Hong Kong (Chan et al., 2009), positive lifestyle changes in South Korea (Son et al., 2012; Yeo and Jeong, 2012), and higher likelihood of early treatment of some target diseases in Taiwan (Lin et al., 2011). For the large part, the literature of GHE in Asia seems to focus more on the effects of early examination toward a specific disease in a specific demographics, with cancer screening the most prevalent (Tang, Solomon, and McCracken, 2000; Yeoh, Chew, and Wang, 2006; Mehrotra, Zaslavsky and Ayanian, 2007; Domingo et al., 2008; Kim et al., 2011; Koo et al., 2012; Siew and Sunny, 2013).

Why Vietnam

It is important to point out that much of the literature on periodic health screening, whether in the West or Asia, has left out the cost of the medical service itself, with the exception of the service being free or covered by insurance in some cases (El Bcheraoui et al., 2015; Yeo and Jeong, 2012). Medical cost, as expected, may significantly determine people’s acceptance of periodic GHE (Oboler et al., 2002). This study for the first time seeks to evaluate the sensitivity to periodic GHE cost of a group of consumers, particularly Hanoi (Vietnam), continuing the line of recent studies such as (Vuong and Nguyen, 2015; Vuong, 2015; Vuong, 2016a; Vuong, 2016b).

Vietnam, which has a young population and a low GDP per capita of approximately US$2,000, offers a case study of human behaviour in the healthcare sector of a developing Asian country. Vietnamese health consumers are facing increasingly common issues–higher medical costs and widening income inequalities–that, in the worst case, could push them to the point of destitution (Vuong, 2015; UNDP Vietnam, 2016). This happened as a result of the health sector reforms in the 1980s. Before Vietnam changed from a centrally planned economic system to a market-oriented one, state subsidies played a major role in its health system, with healthcare services and drugs free of charge. The deregulation of the medical system has since brought about massive changes in healthcare delivery, access and financing (Chaudhuri and Roy, 2008). One of the significant changes to health financing is compulsory health insurance for all citizens from 2008 (Do, Oh and Lee, 2014), although the coverage has reached only 81.7% of the population as of 2017 (Vietnam Plus, 2017). Universal coverage is envisioned in the next few years. However, despite insurance coverage, the introduction of user fees at both public and private facilities has led to a sharp increase in out-of-pocket (OOP) expenses (Chaudhuri and Roy, 2008). A recent study shows that the OOP cost is still so high that the current insurance package, though reduces the vulnerability to high healthcare costs, needs reforms (Nguyen et al., 2012).

Research on Vietnamese healthcare, therefore, has mostly considered the rising OOP expenditure as a major barrier to quality healthcare (Chaudhuri and Roy, 2008; Vu et al., 2016; Van Minh et al., 2013; Nguyen et al., 2012), and left out the personal expenditure for periodic health examinations. This study arises from the need to assess the case in Vietnam as that might present a typical barrier to anticipatory care for health consumers in developing countries today. This research contributes to the literature by increasing understanding of some of the demographic and socioeconomic-cognitive factors that influence individuals to follow or not follow regular health screening guidelines.

Identifying factors affecting human health decisions

Given the controversial nature of periodic health check-up, it is important to take into account factors that could affect the behaviour and attitude of people in considering this service’s cost. With low income as a strong predictor for the low participation in GHE (Wong et al., 2015; Yeo and Jeong, 2012, Dryden et al., 2012; Kuo and Lai, 2013; Sun et al., 2014; Nakanishi, Tatara and Fujiwara, 1996; Wong et al., 2015), this study excludes the income factor from the scope of the investigation, instead focusing on two groups of factors that might influence with the level of willing payments for this service. The first is demographic: sex, marriage and job status; the second is socioeconomic and cognitive: health insurance, perception toward public health status, and hesitation to take GHE due to distrust in healthcare quality (see Table 1). Below is a brief review of the research on the correlation between these factors and periodic health attendance.

Table 1 Basic statistical indicators Full size table

In terms of sex, the majority of studies over the years have shown females to be more inclined to take regular physical examinations than males (Nupponen, 1996; Jepson et al., 2000; Wall and Teeland, 2004; Lai and Kalyniak, 2005; Cherrington, Corbie-Smith and Pathman, 2007; Dryden et al., 2012). Two studies (Hsu and Gallinagh, 2001; Karwalajtys et al., 2005) were found to exhibit no difference in GHE uptake by sex (Dryden et al., 2012). Notably, periodic GHE has been shown to have an obvious, positive impact for female patients on detecting and dealing with breast cancer and uterine fibroids (Yeoh, Chew and Wang, 2006; Domingo et al., 2008; Wu, Yang and Zhou, 2010). Yet, despite widespread fear of cancer, on the health-seeking practices of Vietnamese people, studies have noted the lack of knowledge, as well as irregular check-ups among local women concerning breast and cervical cancer (Pham and McPhee, 1992; McPhee et al., 1997; Domingo et al., 2008).

In terms of marriage, married people are shown to have a higher likelihood of participating in annual physical check-ups, as seen in both developing and developed countries (Lai and Kalyniak, 2005; Leal et al., 2005; El-Haddad et al., 2015). Similarly, in an extensive review of over 17,000 published papers on general health checks, Dryden et al., (2012) found that marital status is associated with higher GHE participation rates, especially among men. The effect of marital status on health screening participation could be explained by a spouse’s attempt to monitor the other’s health and encourage healthy behaviour (El-Haddad et al., 2015; Engebretson, Mahoney and Walker, 2005).

As for job status and related factors, lower attendance of periodic health exam is linked to low incomes, low educational level, and unemployment (Hsu and Gallinagh, 2001; Culica et al., 2002; Wong et al., 2015; Yeo and Jeong, 2012; Dryden et al., 2012; Sun et al., 2014). This is true on an intuitive level as people of higher socioeconomic status are more likely to experience better health status (Kuo and Lai, 2013; Sun et al., 2014; Agborsangaya et al., 2012). By contrast, not only do those with lower incomes often have substandard habitat and unhealthy living habits but they also have restricted access to healthcare services, including periodic GHE (Tucker and Clegg, 2002; Kuo and Lai, 2013; Sun et al., 2014; Nakanishi, Tatara and Fujiwara, 1996). They are more susceptible to diseases and run the risk of astronomical treatment costs that could be worse in case of no insurance (Tucker and Clegg, 2002; Lu and Hsiao, 2003; Wilper et al. 2009).

Given that health insurance is seen as a proxy for healthcare access, it could be a predictor of having had a recent medical check-up (Naimi et al., 2006). Health insurance has been shown to improve the efficiency of healthcare services usages and was especially beneficial for the poor who have demand for screenings and treatment (Finkelstein, 2002; Ross and Mirowsky, 2000; Meer and Rosen, 2004). In Vietnam, national health insurance has been shown to have limited success in reducing medical expenses (Nguyen, 2012; Nguyen et al., 2012). Of the studies on periodic GHE in both developing and developed countries, health insurance coverage is related to a higher probability of using this service (Culica et al., 2002; Yeo and Jeong, 2012; Leal et al., 2005).

The two cognitive factors used in this study, namely perception toward public health status and hesitation to take GHE due to distrust in healthcare quality, are based on the understanding that mutual trust and communications could affect health outcomes (Glantz et al. 2008; Jepson et al., 2000). Problems in the health system could diminish such trust. A large-scale review of patient safety and care quality in developing countries in Southeast Asia found four major concerns, namely (i) patient infection risk, (ii) medications errors, (iii) maternal and perinatal care quality, and (iv) the overall healthcare quality (Harrison, Cohen and Walton, 2015). In Vietnam where healthcare services are being privatised, researchers have noted how many public hospitals are focusing on reaching revenues target rather than improving services (Minh (2011); Cong and Mai, 2014). A study on tuberculosis treatment and management in Vietnam highlights the distrust of patients and their families in the quality of healthcare delivery, such that the lower levels and status of the healthcare system are associated with low trust (Johansson and Winkvist, 2002). Vietnamese patients are known to frequently doubt their physicians’ advice, and thus, fail to follow through on the treatment (Vuong and Nguyen, 2015). Such distrust could hold people back from participating in periodic health screening. Here, because the doctors rely on a one-size-fits-all examination, the patients could feel as though their doctors are not genuinely interested in their views. This presents an asymmetrical relationship: the patients by default are in a vulnerable position where their trust can be abused by the doctors (Djulbegovic and Hozo, 2012). In the case of periodic GHE, Hammond, Matthews, and Corbie-Smith (2010) confirmed in a study among African American men that high medical distrust, plus traditional masculine norms, reduced the likelihood of using this service.

This study will take into account the crisscrossing influences of the above factors over another in the decisions regarding the cost of periodic GHE in Vietnam.