Knowledge, attitudes, and practices toward depression among people living with depression in Vietnam: the cultural dynamics in the era of globalization

doi:10.21203/rs.3.rs-4907941/v1

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Research Article

Knowledge, attitudes, and practices toward depression among people living with depression in Vietnam: the cultural dynamics in the era of globalization

https://doi.org/10.21203/rs.3.rs-4907941/v1

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Background

Despite the high burden of depression in Vietnam, little is known about the knowledge, attitudes, beliefs, and practices of Vietnamese people with depression in contemporary society.

Methods

This is a qualitative study with 40 adults, 18–64 years old, with symptoms of depression. In-depth interviews were conducted to explore knowledge (symptoms, causes, treatment), attitudes, and practices to seek support or care for depression.

Results

Knowledge about depression is good amongst the study participants. They could identify several symptoms of depression and are aware of stress and adverse events as causes of depression. However, biological factors as causes are infrequently mentioned. Most people with depression know about psychotherapy and pharmacological treatment. Stigma related to depression seems lesser compared to that in the past. People with depression receive support from family and friends. Despite high awareness about symptoms, causes, and treatment options, misconceptions remain, concealment of illness is common, as is the avoidance of seeking care. Access to care is hindered by cost barriers and a lack of information about reliable providers. Medicines are frequently discontinued due to side effects and insufficient consultation during examination. Praying and offering to altars as cultural practices to treat mental illness still exist. Based on analysis guided by the ‘glocalization theory’ we offer an explanatory account of the current state off knowledge, attitudes, and practices toward depression amongst people living with depression in Vietnam. This analysis recognizes the co-existence of global and local influences. People are creating and adapting their “glocal” views, attitudes, and norms around depression as well as mental illness.

Conclusions

Societal changes have influenced the knowledge, attitudes, and behaviors towards depression in Vietnam in positive ways; however, historical, cultural challenges continue, while new challenges are emerging. Our findings point to the need for renewed, continued efforts to improve mental health related awareness, while simultaneously improving the availability, accessibility, and responsiveness of mental health services. These efforts should take into account both global and local influences on how people in Vietnam think and act regarding mental health issues.

Trial registration:

Clinicaltrials.gov, NCT06456775. Registered June 12, 2024 – Retrospectively registered, https://clinicaltrials.gov/study/NCT06456775?cond=depression&intr=Tele-SSM&rank=1

depression

knowledge

attitude

practices

people with depression

Vietnam

Findings from the Global Burden of Disease Study (2020) showed that the number of incident cases of depression worldwide increased from 172 million to 258 million between 1990 and 2017 (1). Globally, depression is the leading cause of mental health-related disease burden (2), with 49.4 million (33.6 to 68.7) DALYs lost globally in 2020 alone (3). Recent studies in Vietnam have suggested that the prevalence of depression among adults ranges between 13.2% and 52.3% (4–8).

Despite the high burden of depression globally and in Vietnam, few people with depression receive timely and appropriate treatment, the literature points to a lack of knowledge/awareness and stigma as the key reasons (9).

Effective management of depression requires individuals to possess sufficient knowledge, appropriate attitudes, and adopt suitable practices (10). Thus, knowledge, attitude, and practices (KAP) surveys on depression have long been conducted to gain insights into health-related behaviors and health-seeking practices to inform the planning and implementation of public health programs (10). To our knowledge, only four survey-based studies thus far have assessed the state of knowledge about depression in Vietnam (11–14). In 2015, Thi et al. conducted a survey among Vietnamese undergraduate students (n = 500) and reported that 41.5% of the students had correct knowledge about depression symptoms, 69.5% believed that psychological factors caused depression, and only 8.7% agreed that biological factors (brain injuries, hormonal imbalances, congenital errors) could cause depression (13). A more recent study with medical students revealed that only 56% had correct knowledge about depression, while psychological factors were commonly seen as causing depression, knowledge about the role of biological factors was poor. Awareness about treatment was better—most students were aware of medicine (73%) and psychotherapy (99.1%) as treatment (12). A survey by Dieu, Thao, and Dieu et al. (2021) among 100 elderly people in Quang Ngai revealed that 73% had poor knowledge about the symptoms of depression, and while they recognized psychological factors and substance abuse as causes, the knowledge about biological causes was poor (11). One study that explored knowledge about depression among patients diagnosed with depression in a hospital setting found that only 16.4% of participants could name their health problem as depression (14). This group, however, knew the psychological, social, biological, religion/spirituality causes of their symptoms (14).

Cultural and historical characteristics shape people’s attitudes towards, and practices related to depression. In Vietnamese folk religions, mental illness is attributed to evil spirits or prior sins of ancestors and to gods and genies who, by extension, are the only ones who can help drive evil spirits away (15). In Vietnam, people pray to these gods, spirits, and ancestors and make offerings to seek help from them. In traditional Vietnamese medicine, physical health and emotional health are deeply interrelated (15), and people with mental illness seek care from traditional healers to re-establish what Phan and Silove (1999) have reported as a state of ‘balance’ (16). In the early twentieth century, under French colonization, asylums were established to treat severe mental illnesses such as mania, severe depression, and epilepsy. (15).

This institutional arrangement has meant that the management of mental illnesses and psychiatric care has generally become tangled with the management of what in the Vietnamese language is equal to “craziness” on the one hand and dealing with “terrible” and “evil spirit” on the other—this could generally help explain the high levels of stigma toward depression and mental illnesses (17). Stigma is magnified by a collectivism-oriented culture whereby stigma is not limited to individuals with mental illness but also extends to their families (15, 18). All of these factors translate into fear of rejection, self-doubt, and practices such as the concealment and withdrawal of people with mental illness from society (19).

As if these constraints on the community side were not problematic enough, what Vietnam’s health system has to offer for those with mental illness is far from appropriate or sufficient and adds to the problem. Mental health care in Vietnam continues to be dominated by an institutional approach to delivering care and by a focus on the treatment of severe mental illnesses. While some recent efforts have been made by mental health professionals, organizations, non-profit organizations (NGOs), and government initiatives toward exploring a community mental health approach (15, 20–24), these efforts are still at the piloting stage. The problems posed by this approach are amplified by insufficient human resources and by the poor availability and accessibility of mental health services generally (15).

Given the above, to identify the knowledge, attitudes, beliefs, and practices related to depression in contemporary Vietnamese society, we conducted a qualitative study to generate in-depth insights into the state and nature of knowledge about, attitudes toward, and practices related to depression among those with symptoms of depression.

Sample and study design

In-depth interviews were conducted with respondents who self-reported having symptoms of depression to explore knowledge (about symptoms, causes, treatment options), attitudes, and practices related to depression and to support or care-seeking for depression. The sample included 40 adults with depression symptoms (as assessed using the Patient Health Questionnaire PHQ-9 assessment tool) who were recruited for the study through a telemedicine-based supported self-management intervention for depression (Tele-SSM) (25). The study was conducted from February to September 2022 in Hanoi, Vietnam, among participants aged 18–64 years. Informed written consent was obtained from all participants, prior to commencing the interviews. (25).

Thematic analysis (26) was used to identify patterns and themes in the knowledge, attitudes, and practices of people with depression.

This study was approved by the institutional review boards of the Institute for Social Development Studies in Hanoi, Vietnam.

Data collection

In-depth interviews (IDIs) were semi-structured and involved the use of a topic guide. The guide included topic areas: knowledge on symptoms, causes, and treatment of depression; support-seeking behavior and mental health-seeking behavior; and attitudes of people regarding depression. An interviewer with a background in social science research methods and experience working in mental health conducted IDIs in Vietnamese through Zoom. The interviews lasted from 40 to 60 minutes and were audio-recorded, with consent, and supplemented with written notes.

Analytical methods

Audio recordings were transcribed by two researchers, one of whom was an interviewer. The transcripts and data interpretation were reviewed by both interviewers. When discrepancies were identified, the researchers consulted the transcripts until a consensus was reached regarding interpretation. To compile the data for each interview, the first author used a Microsoft Excel® data spreadsheet containing three columns: participants’ ID #, responses, and coding. Initial coding was independently performed using both inductive and deductive approaches (27). A thematic content analysis approach was used to identify important themes present in the transcripts exploring attributes associated with depression. An iterative codebook was developed starting with the broad domains of inquiry as outlined in the interview guide. Then, as the transcripts were coded, additional codes were identified and created as they emerged in individual transcripts. After the initial coding of all transcripts, the coder revisited each transcript and applied all relevant codes from the comprehensive codebook that was developed during the process. Preliminary analysis revealed major themes, with further generation of subthemes. We took explicit note of contrasting and contradictory points in our analysis.

The age range of the 40 participants was 18 to 61 years old, 85% were female, 12.5% were male, and 2.5% were LGBTs. Table 1 shows the demographic characteristics of the participants.

Table 1

Characteristics of the interview participants
Characteristic (N = 40)	N(%)
Gender
Female	34 (85)
Male	5 (12.5)
LGBT	1 (2.5)
Living area
Urban	39 (97.5)
Rural	1 (2.5)
Employment status
Employed	22 (55)
Unemployed	4 (10)
Freelancer	7 (17.5)
Student	7 (17.5)

Knowledge regarding depression

Depression symptoms

Regarding knowledge about depression, 52% (21/40) of participants correctly identified depression symptoms such as “sadness”, “lack of energy”, “withdrawal”, etc. While one participant did not know any depression symptoms, 45% (18/40) named correct symptoms mixed with incorrect symptoms such as panic, rapid heart rate, trembling, low blood pressure, hair loss, difficulty managing emotions, mood swings, mental retardation, attacking others, delusions, and non-sensory talking. Anxiety symptoms are commonly misunderstood as depression symptoms.

One participant noted that there were differences in awareness about mental health between urban and rural areas, with particularly limited awareness of depression in rural regions of Vietnam. Sharing her experience she said,

“When I talked about it [mental health], people laughed at me. With them, it is something unrealistic; I think in rural areas, no one talks about depression. I live in Dien Bien and have worked in many other districts; I have been in Ha Tinh, and this observation is even more accurate there.” (Female, 37 years old)

Causes of depression

When asked about the causes of depression, the most common causes named were psychological factors, including adverse events (30/40 respondents), stress (15/40 respondents), and childhood trauma (11/40 respondents). As the following excerpts illustrate, sharing personal experiences and circumstances, participants offered a range of reasons for the occurrence of depression.

“I think it can be from some kind of mental trauma, like losing a loved one or breaking up... We are in a situation where we experience losses or have childhood trauma. For example, in my case, being rejected from a young age, not being cared for and supported by family”. (Female, 35 years old)

COVID-19 and COVID-19 quarantine also emerged as factors worsening the mental health of participants.

“Three years ago, I started to have insomnia, and in the [COVID] pandemic, my insomnia became more severe; sometimes, I couldn’t sleep the whole week or stayed up all night and sometimes woke up at 1 am and stayed up until morning. When I had insomnia, I couldn’t bear the noise; I felt stressed and uncomfortable. It was COVID-19 quarantine; everyone was at home, so it was very noisy. After 8 months in COVID, my mentality was down a lot.” (Female, 30 years old)

Only a few respondents attributed depression to biological factors. Five respondents referred to having a “weak mentality” or being a “sensitive person” or introvert as causes. Four respondents talked about changes in hormonal balance or the brain “lacking something”. Two participants indicated genetic causes, and one reported that the cause of depression could also relate to brain injury.

“Some people were born as sensitive people, but when they were young, the problem of depression was not yet revealed. However, when life accumulates with sad memories and sad experiences, those things will pile up at a certain time, and at some points only with a small change in life or a difficulty, these things are evoked and become a very good tool to destroy their emotions, leading to depression”. (Female, 31 years old)

A young woman said, “I think the cause of depression is innate because I got it when I was a child. The other people with depression whom I know also say that they had these feelings since being a child. In some books about depression, it is said that depression is due to brain damage, kind of the brain lacks something”. (Female, 24 years old)

Another woman thought that “[depression] could also be genetic. For some people, it is just naturally like that; there are no problems in their lives. This could also be due to their genes. Additionally, being an introvert is more likely to get depressed than being an extrovert”. (Female, 61 years old)

Knowledge about treatment

The majority of participants (32/40) endorsed the possibility of depression being curable; 4 out of these 32 participants believed that depression could be cured depending on the level of severity. Two were of the view that depression cannot be cured but can only be managed. A total of 3/40 participants were not sure whether their depression could be cured. Three of the 40 participants did not know about treatment for depression.

Regarding treatment options for depression, psychotherapy was reported by most participants (36/40), followed by medication treatment (35/40). However, there was a misunderstanding that psychologists were medical doctors, and the term “psychological medical doctors-bác sĩ tâm lý” was used frequently.

“I studied abroad, and I knew about psychotherapy. Approximately 1998, I brought my brother-in-law to the Psychiatric Department in Hospital X for psychotherapy, and I was told that there were no psychological doctors. There were no psychology departments in hospitals in Vietnam at that time.” (Female, 61 years old)

Nine (9/40) participants reported that social support, including support from friends, family, social interaction, and healing circles (a form of group support), could be a method for treating depression. As the following excerpts allude, Buddhist practices were endorsed as a treatment for depression by 5/40 participants.

“In Buddhism, there are healing programs. Healing comes from understanding ourselves first, which means we learn about the nature of humans, things, and life around us. When we understand it, we can accept or handle things in our lives.” (Female, 31 years old)

Two (2/40) mentioned spiritual methods such as praying, offering to gods, and using the YiJing (an ancient Chinese philosophical approach for seeking guidance and insights into life challenges). In Vietnamese folk religion, the gods can be natural deities, community deities, or ancestral gods of the family. The belief that these gods can cure present problems meant that people could worship and make altars (foods, drink, money, etc.) to ask for the help from these gods.

“In Vietnam, instantly, I think about worship. If someone does not believe in worship, then they will not do that. My friend, she doesn’t believe, she is “vô minh” (ignorant), she uses medicines.” (Female, 47 years old)

Meditation as a depression treatment was reported by 4 participants. A few (2/40), perhaps based on personal experience and readings, talked about approaches that involve the induction of hypnosis to recall memories from past lives to address psychological issues and esoteric techniques such as neurolinguistic programming.

Information sources regarding depression

The internet was the most common source of information (21/40) for respondents. Reading books about depression were reported by 14 respondents. Three sought information from friends, one from a psychology course, and two from a health examination.

Respondents accessed information on the internet by searching on Google, reading Facebook advertisements that appeared automatically after searching on Google, following Facebook posts and blogs of those they considered to be reliable persons working in mental health. Others watched YouTube channels, followed Facebook pages of organizations working on mental health, read online journals, and news about key opinion leaders (KOLs) talking about depression. One person shared that she followed the English website “The Real Depression Project” and learned from there.

People recognize that information on the internet is diverse and sometimes unreliable. They applied strategies to look for reliable information, such as following reliable people and organizations or evaluating the reliability of information themselves.

“I followed the Facebook of a person who graduated from the UK; she has a background in psychology and seems reliable.” -(Female, 31 years old)

“I evaluate their arguments to see whether they are reliable, scientifically reasonable.”- (Female, 24 years old)

Three respondents reported that Buddhism plays a role in educating people about mental health, and some Buddhist Masters are active in helping people with mental health issues. One added that the internet was also used as a tool to reach people in need by Buddhist Masters.

“Master Minh Niem wrote a book “Understand the Heart”, Master Thich Nhat Hanh gave lectures about therapies for mental illness” - (Female, 31 years old)

“Master Minh Niem has series of lectures on YouTube on depression” (Female, 22 years old); “I listen to video clips of Master Minh Niem, he works on therapies also, I learned some information from lectures of Master Minh Niem” (Female, 37 years old).

Attitudes and practices

Sharing with family

Sixteen (16/40) participants did not share their mental health issues with their family for many reasons. Some common reasons are that they did not want their family to worry, were afraid to bother their family, thought that sharing would not be helpful, or had no connection with their family.

“I did not share with my family; I just talked a little bit about my emotions, and my parents did not know about my status because I was afraid that they would be worried” (Female, 42 years old)

One participant used to share her mental health issues with her mother who was a doctor. As a result, her mother forced her to seek help from doctors, but the information she shared during consultations with doctors was relayed to her mother without consent. One 51-year-old male participant had parents and siblings who were elderly. This participant described how people from older generations in Vietnam rarely discuss mental health, especially males.

A total of 30/40 participants shared their experiences with depression with families, seven of whom reported that they were listened to, empathized with, and supported emotionally by family members. However, four reported that sharing with families did not prove helpful.

“My parents worry for me, when they know that I have issues [mental health problems], they care for me a lot, talk with me frequently…” (Female, 29 years old)

“My mom said, “Do not think too much, just do everything to make yourself feel better, do whatever you feel comfortable… I feel safer, more relaxed, and a bit surprised. This is the first time I feel support from my mom” (Female, 19 years old)

However, as the following excerpts illustrate, 9 of 40 participants shared that they received negative responses from family members, such as not receiving empathy or being judged as overreacting, e.g., “sướng hóa hóa rồ” (become crazy because being treated too well), “em chã” (pampered child), or “vong nhập” (possessed by evil spirits). They also talked about receiving many differing opinions from multigenerational families.

“You are crazy because you are too well treated. You get whatever you want, but you still do not feel happy.” (Female, 24 years old)

“One time I was too stressed, I couldn’t bear it, I came home to relax. I talked with my mother, then she smirked that I was “vong nhập” (possessed by evil spirits); my mother said I was kind of crazy or something” (Female, 31 years old)

A total of 4/40 participants shared and received both positive and negative responses. Although they experienced negative reactions from their family members, they still received support from family at different levels.

[When I shared my problems] My mother said that I made a storm over a teacup, and I backbited her. She is a victim, and I am a poisonous snake. Since 2018, my father has accepted my problem and supported me in accessing psychotherapy, caring for me, and thinking about my psychological status in his behavior.” (Male, 30 years old)

“My mother told my husband that I have been like that since I was small, he must empathize with me, then complain to me to magnify small issues. My older sister is like my husband; they don’t understand me; they say my mentality is unstable, and I stay too much at home within 4 walls. They said that I must change to be a good model for my future children. I think it is right, that’s why I agree to participate in the psychosocial program to improve my mental well-being.” (Female, 27 years old)

Sharing with friends/others

A total of 13/39 participants shared with friends or others and were listened to and encouraged. Three of these 13 participants experienced empathy from peers (people in similar situations), and two shared with friends in similar situations. One participant shared with people in a Facebook group, with other group members listening to her issues.

“I do not share with everyone, but when I share, my friends are very willing to listen…. My neighbors are also very nice; when I meet difficulties, my neighbors help me a lot, they are close to me, and I can share with them a lot, so it has helped me over difficult times”. (Female, 42 years old)

My friend is the only person who came to my house when I am in depression episodes to check how I am, whether I am living or dead. I think she is also depressed like me. Her husband had another person, so they divorced, and she was also traumatized. We depend on each other when she is “crazy”; I help her; when I am “crazy”, she helps me.” (Female, 35 years old)

Twelve of the 39 participants shared with friends/others several times and then stopped sharing as they received both positive and negative responses.

I shared with a friend, she understood my problems. With other friends, they didn’t understand, they judged me, they gave me unhelpful advice “You must like this, you must behave like that…”, so I reduced sharing with them (Female, 41 years old)

Eight of the 39 participants received unhelpful advice and felt that they were not understood.

“When I talk about something with negative emotions, people say, “Stop thinking or let’s do something fun to forget about it”. I think they want good things for me, but they don’t know how to soothe my feelings; they don’t know how to advise me, sometimes, I just need them to listen, don’t have to give me solutions.” (LGBT, 19 years old)

A participant also revealed that she does not know how to be helpful and supportive when being shared by her friend with depression: “I tried to listen and help, but I don’t know what I should say, I don’t know how to guide her to focus on the types of activities to forget her issues.” (Female, 42 years old)

Six of the 39 participants opted not disclose their issues for many reasons, including not wanting to receive advice, having no close friends to share, not trusting others, and being afraid to be judged by others.

“I don’t trust them, I kept it for myself. I treat it myself.” (Female, 37 years old)

Treatment

When asked about the treatment of depression, 16/40 responded that most people will try to handle it themselves by searching on the internet, going out, sharing, using healing methods such as, yoga and meditation. As the following quotes illustrate, 6/40 participants reported that people will avoid the issue and not accept that they have problems because of the fear of being stigmatized.

“First, they are not brave enough to accept that they have problems. Second, they do not have support from family and friends, regardless of whether the people around them think they need support. Third, it is about the health care system, doctors or health centers. I don’t know any centers that could be contact points for referral if someone needs mental health services. (Female, 31 years old)

“I observe that most people [with depression] are not aware that they have depression. The mental health of some of my friends is alarming, but they ignore it and don’t do anything. Some have the knowledge, they practice yoga, take medication, they handle it themselves, and rarely seek support from outside, don’t have any one with expertise to support.” (Female, 37 years old)

“My friend, every time “it attacks”, she lies, breathes and talks with herself that “I must live, I must live” until she falls asleep. Then, it is over. Sometimes, it comes again, and she does the same. She said it happens to her every day.” (Female, 24 years old)

Traditional beliefs in Vietnam often attribute mental illness to supernatural causes such as evil spirits or ancestral sins—this belief structure is inherently stigmatizing. The legacy of care for mental illnesses under French colonization played a role in this belief structure by disproportionately focusing on institutionalized care at higher-level tertiary care facilities oriented toward severe mental illnesses (15). These sociohistorical forces, when combined with a collectivist culture, have led to the entrenchment of stigma toward mental illnesses. As the following excerpt alludes, there are signs of a reduction in stigma toward mental illness.

“In the past, my parents thought that people with depression are weak, don’t know how to deal with their emotions, and have negative views about them. I feel that recently, my parents are more open-minded about psychological problems; it [their knowledge] has improved a lot compared with before, but still are not correct completely. I think the reason is using the internet. In addition, their friends and relatives have these issues, so they become familiar with and empathize with them. Their stigma is still a little, does not disappear completely, but doesn’t show up clearly, strongly like before” (Female, 28 years old)

“People around me still have a stigma toward depression. For example, on a scale of 10, their stigma attitude must be 7. They think depression is a type of disease craziness… a bit weakness, a bit abnormality, a bit sickness” (Female, 31 years old)

However, stigma continues to be a significant barrier to care for people with depression, including manifesting in societal rejection and the concealment of affected individuals and their families.

“There is a prejudice that psychological disorders are examined in the psychiatric department. Psychiatry is something terrible, so they will deny that they have psychological problems.” (Female, 31 years old)

“People think that depression is like schizophrenia or craziness, so people avoid treatment and do not accept that they have psychological problems.” (Female, 35 years old)

A total of 5/40 participants shared that people would find solutions in religions such as Buddhism or Christianity.

Spiritual methods are reportedly commonly used. Though their use has recently decreased, they can still be traditional/cultural practices to deal with depression. Such practices were mentioned by two older participants and, in this way, are potentially predominantly used by older generations.

“A long time ago [approximately 20 years ago], it happened with my friend, her family thought that she was “ma làm” (evil spirit leads), and they went praying, altar offering to gods everywhere because suddenly she was like that… And my brother-in-law, our whole family brought him to worship from the South to the North.” (Female, 61 years old)

A middle-aged woman who shared "Glocalization" describes the new reality using both the Vietnamese and English languages due to her international working environment; however, her practice of dealing with depression is very traditional: “A fortune teller said my father is the oldest son, I am the oldest child in the family. My father doesn’t have sons, so I was born to worship our ancestors. For more than 10 years, I did not do anything. My ancestors helped me, but I did not worship them; they are very sad, so I must worship them…My friend brought me to temples, the people there know how to connect us with our ancestors, open the gate for us, and guide us. so that we know what to do next. One temple is in Yen Bai, and two more temples are in Lao Cai; we visited these three temples in one night, very quickly. (Female, 47 years old)

Despite the awareness of participants of psychotherapy as a treatment for depression, their experience with using this form of treatment was limited. Not least by the stigma around depression, affordability, and lack of knowledge on where to find good sources of psychotherapy to access the services.

One participant quickly stopped psychotherapy after one session: “I tried one psychotherapy session, I had many problems, she (psychologist) only listened to me, I think that this session only helped me to talk it out. One session is quite expensive, 500,000 dong. She only noted down, not solved any problems. I did not go anymore.” (Male, 25 years old)

“I prefer psychotherapy or art therapy, but the cost they offer is quite high compared to the average income of most Vietnamese people, but they spend time for clients, and I believe that spending time with clients will be helpful. Treatment by medication is temporary only.” (Female, 31 years old)

Most of the participants’ experiences with medication were negative, such as side effects and being dissatisfied with medical examinations in hospitals. Participants did not take medication after the examination or dropped out during the treatment process.

“ Several years ago, I think I have depression, I went to the hospital, they asked me some questions then they prescribed me medications, and I decided not to take these medications. I and my family also told me not to take medication because these medications inhibit mental functions; I should change lifestyle, not take medication.” (Female, 31 years)

When taking medication, it is like wearing earphones, I feel the outside information is dampened, is kept at an average range, everything is “flat”, there is no energy, and I feel stiff. I took medication for 1 month, then I quit because I couldn’t bear these feelings. (Male, 30 years

This study has shown that, in Vietnam and due to increased exposure to media as well as societal development, people have good knowledge of depression. They can identify several symptoms of depression and are aware of how stress and adverse events can causes depression. Most people with depression in this study are knowledgeable of psychotherapy and pharmacological treatment. Participants also pointed out that stigma related to depression seems less prevalent in Vietnam today, compared to the past. Participants mentioned receiving support from family and friends, however, misconceptions about the symptoms of depression persist, and biological factors as causes are not well-know. Despite awareness of treatment options, this study has shown that concealment and avoidance of seeking care is still common. Access to psychological therapy is hindered by cost barriers and a lack of information about reliable therapy providers. Participants’ accounts also reveal that that they discontinue medication prescribed for depression due to side effects and insufficient consultation during examination by psychiatrists. Praying and offering to altars as cultural practices to treat mental illness remain in use, while nonscientific methods of treatment from the West have been introduced in Vietnam. These findings suggest that societal changes have influenced the knowledge, attitudes, and behaviors toward depression in Vietnam in positive ways; however, historical/cultural challenges still exist while new challenges appear.

There is limited literature on the impact of social changes on views, attitudes and practices towards mental illness in low- and middle-income countries. A study in Ethiopia revealed that the availability of health care services, literacy, and exposure to media improved knowledge and attitudes toward mental illness (28, 29). In another study in Nigeria, urban respondents were more likely to endorse psychosocial factors as causes of mental illness, while rural respondents were more likely to endorse supernatural factors; additionally, urban respondents were more “western-oriented” than rural respondents were (30). Our findings about the knowledge, attitudes, and practices of people with depression in Vietnam and the findings from aforementioned studies from Southwest Ethiopia and Nigeria correspond with the concept of “glocalization” in social theory (31). “Glocalization” describes the new realities that emerge from the interpenetration of global and local understandings. The premise of the theory is that both globalization and localization occur together in a social arena and result in the integration of ideas, values, norms, behaviors, and ways of life. Based on glocalization theory and the findings of this study and previous literature, we develop a glocalization model on peoples’ knowledge, attitudes, and practices toward depression in Vietnam, as shown in Fig. 1. According to glocalization theory, local people are agents that adapt, innovate, and create a “glocal” world (31). These “glocalization” processes are relational and contingent; they could be localist entrenchment or cosmopolitan embrace or create something new out of both cosmopolitan and localist. Information and communication technologies are tools that local people use in glocalization processes.

In the context of glocalization, “cosmopolitan embrace” involves a willingness to engage with and accept global ideas and practices (31). In this study, cosmopolitan embrace trends were obvious in the literacy of people with depression. Most of the participants correctly named some depression symptoms, perceived psychological factors as causes of depression, and were well aware of psychotherapy and medication as treatment options. Participants also reported a reduction in stigma toward mental illness, which is also borne out by emerging literature on the effects of societal changes on stigma toward mental illness (28–30, 32). The internet, media, and technology contribute significantly to the knowledge of people with depression. These tools are used by mental health professionals, organizations, NGOs, and government initiatives to educate people too. People with depression reported that these tools are the main source of information to learn about depression.

However, with globalization, the cosmopolitan embrace has developed not only with standard knowledge about depression but also with the introduction of other pseudoscience methods in Vietnam. These pseudoscience methods resonate with long-lasting supernatural, religious, and magical beliefs regarding mental illness in Vietnamese culture (33), so they can be quickly adopted by a part of Vietnamese people experiencing depression in Vietnam. Literacy about depression among people with depression is encouraging. However, half of the participants mixed correct depression symptoms with incorrect symptoms, and a few participants mentioned biological factors as causes of depression.

While the cosmopolitan embrace trend was observed in knowledge and attitudes toward depression, the “localist entrenchment tendency” seems stronger in the practice of people with depression. Despite the awareness of psychotherapy and medication as a treatment for depression, most people with depression handled it themselves or deny that they had mental health issues in the first place. A study of patients with depression in two hospitals in Vietnam also revealed that patients with depression do not seek psychotherapy but share it with families, manage it themselves or use medication or spiritual methods (14). The participants’ experience with psychotherapy is limited due to stigma, affordability, and lack of knowledge on where/how to find good psychotherapy. Many people with depression who sought care did not take the prescribed medication after the examination or stopped using the medication because of side effects and a lack of consultation from doctors. Those who did not attend the examination also had negative impressions about medication treatment from the experience of others whom they knew. Praying and offerings to gods were still practiced, although these practices seem to be less prevalent. Moreover, this study found that when participants shared their condition with their family, family members could attribute the cause to evil spirits. As a result, participants’, who possessed good knowledge of the causes of their condition, felt that their mental health issues were not acknowledged and understood. This prompted them stop sharing their concerns with family members, thus losing an important source of support.

In addition to affordability, the shortage of information on mental health care, negative perceptions about medication, and perceived stigma toward mental illness could contribute to the discrepancy between knowledge and practice in seeking care of people with depression. Both the belief in the relationship of mental health with evil spirits, prior sinness or craziness, and terrible things create norms to “blur” social distance to those with mental illness. In a collectivist culture, community acceptance is valued. This approach fosters strong kinship ties, with family members supporting one another extensively. However, it also has a downside: the fear of rejection can be exacerbated because stigma is attached not only to individuals but extend to the family too. Consequently, people with depression could conceal or avoid seeking care, and family members might deny the existence of mental illness within their circle to shield the family from potential stigmatization. Families may not also have sufficient skills and/or knowledge to help and support people with depression, so they may try to help people with depression in unhelpful ways.

The interaction between the global and local could also be seen in the adoption of the term “depression” and other similar psychological terms from the West in the lectures and books of Vietnamese Buddhist Masters and in social media, such as Facebook and YouTube. A Buddhist Master also collaborates with Hanoi National University to provide psychological support for free in some pagodas in Hanoi (34). When the global and the local meet, something new is created. For example, people with depression have created a Facebook group, when members need someone to listen to them, they post on the Facebook group, and members who have time and are willing, respond and listen to the person in need. The activity is organic and contingent and not organized by any organization.

Local (Vietnamese) people are creating and adapting their “glocal” views, attitudes, and norms around depression as well as mental illness in general. The extent of mix of the cosmopolitan and the local varies across and within individuals. When cosmopolitan embrace is more prominent, localist entrenchment is subordinate, and vice versa. Some adopt cosmopolitan views on mental illness, while others still adhere to localist norms and practices. Even within the same individual, one can see the adoption of cosmopolitan views on certain aspects of mental illness but adherence to localist norms, in other for example one can have sufficient knowledge of depression—but still heavily depends on praying and offerings to altars to solve mental health issues. We argue that an explanatory model that recognizes the co-existence of global and local influences and rationales in how people in Vietnam relate to and engage with matters of mental health, can help better account for, explain, and respond to the current state of complexity and contradictions one sees in the knowledge, attitudes, and practices toward depression among people with depression in Vietnam. By allowing and incorporating more historically grounded and pragmatic explanations, this model can help inform the design and implementation of contextually appropriate policies and interventions about depression and mental health broadly. This simultaneous presence of global and local understandings within society also has its challenges. With globalization, while new science and knowledge have been introduced into Vietnam, such as elsewhere in the world, pseudoscience has also arrived. While local culture and history have their own values, such as the contributions of Buddhist Masters to mental support or strong connections among people in a community in collectivist culture, the persistence of local understandings that are either at odds with new scientific knowledge or are harmful or stigmatizing is also a challenge. The findings of this study also underscore the need for targeted interventions addressing knowledge gaps, reducing stigma, and enhancing social support and mental health care for people with depression, such that these interventions take into account the context of glocalized understandings around mental health in Vietnam.

Limitations

This study has some limitations. First, most participants were from urban areas and were recruited for a telehealth intervention; therefore, the technology literacy of this sample might be greater than that of people with depression in the general population. Thus, our small sample may not be reflective of the general adult population with depression but may be limited to adult populations with depression in urban areas in Vietnam. However, internet penetration and technology development in Vietnam are high. (35). The Vietnamese economy is considered one of the fastest-growing among Asian countries. Economic development induces social changes while capital migrates between sectors, communities, and nations. Therefore, glocalization processes likely occurs quickly in Vietnam at various speeds of localist entrenchment or cosmopolitan embrace at the individual and community levels. With only five men (versus 35 women) in our sample, our findings are disproportionately reflective of the perspectives of women. Given the gender norms in Vietnam that men should not be weak and should be strong and dependable (36), Vietnamese men’s understanding of depression is likely not only to be different from that of women, but their attitudes toward mental health and mental health-seeking behavior are likely to be much more complex.

We found that the level of knowledge about depression amongst the study subjects is generally good. Our analysis and the current literature from Vietnam suggest that this is likely the result of health promotion initiatives of government and NGOs, the efforts of mental health professionals over decades, and improved socioeconomic development generally. However, a clear disconnect between knowledge and practice emerges – people have embraced ‘cosmopolitan’ knowledge but, people’s practices continue to be predominantly ‘localist’. This paradox is further complicated by the finding that despite good, cosmopolitan knowledge, people with depression either deny their problems or do not seek help or simply manage problems themselves. Many did not take prescribed medicines or dropped out of care. Our findings point to the need for continued efforts on two fronts in Vietnam: improve mental health related awareness, while simultaneously taking steps to improve the availability, accessibility, and crucially, responsiveness of health services for those with mental health related needs. These efforts should take into account both global and local influences on how people in Vietnam think and act regarding mental health issues. The insights from this study about the simultaneous presence of global and local (glocal) influences offers opportunities to better tailor and nuance these efforts. Our findings suggest that these efforts could also benefit from and need to better engage with the digital social sphere, not least to help people better handle the risks and dangers of pseudoscience.

DALY	Disability-adjusted life years
IDIs	In-depth interviews
KAP	Knowledge, attitude, and practices
KOLs	Key opinion leaders
LGBTs	Lesbian, gay, bisexual, and transgender
NGO	Non-profit organization
PHQ-9	Patient health questionnaire
Tele-SSM	Telemedicine-based supported self-management

Ethics approval and consent to participate

The study has conformed to the Declaration of Helsinki and was approved by the Institutional Review Board at ISDS (IRB00011703) on 05th May 2021 in Hanoi. Informed consent was obtained from all participants in the study.

Consent for publication

Not applicable

Availability of data and materials

The qualitative data are not publicly available due their containing information that could compromise the privacy of research participants, but are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The work was supported by the National Foundation for Science and Technology Development (grant number NCUD.05-2019.29).

Authors' contributions

NTK conceived and designed the study as well as contributed in data collection of this study. NTK and TNK involved to data analysis. The first draft of the manuscript was written by NTK, QCTN, MHD. MHD, SM and MHV provided supervisory support and reviewed this paper. All authors reviewed and approved the final version of the paper.

Acknowledgements

We would like to express our thanks to Dr. Mary Bachman DeSilva, University of New England for valuable advice on the study. Additionally, sincere thanks go to all participants of this study.

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No competing interests reported.

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Knowledge, attitudes, and practices toward depression among people living with depression in Vietnam: the cultural dynamics in the era of globalization

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Abstract

Background

Methods

Results

Conclusions

Trial registration:

Figures

INTRODUCTION

METHODS

Sample and study design

Data collection

Analytical methods

RESULTS

Knowledge regarding depression

Depression symptoms

Causes of depression

Knowledge about treatment

Information sources regarding depression

Attitudes and practices

Sharing with family

Sharing with friends/others

Treatment

DISCUSSION

Limitations

CONCLUSIONS

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1