Conceptualizing depression in Vietnam: Primary health care providers’ explanatory models of depression

Abstract

The purpose of this qualitative study was to elicit the explanatory models (EMs) of primary healthcare providers (PHPs) in Vietnam in order to (a) understand if and how the concept of depression is understood in Vietnam from the perspective of nonspecialist providers and community members, and (b) to inform the process of introducing services for depression in primary care in Vietnam. We conducted semistructured interviews with 30 PHPs in one rural and one urban district of Hanoi, Vietnam in 2014. We found that although PHPs possess low levels of formal knowledge about depression, they provide consistent accounts of its symptoms and aetiology among their patient population, suggesting that depression is a relevant concept in Vietnam. PHPs describe a predominantly psychosocial understanding of depression, with little mention of either affective symptoms or neurological aetiology. This implies that, with enhanced training, psychosocial approaches to depression care would be appropriate and acceptable in this context. Distinctions were identified between rural and urban populations in both understandings of depression and help-seeking, suggesting that enhanced services should account for the diversity of the Vietnamese context. Alcohol misuse among men emerged as a considerable concern, both in relation to depression and as stand-alone issue facing Vietnamese communities, indicating the need for further research in this area. Low help-seeking for depression in primary care implies the need for enhanced community outreach. The results of this study demonstrate the value of eliciting EMs to inform planning for enhanced mental health service delivery in a global context.

Keywords

depression explanatory models global mental health help-seeking primary care Vietnam

Introduction

Depressive disorders are a major contributor to the global burden of disease, and are expected to become the leading cause of disability adjusted life years (DALYs) worldwide by 2030 (Mathers & Loncar, 2006). Depressive disorders are associated with numerous comorbidities (Kessler et al., 2014; Prince et al., 2007) and with negative socioeconomic consequences, including increased risk of intimate partner violence (Kessler et al., 2014) and increased absenteeism from work (Alonso et al., 2011). Based on evidence of the high global burden of depression and a severe shortage of mental health human resources in many low- and middle-income countries (LMICs; Kakuma et al., 2011), proponents of a global mental health approach have recommended the scale-up of evidence-based, low-cost interventions (Eaton et al., 2011; Patel, Simon, Chowdhary, Kaaya, & Araya, 2009). This includes the scale-up of task-shifting approaches whereby services for mental health problems are delivered by nonspecialists.

While all cultures seemingly experience symptoms that are consistent with depressive disorders, depression as an illness may be experienced, understood, and treated differently across cultures (Jenkins, Kleinman, & Good, 1991). The symptoms associated with depression and the meaning attributed to those sets of symptoms may vary, thus influencing patterns of help-seeking and care provision. Understanding the ways in which depression is conceptualized among diverse cultural groups is an essential component of planning for care provision in a global context and among diverse populations. While task-shifting approaches, including the integration of mental health services into primary care, may effectively help to fill a critical gap in health services and to improve service access for people suffering from mental health problems including depression, these approaches must take into account the sociocultural context of depression in order to ensure that interventions are both evidence-based and culturally appropriate.

Explanatory models (EMs) refer to “the notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process” (Kleinman, 1980, p. 105). EMs help to explain how people—whether they are patients, family members, or practitioners—give meaning to the experience of being ill. They help to understand how and why a series of symptoms may be classified as an illness, how and why decisions are made about care and help-seeking, and beliefs about illness course and outcome. Four broad components of EMs can be identified: what is the nature of an illness?; what causes it?; what should be done about it?; what is the expected outcome? (Kleinman, 1980; Niemi, Falkenberg, et al., 2010). Understanding health care providers’ EMs can provide insight into how they understand and respond to specific illnesses. This in turn provides essential contextual information to guide the adaptation or development of tools and interventions for use within specific communities. Although providers might be considered to have “expert” knowledge about specific illnesses and their required interventions, Kleinman notes that EMs are largely tacit, and are “partly conscious and partly outside awareness” (Kleinman, 1980, p. 109).

Efforts are currently underway to improve service provision for common mental disorders in primary care in Vietnam. The present qualitative study aimed to elicit the EMs of primary healthcare providers (PHPs) in Vietnam in order to (a) understand if and how the concept of depression is understood in Vietnam from the perspective of nonspecialist providers and community members, and (b) to inform the process of introducing services for depression in primary care in Vietnam.

The Vietnamese context

Vietnamese beliefs about health and illness are influenced by a number of paradigms, including Buddhist, Confucian, and animistic beliefs. In traditional Vietnamese medicine (TVM), health is influenced by both biophysiological and cosmological concepts (Phan, Steel, & Silove, 2004). Maintaining balance between yin and yang is important to maintaining good health, with environmental factors—composed of the five elements (metal, earth, fire, water, and wind)—influencing health. Achieving balance between “hot” and “cold” forces is also essential to maintaining good health (Purnell, 2008). Little distinction is made between mind and body, with internal organs being associated with emotional states (Phan & Silove, 1999; Phan et al., 2004). Traditional healers have been used in Vietnam for both physical and psychological issues (Phan & Silove, 1999), and traditional medicine, including herbal remedies and interventions such as cupping and acupuncture, is integrated into the mainstream health system. Folk traditions, such as the belief in ancestral ghosts and spirits, also influence health beliefs, where “ghosts” might be responsible for symptoms (Nguyen, 1985; Phan et al., 2004). In addition to diverse traditional beliefs, Vietnam also has a history of Western psychiatry dating back to the early 20th century that has been especially influential in urban areas (Phan et al., 2004).

Previous research about beliefs related to depression has been limited, although some studies do provide important insight. Van der Ham, Wright, Van, Doan, and Broerse (2011) assessed attitudes and perceptions about mental illness and help-seeking behaviour among adults in an urban population in Hue using a questionnaire and eight focus group discussions. Questionnaire respondents (N = 200) were randomly selected from the general population, while four focus groups were with relatives of mental health patients, and four were with people with no known relationship to people with mental illness. The study examined attitudes and beliefs related to four categories of mental illness: major depression, anxiety disorder, alcohol use disorder, and schizophrenia. Niemi, Falkenberg, et al. (2010) conducted semistructured interviews with nine mothers and nine health workers in a semirural area of Ha Tay province in northern Vietnam to elicit explanatory models of depression and perinatal depression. Both studies found that there are low levels of knowledge about depression in Vietnam, although DSM-IV depression symptoms were recognized when closed questions and vignettes were used. The use of the term “depression” to refer to these symptoms was limited, and respondents were more likely to refer to “thinking too much” or “thinking illness” (Niemi, Falkenberg, et al., 2010; van der Ham et al., 2011). The causes of depression were most often attributed to relational and family problems (Niemi, Falkenberg, et al., 2010; van der Ham et al., 2011). Help-seeking for depression was found to be low, with biomedical treatment unlikely to be sought except in the most severe cases (Niemi, Falkenberg, et al., 2010; van der Ham et al., 2011). Niemi, Falkenberg, et al. (2010) found that the reluctance of patients to communicate emotional symptoms meant that diagnosis of depression was unlikely in primary care contexts.

Vietnam is a lower middle income country with approximately 90 million inhabitants, 17% of whom live under its national poverty line (The World Bank, 2016). The country is culturally diverse, with 54 distinct ethnic groups (International Work Group for Indigenous Affairs [IWGIA], 2017). Vietnam has a long history of conflict, having experienced numerous conflicts throughout the 20th century. This history likely has implications for mental health in Vietnam, as populations exposed to long-term conflict, displacement, and other trauma show higher prevalence rates of depression and posttraumatic stress disorder (Steel et al., 2009). Health care in Vietnam is delivered by a four-tiered system, which ranges from the central level, to provincial-, district-, and commune-level services. In some remote regions, a network of village health workers work under the management of commune health centres. As in many countries, mental health has historically been given low priority within the health system, resulting in limited financial and human resources dedicated to it (V. K. Ngo et al., 2014). Mental health care is offered at 27 provincial psychiatric hospitals and departments, which are distributed among Vietnam’s 63 provinces, operating at the provincial level. At the district level, hospitals have no mental health departments. Psychiatric patients at the district level will be admitted to the internal medicine department. Hospital care for mental illness is predominantly focused on schizophrenia and epilepsy (Ng, Than, La, van Than, & van Dieu, 2011; Vuong, van Ginneken, Morris, Ha, & Busse, 2011).

Primary health care in the public sector is delivered by commune health stations (CHSs) in Vietnam, which, in addition to providing patient consultations, administer national health targeted programs (e.g., immunization, TB, malaria, goiter, diarrhea, and health education campaigns) and provide antenatal care (A. Ngo & Hill, 2011; V. K. Ngo et al., 2014). Outpatient clinics (OPCs) also provide primary care services, operating as either stand-alone clinics or as part of district health centres.

The government of Vietnam has recognized the need to improve community-based care for mental health, and the Ministry of Health (MOH) has included mental health care in the community as part of its 5-year mental health plan (V. K. Ngo et al., 2014). In practice, however, services in the community remain predominantly focused on the management of psychopharmacological treatment for schizophrenia and epilepsy. There is very limited availability of antidepressant medications at the community level, and psychosocial interventions are almost nonexistent (Niemi, Huong, Tuan, & Falkenberg, 2010, Minas, Edington & Kauma, 2017).

Methods

Data collection

This study took place in Hanoi, Vietnam, between August and October 2014. We conducted 30 semistructured interviews with primary healthcare providers (PHPs) at eight commune health stations (CHSs) and two outpatient clinics (OPCs) in one rural (Thach That) and one urban (Dong Da) district of Hanoi. CHSs and OPCs are often the first point of contact for patients within the Vietnamese public healthcare system and are staffed by physicians, nurses, pharmacists, and physicians’ assistants. Some physicians’ assistants have specific training in areas such as midwifery or TVM. Table 1 displays the number and type of PHPs included in the study. The majority of providers interviewed (n = 27) were female, which is representative of the composition of staff at the centres included in the study. One physician, one physician’s assistant, and one pharmacist were male. The results of the 30 interviews, described below, suggest that thematic saturation was achieved. Data saturation can be described as “the point in data collection and analysis when new information produces little or no change to the codebook” (Guest, Bunce, & Johnson, 2006, p. 65). The sample size was also manageable given the study timeframe and resources.

Table 1.

Number and role of interviewees by district

	Thach That (rural)	Dong Da (urban)
Doctors	5	3
Nurses	4	7
Physicians’ assistants	5	3
Pharmacists	3	0
Total	17	13

The original study design involved the use of vignettes to elicit explanatory models. This approach was used successfully among community members and practitioners in Ba Vi, Vietnam, by Niemi, Falkenberg, et al. (2010) and has been used in similar studies in other contexts (Torres, 2009). In pretesting, however, the vignette approach was ineffective and caused concern among the research team. It was evident that participants felt they were being tested or evaluated and showed obvious discomfort with the vignettes, expressing concern about giving the “right answer.” As a response to this, we decided to “reverse” the vignette approach in a way that would be more acceptable to the participants, but would serve the same methodological purpose as vignettes, which are effective for understanding beliefs and attitudes about topics that may be abstract (Torres, 2009). We therefore asked participants a series of questions, employing Kleinman’s (1988) four components of explanatory models, beginning with broad questions about “mental illness” in general, followed by questions specifically related to depression (see Table 2). We took this approach in order to mimic the methodological approach of using vignettes; by first asking broadly about “mental illness” without using specific psychiatric terms, participants were able to respond in a manner that was unbiased and allowed them to describe their own explanatory models.

Table 2.

Semistructured interview questions

1. Think of a patient with a severe mental illness/less severe mental illness:

What types of symptoms does the patient have?

How does the patient act?

What words might the patient use to describe their symptoms? What words might their family use to describe the patient’s symptoms?

Is there a name for this condition?

Is there a different traditional or informal name that might be used in the community?

2. Think about a patient with depression:

A: If they have not used the word depression yet, unprompted, ask the same questions about symptoms above, followed by questions below

B: If they have used “depression” to describe symptoms already:

What can cause a person to experience depression?

Have you ever had a patient with depression?

What did you/would you do if you had a patient with depression?

What would people in the community do if they had a family member with depression?

Do you think that someone with depression can recover?

As shown in Table 2, we first asked them to think of a patient with a severe mental illness, and to describe the symptoms a patient might experience and the terms that would be used to describe this condition. We then asked them specifically to think about a patient with a less severe mental illness, asking them the same questions in order to establish whether discrete symptoms would emerge when participants were unprompted by psychiatric labels. Previous research from Vietnam indicates that while schizophrenia, epilepsy, and alcohol use disorder are considered to be severe mental illnesses, depression and anxiety disorders are considered less severe (van der Ham et al., 2011). We therefore asked them to make this distinction, initially avoiding specific psychiatric labels, to establish which symptoms would emerge unprompted, whether these symptoms would be distinguishable from symptoms of other mental illnesses, and whether any of these sets of symptoms would be labeled as “depression” (trầm cảm) by PHPs without prompting from the interviewer.

Finally, we asked questions specific to depression. If the term “depression” (trầm cảm) was used to refer to the symptom descriptions related to severe or less severe mental illness, we moved directly to questions related to familiarity, cause, approach to treatment and help-seeking, and prognosis (see Table 2). If they had not yet used the term “depression,” we began by asking questions specifically about the symptoms of depression, followed by the same questions about familiarity, cause, treatment and help-seeking, and prognosis. Because PHPs are closely embedded in their communities, we asked them to respond both as clinicians/experts and as community members, drawing on personal as well as clinical experience. This appeared to work well, as it allowed them to reflect on experiences that went beyond the clinical or biomedical domain and provided insight into beliefs and behaviours within the broader community.

The interview schedules and consent forms were translated from English to Vietnamese and then back-translated for semantic equivalence. The interviews were then pretested, with adjustments made as necessary to the interview questions and approach as described above. Semistructured interviews were conducted by the first author with the assistance of a bilingual interpreter/research assistant. The majority of interviews were recorded with the permission of the participants, and were later transcribed by Vietnamese research assistants and translated into English by a translator with expertise in public health. Five participants preferred not to have the interviews recorded. In these cases, extensive field notes were taken. The research process was iterative, with ongoing discussions held between the researchers throughout it. Debriefing took place between the primary author and interpreter/research assistant following each interview, and discussions regarding terminology and concepts related to depression and mental health were held frequently with the interpreter/research assistant and with the translator of the interview transcripts. Because the primary author is not Vietnamese, the role of Vietnamese partners, including the research assistant and translator, was essential. The ability to discuss at length the meaning of terminology, including both psychiatric and colloquial expressions, was essential to the research process.

Data analysis

The data were analysed using a thematic analysis approach, whereby “patterns of meaning” are identified (Crowe, Inder, & Porter, 2015), with themes emerging from the data (Braun & Clarke, 2006). The theoretical thematic analysis approach (Braun & Clarke, 2006) used reflected the design of the interview questionnaire, which was structured to elicit responses around the four components of EMs (the nature of an illness, its cause, the appropriate treatment or response, and the expected outcome), in addition to community perspectives about depression. The analysis process began with an immersion in the data with thorough readings and rereadings of the interview transcripts. This was followed by the generation of initial codes, with additional codes added as they emerged throughout the coding process. Coding was conducted using NVivo 10 software (QSR International). The codes were then grouped into categories, from which themes were identified. Themes were then reviewed and refined, with a detailed analysis of each theme conducted for the final analysis (Braun & Clarke, 2006).

Results

Symptoms

Participants were asked to first describe the symptoms and behaviour of a patient with a severe mental illness and then to describe a patient with a less severe mental illness. Table 3 displays the most commonly mentioned symptoms of both “severe” and “less severe” mental illnesses as described by PHPs.

Table 3.

Symptom description of severe and less severe mental disorders

Severe mental disorders	Less severe mental disorders
Wandering around	Don’t talk or communicate
Aggressive behaviour	Keep to themselves
Destructive behaviour	Fatigue
Saying strange things	Trouble sleeping
Paranoia and delusions	Unable to work

PHPs made a clear distinction between symptoms that they associated with “severe” mental disorders and those they associated with “less severe” disorders. We subsequently asked participants to provide labels for each set of symptoms. They frequently used the term for “schizophrenia” (tâm thần phân liệt) for severe symptoms and sometimes also used a general term for “mental illness” (tâm thần) or used informal words (r̀, điên), which translate as “crazy.” For the less severe symptoms, they often used the term for “depression” (trầm cảm), but also sometimes referred to them as general “mental illness” (tâm thần) or as tự kỷ, which the interpreter and translator explained translates as “autism,” but is also commonly used to refer to anyone who does not often socialize or talk to others (perhaps best translating to the colloquial “antisocial” in English). The following quote illustrates the distinction between symptoms made by a PHP:

There are also patients, like in my neighbourhood, who scream and wander around, or even take off all their clothes and go out on the street. Those are serious cases. There are less serious cases in which the patients just don’t say anything, like depression, they don’t communicate with other people. (Nurse, Dong Da district)

We subsequently asked PHPs to think specifically about depression, using the Vietnamese term trầm cảm. Their description of symptoms emphasized social withdrawal and functional disruption. The most commonly described symptoms of depression were not wanting to communicate with other people and “keeping to themselves.” Inability or unwillingness to work and reduced productivity were also described as symptoms of depression. Physical symptoms, such as fatigue, insomnia, and headache were also described.

The clearest symptoms of depression [are] that they don’t communicate with anyone, they don’t want to, they don’t want to go out, they isolate themselves and have no social relationship [sic]” (Nurse, Dong Da district).

PHPs noted that patients would likely not describe their own symptoms. They explained that families would bring patients to the health centre and would participate actively in the consultation, often relaying the patients’ symptoms to providers. In some cases, PHPs reported never having seen a patient with depression, but were familiar with a family member or community member who had experienced it. In three cases, PHPs reported having experienced depression themselves.

Cause

PHPs described causes of depression largely in psychosocial terms. Causes of depression as described by PHPs can be categorized as interpersonal, external, and internal/psychological. Family problems, including tension between spouses, pressure by parents on children, and relationships with in-laws were the most commonly mentioned causes of depression across all categories, described as having a serious impact on mental health. Social problems or problems in the community were also described as contributing to depression, with “neglect” by the community described as a possible contributing factor.

External factors contributing to depression include pressure at work and financial problems. One PHP stated: “There are many influencing factors, including family, economic situation, or being stressed at work. Many factors” (Pharmacist, Thach That district).

Internal and psychological problems were also described, with “shock” emerging as an important cause of depression. “Shock” seems to be understood as a psychological response to an adverse event (e.g., bereavement or sudden economic loss) or disappointment (e.g., poor performance on academic exams, not having a son). “Shock” was described as leading to depression when a person was unable to cope properly with these events:

There are many causes, for example, they don’t get what they expect, or they have some kind of shock. For example, when they expect something too much but it does not happen, it would make them shocked and lose their hope in life. I think that is one type of depression. The patient feels discouraged, tired, does not like anything anymore. Well, it’s hard. (Physician’s assistant/midwife, Dong Da district)

Addiction and substance use were also associated with depression, with alcohol misuse in particular described as an important cause of depression among men. Alcohol misuse by men was described as a serious concern in many communities and emerged both in relation to depression and as a distinct concern.

Interventions and approaches to care

When describing interventions and approaches to care, PHPs describe the importance of identifying the cause of the depression as the first step in providing advice and counselling to the patient. The advice provided would be specific to the perceived cause, with some providers stating that they would provide advice about dealing with spousal conflict or economic difficulty, for example:

Doctors and nurses working with this type of patient need to be very patient and sympathetic when asking and consulting the patient, so that we can have the right information we need, like the cause of the disorder. For example, it might be because they are involved in some type of bad business leading to a bad financial situation or some troubles at home, or some other reason; we need to know those reasons to have an appropriate treatment instruction. (Doctor, Dong Da district)

Referrals are a common course of action when advice is seen as insufficient. Patients considered to be suffering from a mental health problem would be referred to the district hospital (one level above the CHSs) or to a specialized mental health department or psychiatric hospital.

PHPs also described prescribing sleeping pills, vitamins, supplements, and tonics (traditional herbs used for healing purposes) to help the patient to restore blood flow to the brain, which was associated with symptoms such as headaches and insomnia. Antidepressants are not available at the CHSs; under Vietnamese regulations they may only be prescribed by a specialist and are therefore not prescribed by PHPs. These supplementary medications are provided in addition to advice about nutrition, rest, and lifestyle changes:

We are not implementing a mental health program here, so I prescribe medicine to help sleeping and increase brain blood circulation. I combine those medicines and they feel better after a while following the prescription … I need to explain to them and advise them to eat, to take a rest, and take medicine as prescribed for 20 days, and to get rid of alcohol to recover quickly. (Pharmacist, Thach That district)

Family and community support were also described as essential to care for depression. In addition to providing advice to patients themselves, PHPs indicated that they would provide advice to families about how to care for and support their depressed family member. The following quote demonstrates the various approaches to a patient with depression that might be taken by a PHP:

Firstly, I would try to find out the cause of depression. If [they] did not have depression before, we need to know what has caused [them] to be like that. If I cannot help [them], I will advise [them] to go to see a specialist on depression, so that they can give [them] treatment. Along with that, I would encourage [their] family to support [them]. (Pharmacist, Thach That district)

Prognosis

PHPs believe that with proper treatment and family and community support, patients can recover from depression. Similarly to treatment, they link recovery to identifying a clear cause of the depression, stating that once the cause is known, proper support can be provided by PHPs and by family members to help the patient to recover.

The importance of medication was also raised, with nonadherence to medications identified as a challenge to recovery. “Medications” might refer to antidepressants that are prescribed at a higher level of care, or to the types of supplements and sleeping pills described above.

Some PHPs also believe that mental illness exists on a spectrum, where less severe symptoms of depression might lead to more severe forms of mental illness. For example, several PHPs stated that untreated depression might lead to schizophrenia. The following quotations are from two different doctor’s assistants in Thach That district: “Receiving medicine and advice, the patient feels satisfied and the condition gets stable,” “Otherwise, if he continues being in this condition, he will get schizophrenia.”

While some severe cases of depression may indeed lead to symptoms of psychosis if untreated, the belief of some PHPs seems to be that “milder” forms of mental illness will progress, leading the patients to experience more “serious” or psychotic symptoms.

Community perspectives

Awareness

PHPs indicated that although depression is seen in the community, community members lack awareness about mental illness and depression. They explain that there has been more coverage of depression in the media recently, causing awareness to gradually increase, but despite this increase in awareness, they believe that very few community members would use the word “depression” to describe their symptoms. PHPs also believe that there are many people living in their communities who suffer from depression and do not seek help. Many of the PHPs’ experiences with depression were based on knowledge of family and friends, or personal experience, rather than patients encountered through their role as health care providers.

In Thach That, the rural area, mental illness is often conceptualized in spiritual terms, and families might believe that the person experiencing depression is “ghost-driven” (ma lam) or possessed by malevolent spirits. Although the belief in spirit possession might be more common with very severe cases of depression or psychotic disorders, it is evidently relevant to the overall understanding of mental illness EMs in rural communities:

Well, when talking about mental illness, people in the community often think of ghost-controlled [ma lam]. It’s because of their low awareness; they think that when they see someone with strange behaviour. (Doctor, Thach That district)

Care pathways

When asked what steps people in the community might take in response to the symptoms of depression, three pathways were identified by PHPs. The first was that the family of the patient would help them to seek biomedical care, usually at a psychiatric hospital. This was particularly likely in the urban area, where hospitals are more easily accessible for families who can afford to pay a user fee. Only families unable to pay this fee would first seek help from a primary care centre.

Not seeking help at all was also described, with PHPs indicating that stigma might prevent families from seeing a mental health specialist or informing their primary care doctor of a mental health problem. Individuals and families would be reluctant to admit to having a mental illness. For illnesses like depression, community members might not believe that biomedicine is the appropriate course of care or treatment, as described in the following quotation:

I think in Vietnam, seeing a doctor for this kind of matter seems difficult. People go to see a doctor for something specific, but for a mental matter almost no one would seek help from a doctor, even if they want to … People often think that seeing a doctor is for physical problems, not for mental health problems. (Midwife, Dong Da district)

In rural areas, families might first seek help from spiritual means, by visiting a pagoda, making offerings to ancestral graves, or visiting a fortune-teller. This was often described by PHPs as the first step a family in a rural area might take to address mental illness. They might seek biomedical care if the spiritual route did not prove effective. Again, this type of care might be more frequently sought for the most severe symptoms of mental illness, while families might not seek help at all for mild to moderate symptoms of depression.

Discussion

The depression experience as described by PHPs, including symptoms, beliefs about aetiology, and recommendations for treatment and care, predominantly emphasizes the psychosocial nature of the illness experience. While some PHPs do describe the prescription of a tonic to “increase blood flow to the brain,” PHPs do not extensively describe beliefs about neurological or genetic origins of depression or discuss theories about brain structure or chemistry. This emphasis on the psychosocial origins of depression differs from the predominant EMs of Western countries, where biological models are influential (Bracken et al., 2012; Deacon, 2013). PHPs’ explanatory models also do not seem to reflect traditional Vietnamese medical beliefs. While they are certainly aware of community animistic and spiritual beliefs, and describe the provision of traditional teas to ease sleep disruption, they do not attribute traditional or spiritual factors as causes of depression or identify them as appropriate approaches to care. The psychosocial nature of depression from the perspective of PHPs is a common thread throughout the findings, and has important implications for the expansion of depression treatment in primary care. Antidepressant medications are not widely available in Vietnam and PHPs are not permitted to prescribe them under Vietnamese regulation. The psychosocial understanding of depression by PHPs and the fact that, unlike in many contexts, the widespread prescription of antidepressants is not yet a reality in Vietnam, suggest an important window of opportunity for the enhancement of psychosocial interventions in primary care settings. Improved availability and access to antidepressant medications for those who need them is certainly an important factor in mental health system strengthening in Vietnam. The opportunity, however, to enhance the use of psychosocial interventions is one that must be taken with some urgency, as the influence of biomedical models of mental illness and the belief in the widespread necessity of pharmacotherapy for depression is likely to grow.

The symptoms of depression as described by PHPs in Vietnam emphasize psychosocial factors, including interrelational and functional disruption and somatic complaints, while emotional or affective symptoms are rarely described. This is consistent with previous findings from research on depression symptoms in Vietnam (Niemi, Falkenberg, et al., 2010; van der Ham et al., 2011). It is possible that the lack of emphasis on affective symptoms might be due to the reluctance of patients to talk about these symptoms themselves (Niemi, Falkenberg, et al., 2010), leading to the identification of only the most visible symptoms by family members and health workers. However, the lack of association of depression with lowered mood has been identified in other non-Western cultures and is a relatively recent concept even in Western psychiatry (Paykel, 2008). The predominantly relational experience of depression has also been seen in other cultures (Jenkins et al., 1991), while the reluctance of patients to disclose symptoms of depression due to self or family stigma was found among Vietnamese patients in Vietnam and in the United States (Do, Pham, Wallick, & Nastasi, 2014).

The emphasis on relational and somatic symptoms of depression might mean that Western-derived measures will fail to detect cases of depression in Vietnam. The lowered emphasis on somatic symptoms in standard international diagnostic instruments has been associated with underreporting of depression in Vietnam (Liddell et al., 2013; Murphy et al., 2015; Rees et al., 2012). This underlines the importance of using measures that are rigorously validated, including for construct validity, in cross-cultural research and practice (Murphy et al., 2015).

The family plays an important role in the illness experience in Vietnam. In addition to playing an active role in the identification of illness and patient consultations, the family is simultaneously described as the potential cause of depression and an important source of support to the patient. Family trouble emerged as the most common cause of depression, while PHPs also described the importance of the family for patient care and recovery. Social and familial expectations were also linked to cause. Pressure to perform well on exams was commonly cited as a cause of stress leading to depression among youth, while the failure of a child to achieve academically was cited as one cause of “shock” for parents. Failure to have a male child was also described as a potential cause of depression among women. Although the topic was often discussed with some humour, a poor relationship with a mother-in-law was described as a cause of depression among women. In addition to the relational nature of symptoms, the importance of the family suggests that mental health and wellness are embedded within the relational realm, with familial and social support and expectations playing a substantial role in the experience of depression. This suggests that approaches to screening and treatment that focus solely on the individual might be inappropriate and that approaches that include families should be explored. Of course, given the complex nature of families as both possible causes of depression and essential to the recovery process, family roles in patient treatment should be negotiated with care.

Also important was the use of alcohol by men, which emerged as a considerable concern. Alcohol use was seen as a potential cause of depression and also as a serious concern in and of itself. There is little research on depression among men in Vietnam, although previous research has shown that rate of alcohol abuse among men is high (Minh, Huong, & Giang, 2008; Vuong et al., 2011). This points to the need for more research about men’s mental health, including the relationship between depression and alcohol use. It also indicates a need for improved capacity in identifying and addressing substance use at the community level.

Existing approaches to depression care

PHPs state that they would take on a counselling or advising role for patients experiencing depression despite the lack of formal training in this area and the absence of psychosocial interventions in the country. Advice is connected to identifying a clear cause of depression, which can then be discussed and negotiated together, along with support from the family. This reflects the belief in the psychosocial nature of depression both in terms of cause and treatment. Referrals are also common, which is indicative of the structure of the health care system in Vietnam and the role of primary care centres as gatekeepers to the higher levels of care. As case detection for mild and moderate depression is currently very low in primary care, it is unlikely that many such cases are referred to higher levels of care. However, as screening for depression becomes further integrated in primary care practice, PHPs will require training to deliver appropriate treatments in order to minimize unnecessary referrals to specialists and to provide support to patients in a context with very limited mental health human resources within the system as a whole (Kakuma et al., 2011). As previously discussed, there is a clear opportunity for the enhancement of psychosocial interventions for depression in primary care, building on the “advice” that is already provided by PHPs. Supported self-management is one intervention that is currently being tested in Vietnam (Bilsker, Goldner, & Anderson, 2012, Murphy, et. al., 2017).

Much of the discussion about depression with PHPs was based not on clinical but on experiential knowledge. All PHPs indicated that they believe there are many people living in their communities with depression, but that people are unlikely to seek help or to identify their symptoms with the term “depression.” This suggests that there is likely a gap in case detection where patients may present with somatic symptoms or show other signs of depression during consultations for other health concerns, but are not screened or diagnosed. This is unsurprising given the low levels of training of PHPs in mental health.

PHPs’ lack of clinical experience with patients with depression is also likely due to low levels of help-seeking by community members. PHPs believe that community awareness about depression is very low and that help-seeking for depression in primary care is limited. These findings are consistent with other studies in Vietnam (Niemi, Falkenberg, et al., 2010; van der Ham et al., 2011). When depression is very serious, families might seek help directly from a psychiatric hospital. Help-seeking for mental health problems might, however, be limited due to fear of stigma and the belief that biomedical health services are only appropriate for physical health problems. Enhanced community awareness about depression and other mental illnesses is essential for improving service access in Vietnam. More research is needed to understand community EMs about depression and help-seeking behaviours.

Some differences emerged between rural and urban areas. In rural areas, spiritual beliefs, including beliefs about spirit possession, influence illness EMs and help-seeking. The notion of mental illness having spiritual origins was not raised by PHPs in the urban area, which suggests that EMs might differ somewhat between rural and urban populations. In urban areas, help-seeking for mental illness is more likely to involve a patient going directly to a psychiatric facility. This is less likely in rural areas, where access to hospitals is more challenging. This distinction was found within the greater Hanoi area, which represents only a small portion of the Vietnamese population. Vietnam is a diverse country, with numerous minority ethnic groups as well as cultural and linguistic differences between the north, central, and southern regions. The diversity of Vietnam must be considered when planning mental health interventions; and research about locally distinct EMs should be undertaken prior to service planning and implementation in regions where no such research has previously been conducted.

The need for enhanced training

PHPs provided a consistently defined set of symptoms and causes that they associated with a syndrome called “depression” (trầm cảm). This suggests that despite low levels of awareness within the community, depression is a culturally valid construct and is a condition that is present within the community. PHPs did, however, display a lack of knowledge about depression and mental illness in general. For example, many talked about depression as if it existed along a continuum of “mental illness,” where depressive symptoms would turn into schizophrenia if untreated. While severe depression may certainly present with psychotic symptoms, the nature of the responses suggests that some PHPs believe that the prognosis for depression, if untreated, is psychosis. Some PHPs, despite identifying discrete symptoms of “severe” and “less severe” disorders, would later describe symptoms of psychosis when asked directly about a patient with depression. This also points to the conflation of psychiatric symptoms under the broad category of “mental illness.” Some PHPs described the need to test for depression using biometric tests or electroencephalography. As PHPs receive very little to no mental health training, it is not surprising that their formal knowledge of mental disorders is limited. This points to the need for improved mental health training for primary care providers, both in their initial training and through professional development opportunities. Such training programs could be enriched by including culturally specific EMs of mental illness so as to ensure that they are appropriate and acceptable and that they lead to a delivery of care that is meaningful for communities.

Limitations

As described above, the study sample consisted of n = 30 PHPs working in eight CHSs in two districts of Hanoi. The limited sample size and geographic scope of the study means that it might not be generalizable to the rest of the country and that it is not representative of the broad diversity of Vietnam or of the Vietnamese diaspora communities living in many countries worldwide. The sample size did, however, lead to theoretical saturation, and we are confident that the results are representative of the experience of PHPs working in the Hanoi district. Further research examining depression EMs among both PHPs and community members in other regions of Vietnam would further enhance understanding of this topic.

An additional limitation is the cultural origin and linguistic limitations of the primary author, which meant that interviews were conducted with the collaboration of a Vietnamese interpreter and that transcripts were translated from Vietnamese to English prior to analysis. The collaboration of Vietnamese colleagues was therefore essential to this research. Every effort was undertaken to validate study materials and to ensure semantic equivalence between original and translated transcripts. The primary author and research assistants/interpreters worked closely together, debriefing after each interview and discussing emerging themes. The research assistants are coauthors of this paper (DTL and PTO). The interview transcripts were translated by a Vietnamese translator who has expertise in public health and who is familiar with the research setting. The primary author and translator worked closely together, discussing the nuances of terminology and any uncertainties in the language. While there are always risks associated with conducting research where language and culture might create a barrier, we feel that the collaboration with colleagues in Vietnam and the iterative nature of the research process helped to minimize this risk.

Conclusions

The results of this study suggest that although symptoms and illness experience differ somewhat from Western nosology, depression is a culturally relevant concept in Vietnam. Despite having minimal training in mental health, PHPs distinguish between severe and less severe conditions, and commonly identify the symptoms of less severe illnesses with the term “depression” (trầm cảm). Psychosocial factors predominate in causal understandings of depression and guide the approach taken by PHPs to providing care. Substance use, particularly alcohol misuse among men, is also a serious concern in primary care. The family plays an important role in the illness experience that must be considered in all aspects of care.

PHPs are embedded within the communities in which they work, and their knowledge and experience bridge their formal training and the illness beliefs and behaviour of their communities. In rural areas they are aware of spiritual beliefs related to mental illness, and they understand the implications of stigma for patients and their families. Overall, PHPs express compassion for people with depression and a desire to provide advice and support. While formal training and knowledge about mental illness are lacking among PHPs, there is an opportunity to introduce improved training and enhanced psychosocial services in primary care.

Help-seeking for depression is low in primary care in Vietnam. Further research about community EMs and help-seeking behaviour will contribute to an enhanced understanding about how depression is conceptualized in the country, providing more insight into how to ensure that services for depression are acceptable and accessible to communities. Research is also needed in diverse cultural groups, including minority populations, and across the different regions of the country.

Vietnam is at an important stage in the development of its mental health system because its government has prioritized the enhancement of community-based depression care. While the lack of access to antidepressant medications must certainly be addressed, the fact that overprescription of such medications in primary care is not yet a challenge represents a significant opportunity. The EMs of PHPs show that depression is conceptualized largely in psychosocial terms, suggesting a favourable environment exists in which to develop and adapt psychosocial interventions for depression that are culturally acceptable and accessible for implementation in primary care in the country. Investment by the government of Vietnam in such approaches would represent a positive step in the improvement of community-based care delivery.

Understanding primary care providers’ EMs can provide essential guidance for the planning and implementation of mental health interventions in diverse contexts. Understanding EMs helps to inform the development and adaptation of instruments and interventions that are both evidence-based and tailored to the local context, making them more acceptable and appropriate for communities and providers. The findings of this study support the value of understanding EMs when planning for enhanced mental health service delivery in a global context.

Footnotes

Acknowledgements

The primary author would like to thank the Institute of Population, Health, and Development in Hanoi, Le Mai for translation support, and the study participants for their contributions. The authors would like to dedicate this paper to the memory of Dr. Elliot Goldner, who suddenly passed away at the end of 2016. Dr. Goldner was a wonderful mentor, colleague, and friend. His leadership in mental health in Canada and internationally reflected his passion for improving the lives of people living with mental illnesses. He is sorely missed by the research team.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding support for this study was provided to the primary author by the International Development Research Centre (IDRC) Doctoral Research Fellowship and by the Mitacs Globalink Travel Award. Funding for the “Feasibility Study in Preparation for Randomized Controlled Trial” study was provided by Grand Challenges Canada (0330-04).

Ethical approval

Ethical approval for this study was obtained by the Office of Research Ethics at Simon Fraser University and the Institutional Review Board at the Institute of Population, Health and Development.

Jill Murphy, PhD, is a postdoctoral fellow at the Centre for Applied Research in Mental Health and Addictions (CARMHA) in the Faculty of Health Sciences at Simon Fraser University, Vancouver, Canada. Her research focuses on bridging global and cross-cultural approaches to understanding and addressing mental health in diverse contexts, mental health services delivery and implementation in low- and middle-income countries, and research partnership ethics. Jill is currently the Research Director for the Mental Health in Adults and Children: Frugal Innovations (MAC-FI) Study, funded by Grand Challenges Canada. Her published work focuses on the delivery and scale-up of culturally and contextually appropriate services for depression in Vietnam, and on guidelines for promoting ethical approaches to global health research partnerships.

The late Dr. Elliot Goldner’s research activities were focused on the advancement of policies and services to address mental health and substance use at the population level. In Canada, he worked closely with government ministries and national organizations, particularly with the Ministry of Health in British Columbia and the Mental Health Commission of Canada, to provide research information to support evidence-based decision-making and assist in the implementation of improved systems of service delivery. Dr. Goldner was co-Principal Investigator of the Mental Health in Adults and Children: Frugal Innovations (MAC-FI) Project in Vietnam, and worked closely with the government of Vietnam and other in-country stakeholders to inform the enhancement of the mental health and social services systems. Dr. Goldner received a number of awards for his scholarly work and teaching and served on various boards of directors. He was the Chair of the Science Advisory Committee of the Mental Health Commission of Canada and was the Scientific Lead of the Mental Health Commission’s Knowledge Exchange Centre. Dr. Goldner founded the Centre for Applied Research in Mental Health and Addiction (CARMHA), an internationally renowned research centre that pursues the creation of knowledge and promotes the implementation of evidence-based policies and practices. Dr. Goldner sadly passed away in November, 2016.

Kitty K. Corbett, PhD, is a Professor in the School of Public Health and Health Systems at the University of Waterloo, Ontario. She is a medical anthropologist committed to public health. Her research is about and for change, emphasizing social science theory, methodology, and tools for knowledge translation, health communication, quality improvement, and health promotion. She has worked on teams and published work addressing diverse multidisciplinary challenges related to infectious diseases (e.g., antibiotic resistance, HIV, Chagas); noncommunicable diseases (e.g., oral cancer, mental health, tobacco-related diseases); environment and global health; traditional and local food ways; etcetera. Beyond Canada and the US, she has been a Fulbright Scholar in Mexico and Taiwan, worked on projects in Argentina, Mongolia, Russia, and more, and has supervised students’ work in over 20 countries.

Marina Morrow, PhD, is Chair of the School of Health Policy & Management, York University, Toronto, Canada. Her research explores: (a) mental health reform, service provision, and access to health services; (b) mental health and social inequity; (c) mental health, citizen engagement, and social justice; (d) neoliberal reforms, gender and health; and (e) intersectional theory and approaches in mental health. Before joining the School of Health Policy and Management, Marina was a charter faculty member in the Faculty of Health Sciences, Simon Fraser University. Marina is lead editor of Critical Inquiries for Social Justice in Mental Health (2017, University of Toronto Press). Marina’s research supports public scholarship and collaborative research partnerships with community-based organizations, health care practitioners, advocates, and policy makers.

Vu Cong Nguyen, MD, MPH, is the Deputy Executive Director of the Institute of Population, Health, and Development and Adjunct Professor of Psychology in the Department of Behavioural Health at the Hanoi University of Public Health. Dr. Nguyen’s research focuses on community-based mental health services for Vietnamese people and the application of e-Health. He is currently the Co-Principal Investigator of the Mental Health for Adult and Children (MAC-FI) Project in Vietnam (funded by Grand Challenges Canada), and Coinvestigator of the National Supporting Adolescent Adherence in Vietnam (SAAV) Study, as well as the Co-Principal Investigator of the e-Health for Maternal and Child Health Care for Ethnic Minorities in Vietnam Study. His published works focus on mental health services research, conceptual and methodological issues with minority populations, risk behaviours, e-health, and disparities in service delivery.

Linh Thuy Dang, MPH, is a researcher at the Institute of Population, Health, and Development in Vietnam. She is currently responsible for various duties such as data management and data analysis. Her published works focus on mobile health services research, mental health issues, and other social issues.

Pham Thi Oanh, BA, is a researcher at the Institute of Population, Health, and Development in Vietnam. Ms. Oanh Pham researches common health disorders and health services for common mental illness and affected populations. Currently, she works as a researcher/Project Manager in the Mental Health in Adults and Children: Frugal Innovations (MAC-FI) Project. Her published works focus on mental health issues and services research.

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