The social contexts of depression during motherhood: A study of explanatory models in Vietnam

Journal of Affective Disorders 124 (2010) 29–37

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Journal of Affective Disorders j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d

Research report

The social contexts of depression during motherhood: A study of explanatory models in Vietnam Maria E. Niemi a,⁎, Torkel Falkenberg a, Mai T.T. Nguyen b, Minh T.N. Nguyen c, Vikram Patel d, Elisabeth Faxelid e a Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Unit for Studies of Integrative Care, Alfred Nobels Allee 23, SE-141 83 Huddinge, Sweden b Hanoi Medical University, Department of Pediatrics, Hanoi, Vietnam c Hanoi Medical University, Department of Public Health, Hanoi, Vietnam d London School of Hygiene and Tropical Medicine, London, United Kingdom e Karolinska Institutet, Department of Public Health Sciences, Stockholm, Sweden

a r t i c l e

i n f o

Article history: Received 20 May 2009 Received in revised form 28 September 2009 Accepted 28 September 2009 Available online 24 October 2009 Keywords: Depression Postnatal depression Illness explanatory model Vietnam Care-seeking behaviour

a b s t r a c t Background: Major depression is increasing world-wide, and is the fourth leading cause of the global disease burden. Depression is rarely diagnosed in primary care settings in Vietnam, and those afflicted usually only seek professional care when the illness has become very severe. Depressive disorders affecting mothers are an important cause of low birth-weight, childhood stunting, under nutrition and adverse mental development, and a study has shown a 33% prevalence of postnatal depression symptoms in Ho Chi Minh City. Methods: The aim of this study was to elicit Illness Explanatory Models (EMs) of depression and postnatal depression from nine mothers and nine health workers. The study was conducted in a semi-rural area in Vietnam, and the EMs were elicited through semi-structured interviews where a case vignette of depression was used as the basis of questioning. Results: The EMs elicited were predominantly somatosocial in nature and the mothers assigned a strong personal responsibility for care. Psychiatric treatment and care was seldom recommended. Lack of communication was described as an important factor concealing depression, and together with the lack of care-seeking can be expected to impede effective treatment. Limitations: The results of this study cannot be generalised beyond the group studied, or the context of Ba Vi, though we believe that analytical generalisation to other contexts can be made. Conclusion (clinical relevance): The results of this study highlight the importance of depression and postnatal depression being diagnosed in primary care, and of a cross-sectoral approach for the prevention of depression in Vietnam, which takes into account the social causation of depression in women. © 2009 Elsevier B.V. All rights reserved.

1. Introduction Major depression is increasing world-wide, and is the third leading cause of the global disease burden (WHO, 2008). Counter to prevalent misconceptions, mental illness is equally, if not more abundant in low income countries than in high income countries (IOM, 2001). Depression is very ⁎ Corresponding author. Tel.: +46 8 524 83947. E-mail address: [email protected] (M.E. Niemi). 0165-0327/$ – see front matter © 2009 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2009.09.017

rarely diagnosed in primary care settings in Vietnam, and those afflicted seek professional care only when the illness is very severe (Nguyen et al., 2005). Among suicide attempters in Hanoi, only six% had received a psychiatric diagnosis prior to the attempt (Thanh et al., 2005). Evidence from the South Asian region, home to more than half of the underweight children in the world (Bhutta, 2000), reveals that depressive disorders affecting mothers are an important cause of low birth-weight, childhood stunting, under nutrition and adverse mental development (Patel et al., 2003;

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Rahman et al., 2004a,b). Consistent risk factors in Asian countries for postnatal depression include economic deprivation, low education, marital disharmony, violence and lack of social support (Liabsuetrakul et al., 2007; Chandran et al., 2002; Patel et al., 2002; Rahman et al., 2003; Fisher et al., 2004). A study in Ho Chi Minh City, Vietnam has shown a 33% prevalence of postnatal depression symptoms (Fisher et al., 2004). Byron Good (1992) has discussed that the symptomatic presentation of depression varies from culture to culture. In Vietnam, Confucianism, Buddhism and Taoism have carried major impacts in creating a holistic thinking where clear distinctions between physical and psychological symptoms are not made (Phan and Silvoe, 1999). Phan and Silvoe (1999) have shown that the Cartesian mind/body dualistic fashion of thinking that underlies Western psychiatric nosology does thus not necessarily coincide with this holistic view. Also, the Vietnamese are found to often seek care from traditional approaches for mental illness, including traditional Vietnamese medicine, traditional Chinese medicine, witchcraft, spiritual blessing and sorcery (Phan and Silvoe, 1999). This array of treatments reflects the underlying notion of illness, including the holistic concept of mind and body, and the importance of the individuals relationship to the immediate environment as well as the cosmos (Phan and Silvoe, 1999). Depression as an emotion is described in the Vietnamese literature (Phan and Silvoe, 1999), but due to the distinctive symptomatic expression of depression, Phan et al. (2004) have deemed it necessary to develop a Vietnamese psychiatric scale, the Phan Vietnamese psychiatric scale. This scale assesses multiple dimensions of psychological distress, including depression, anxiety and somatisation. Non-western health beliefs, such as undifferentiated reference to affective and physical symptoms (e.g. “felt doleful [downhearted], pale, or had dark ring around [dark bags under] the eyes”), and the powerful influence of cosmological beliefs (e.g. “lost hope in fate”) can be found in some of the scale items (Phan et al., 2004). Illness explanatory models (EMs) are “the notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process” (Kleinman, 1980). By studying practitioner EMs, one can learn how they understand and treat sickness. By studying the EMs of patients and families, one can learn how they make sense of given episodes of illness, how they give it personal and social meaning, and how they choose and evaluate particular treatments. Thus, the study of EMs gives an important understanding of how cultural and social structures will affect the patient–practitioner relationship, as well as the care-seeking behaviour of patients. EMs can be divided into four specific components which include: 1) What causes the illness? 2) What is the illness like? 3) What should be done to address the illness? 4) How will the illness turn out? (Kleinman, 1980). The aim of the present study was to elicit EMs of depression and postnatal depression from mothers and health workers who meet mothers during their pregnancy and/or postpartum period. The reason for eliciting EMs for both depression and postnatal depression was to investigate whether depression per se is something that is inherently associated with postnatal onset by the interviewees, when this causal link is not explicitly suggested by the interviewee.

2. Methods 2.1. Sample and setting This study was conducted in June 2007 at the community health centre in Ba Vi, which is a district in the Ha Tay province in Northern Vietnam. The health centre is at most 15 km away from district households. The district contains both peri-urban and rural areas with a population of 240,000 people. The main forms of production are agriculture and livestock breeding. The study area was chosen because it holds an epidemiological field laboratory where 21% of the population is under continuous surveillance. The field laboratory has been funded by the Swedish International Development Agency since 1997, and household surveys are conducted tri-monthly regarding occupation, migration, health status, disease, health service access, pregnancy, births and deaths. Semi-structured interviews were conducted with nine mothers and nine health workers who meet mothers during the pregnancy/postpartum period. The mothers were chosen with regard to variation in age and occupation from the list of field laboratory households. The health workers were chosen from those medical specialties that meet mothers during pregnancy and/or the postpartum period. All interviewees were recruited through the Ba Vi field laboratory, and health workers were recruited from communal medical centres and the district hospital. Participants signed a written informed consent form before inclusion in the study — none of the participants were illiterate — and were compensated for time away from income-generating work with 150 000 Viet Nam Dong (= 8.42 USD). Ethical committees in Stockholm, Sweden and at the Hanoi Medical University, Hanoi, Vietnam approved the study.

2.2. Data collection The semi-structured interview schedule was designed in accordance with the four main categories that consist Kleinman's illness explanatory model framework (Kleinman, 1980). The interviewees were informed that the interviews regarded the women's situation in their community, but it was not mentioned that the interview topic involved mental health, in order not to influence the answers in this direction. The interviews were initiated by reading a case vignette (Box 1) (Torres, 2009), which described depression in accordance with the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria for major depressive disorder (Frances, 1994), and questions were posed with regard to the vignette. Previous cross-cultural research on depression in Slovak republic, Russia and Germany (Angermeyer et al., 2005) and Rwanda (Bolton, 2001) has used a similar case vignette with culturally meaningful results. The DSM-IV diagnostic criteria for major depressive disorder with postpartum onset are the same as those for major depression, apart from the time of onset (Frances, 1994). Thus, the same vignette was used to illustrate a case of postnatal depression and the same questions were posed again with regard to postnatal onset. The suitability of the questions and vignette for the Vietnamese context was checked with a Vietnamese psychiatrist with postdoctoral research competence and a

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Vietnamese physician with postdoctoral research competence, who also conducted the interviews. Box 1 Case vignette, depression For a few months, a 30-year-old woman has been looking very sad, miserable and unable to look after her home and children, and is slow in speech and movements. She says that life is not worth living. Nothing seems capable of cheering her up. She complains of often waking up in the middle of the night and not being able to get back to sleep. Already in the morning she feels exhausted and without energy. Once she even tried to take her own life.

Interviews were conducted at the district hospital in a meeting room, and tape recorded after permission from the interviewee. The interviews were conducted in Vietnamese and varied in length between 20 and 70 min. Present at the interviews were the interviewee, the interviewer, a research assistant bilingual in English and Vietnamese and the first author of this article. While the interview was being conducted, the bilingual research assistant interpreted what was being said for the first author, so that she could pose any additional questions for clarification if needed. Interviews were transcribed verbatim and translated to English by the bilingual research assistant.

2.3. Analysis The interviews were analysed using the qualitative content analysis method (Graneheim and Lundman, 2004), specifically so-called conventional content analysis (Hsieh and Shannon, 2005), where preconceived categories are not used. Though the questionnaire was designed according to the categories of the illness explanatory model framework, in the analysis procedure the categories were allowed to ‘flow from the data’. The interview transcripts were read several times and all the passages that described the interviewee's views and attitudes regarding depression and postnatal depression were divided into meaning units, on which the analysis was based. The meaning units were condensed into codes where the essential meaning relevant for the analysis was preserved. Once this had been done for all the interviews, the codes were analysed and compared with each other to form categories, subcategories and themes. The interviews with mothers and those with health workers were analysed in two separate groups. After the analysis of the English versions of the interviews, the analysis was checked against the Vietnamese versions by the third author. This second analysis aimed to see if the codes and categories that arose from the English translations still made sense when compared to the original, Vietnamese interviews. Third, the analysis procedure was checked in detail by the last author of the study, and points of disagreement between the first, second and third analyses were discussed among the authors and adjusted accordingly. The interview material was grouped according to the following themes: What is the depression/postnatal depression

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called? (label); how common is it considered to be? (experience); what might have caused the depression/postnatal depression? (cause); what might its consequences be? (consequences); what should be done to it? (advice). An example of the different steps of the content analysis is shown in Table 1, where the condensation of quotes to subcategories is presented. The results of the content analysis are presented in the results section in sequence for the depression and postnatal depression explanatory models. The results from mothers and health workers are presented together, and differences between them are mentioned when such have been found. Quotes are shown that are illustrative of the manner in which specific issues were expressed in the interviews. Quotes were chosen either due to that they were typical, and illustrated the statements of many, or by that they were particular, and not found in other interviews. 3. Results Interviewee characteristics are summarised in Table 2. 3.1. Labels given for the vignette When asked whether they had ever heard of or met anyone with the symptoms as in the depression vignette, three mothers and five health workers said that they had. The rest said they had never met anyone with the symptoms. Most of the mothers and few health workers said they had not encountered a woman with the postnatal depression symptoms. The labels that were given for the vignette are given in Table 3. 3.2. The causes for depression and postnatal depression The causes of depression and postnatal depression given by health workers and mothers were grouped into four main categories: the external, the relational, the personal and not known. The external causes were those that could not directly Table 1 The content for the external cause category from all interviews shown as subcategories and quotes. Subcategory

Quotes

Mental Physical

“She has a problem with her mind.” (health worker) “She may be sad because she suffers from a health problem.” (health worker) “She cannot solve some problems, which push her into that situation.” (mother) “Some people committed suicide because they were heavy in debt.” (mother) “She may have children with unwanted sex.”(health worker) “If we do something wrong which may dissatisfy their ancestors. So they may feel angry with them and cause them some difficulties.” (mother) “Those who are not comfortable will be upset all the time.” (mother) “Those symptoms may say something about her spirit.” (health worker) “They haven't done anything wrong to be embarrassed about.” (mother) “She was suffering from some pressure which pushed her into that situation.” (mother) “Everyone has their own destiny.” (mother)

Burden Economy No son Dissatisfied ancestors Lack of comfort Spirit problems Not own fault Pressure Destiny

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Table 2 Characteristics of interviewees — 9 mothers and 9 health workers. Mothers

Age

Mean Range Mother Mother Mother Mother Mother Mother Mother Mother Mother

34 23–54 1 2 3 4 5 6 7 8 9

Children

Employment

Years of education

Health workers

8.6 19 months 6 and 15 years 2 children (age ?) 1 and 9 years 3 adults (age ?) 3 years 4 adults (age ?) 4 and 8 years 6 and 9 years

Farmer Farmer Farmer Farmer Farmer Farmer Farmer Other Other

be influenced by the person with the depression. The relational causes were those that had to do with relationships with others, and thus possible to influence to some extent. Finally, the personal causes could largely be seen as influenceable by the person herself.

3.2.1. External causes For the mothers, the most common subcategories of external causes were physical and economical problems. Physical cause usually implied that the person had a depression because she had some other illness, but not that the depression was a direct symptom of that illness. Some expressed that another person's illness could cause the depression. Mental illness in general and depression in particular were never mentioned by anyone as a cause in itself. For health workers, the most common subcategory of external causes was physical cause. Unlike the mothers, health workers sometimes described depression as a direct symptom of a physical problem. Interestingly, already when only asked about depression in general, and not postnatal depression in particular, some health workers gave failure to conceive a male child as a cause. The most commonly mentioned cause for postnatal depression was

Age

Employment

44 36–51 HW HW HW HW HW HW HW HW HW

1 2 3 4 5 6 7 8 9

(woman) (woman) (woman) (woman) (woman) (woman) (woman) (woman) (woman)

Time in employment 18.4

Midwife Midwife Midwife Midwife Doctor Doctor Doctor Assistant doctor Assistant doctor

not having a son, where almost all mothers and health workers gave this cause. In some cases the health workers had even experienced this cause in their own practice. Traditional customs were often given as a reason for preferring sons.

3.2.2. Relational causes Relational causes formed the largest causal category given by mothers. Every mother and almost all health workers gave at least one type of relational cause. Family problems causing depression could include problems with the core family (the husband and children) as well as problems with parents and in-laws. The husband's behaviour could cause depression and was often described as physically aggressive, or in other ways harmful for the family's life, as shown in the personal experience of a mother describing someone she knows: “Her husband did a lot of gambling while she had to work very hard. They had to pay the debt to the bank, but they couldn't earn enough money.” (mother) Among mothers, the husband's behaviour was the most prominent subcategory for postnatal depression, given by

Table 3 Labels given by mothers and health workers for the depression vignette and the postnatal depression vignette.

Depression label

Postnatal depression label

Mothers

Health workers

Label (Vietnamese) N

Label (Vietnamese) N

Not known 6 Thinking problems (tư tưởng) 3 Mental problems (thần kinh căng thẳng) 2 Being fed up (chán nản) 1 Sleeplessness (đêm không ngủ được) 1 Memorial disorders (trí nhớ bị rối loạn) 1 Negative thinking (nghĩ đến những cái tiêu cực) 1 Crazy (điên) 1 Depression (trầm cảm) 1 Psychological illness (bệnh về tâm lý) 1 Crazy (colloquial) (chập mạch) 1 Unstable mind (thần kinh không ổn định) 1 Problems with spirits (rối loạn tinh thần) 1 Not known 6 Sad/worried (uc che than kinh) 1 Thinking problem (tư tưởng) 1 Mental illness (bệnh thần kinh) 1 Thinking too much (nghĩ mãi đau đầu) 1

Not known 2 Depression (trầm cảm) 2 Thinking problems (tư tưởng) 2 Mental problems/mental stress (thần kinh căng thẳng) 1 Neurasthenia (suy nhược thần kinh) 1 Mental inhibition (bệnh tư tưởng) 1 Mental illness (bệnh về thần kinh) 1 Emotional problems (tình cảm) 1

Not known 6 Mental problems/feeling down (suy sụp về tinh thần) 1 Depression (trầm cảm) 1 Schizophrenia (bệnh tâm thần phân liệt) 1 Neurasthenia (suy nhược thần kinh) 1 Psychological illness (bệnh tâm lý) 1

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almost all interviewees. Lack of support was the most common relational cause mentioned by the health workers: “[She may feel like this] because no one cares about her after she gave birth.” (health worker) 3.2.3. Personal causes The personal causes were those that were related to the personal characteristics or behaviour of the depressed person. For mothers, thinking problems was the biggest subcategory, mentioned by almost half of them. The thinking could be negative in nature, but also too much thinking in general could form a cause. Personal responsibility, including carrying the burden of the vignette ailments by themselves, was another prominent subcategory among mothers, and is illustrated in the following: “They think that they are useless and don't want to become a burden for others.” (mother) “As a wife, we should endure our husbands. Being tense to them would lead to spousal quarrel, which can cause depression.” (mother) For postnatal depression, the personal cause category was very uncommon among mothers, consisting of only one subcategory — thinking — where only two respondents mentioned this cause. Health workers did not mention any causes within the category personal causes. 3.2.4. Cause not known This category included those responses where the cause for the depression or postnatal depression was unknown, and this was said to be due to lack of communication from the person suffering. This “cause” for depression was given by almost half of the health workers and also by some mothers. “It is difficult for us to know about the causes for their sadness because they don't often talk with us about their contact, their family or their personal life.” (health worker) For postnatal depression, half of the mothers and two health workers did not know the cause. 3.3. Consequences of depression and postnatal depression The consequences of depression and postnatal depression could be grouped into three categories, which included general impacts on life, impacts on the self, and impacts on others, especially other family members. Depression was said to cause not wanting to work and financial status was said to be impacted due to ignoring work. Depression was also said to impact health as a result of the impact of mental ailments on physical health. The consequences on the family ranged from the family being unhappy to the husband leaving the family. The negative impact on the baby was the most commonly mentioned consequence of postnatal depression. This included malnutrition due to the mother not having enough milk, poor mother–infant relation, and the mother not taking care of the infant.

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3.4. Advice given for treating depression and postnatal depression The advice that could be given to those with depression and postnatal depression was grouped into four categories: seeking formal help, advice against medical help, others' involvement in help and self-help. The formal help included all help-seeking that was not from peers and family, but from a more formal setting, such as medicine, traditional medicine, fortune tellers etc. The advice against something was when the depressed person was explicitly advised not to seek medical help. Others' involvement in help included all help from peers and family, and finally self-help was when the person with depression was advised in some manner to help herself.

3.4.1. Formal help The most common subcategory was that of somatic medical help, where all health workers and almost all mothers gave this advice. However, this medical help was most commonly not advised in order to treat the depression itself, but to treat a physical illness or disease that was considered the underlying cause for the depression: “I would just advise them to go to the hospital, to the western medical doctors. For example they should find out the causes for their headache.” (mother) “I would ask her something about obstetric problems such as something about her period, or whether she suffered from amenorrhea or not.”(health worker) Psychiatric treatment was the second most common advice given by over half of the health workers. Advice to seek formal help for depression itself, and not its causes, was rarely expressed by the mothers. However, seeking other forms of formal help, such as traditional medicine and fortune tellers, were advised by mothers in order to care for the depression itself, and not its possible causes. “Traditional doctors can also check our minds.” (mother) Formal advice for postnatal depression was similar to that given for depression. Medical care of the infant was recommended by both mothers and health workers if the infant's illness was thought to be the cause of the postnatal depression. Medical referral was often recommended, as the interviewees themselves did not know how the woman with postnatal depression should be treated, but referral to a psychiatrist was only advised by two health workers.

3.4.2. Others' involvement For mothers, the involvement of family members was predominant, but in some cases support could also be given by friends and peers. The subcategory support was given by over half of the health workers. For postnatal depression, advice for others' involvement was not common among mothers. Among health workers, the subcategory support was mentioned by all interviewees, and most commonly implied support from the health workers themselves.

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3.4.3. Self-help This category consisted of the most common form of advice by mothers. The subcategory personal responsibility/ coping was the only form of advice that was given by all mothers. This subcategory included advice to simply cope with the problems on one's own, and in some cases advice to not bother others with one's own troubles, and even conceal the problems from others. “When she gets married, she knows whether she is happy or miserable, she must console and cheer herself up.” (mother) Sometimes this subcategory included advice to continue with things as they were before. “I would act as normal. I would still continue working.” (mother) “The main factor is that they should try to take good care of the family as a mother and a wife in the family.” (mother) Among health workers on the other hand, this category was very infrequently mentioned. Only three health workers mentioned personal responsibility/coping for getting better. Self-help as advice for postnatal depression was given by less than half of the mothers, and by very few health workers. 3.4.4. Advice against medical help This advice category differs from the other three in the sense that it does not consist of advice for some specific form of help, but rather advice against a specific form, i.e. medical help. This form of advice was mentioned by over half of the mothers, but only by one health worker. “The doctors just can check their health when they have a certain disease, but the doctors cannot check them when they have something wrong with their thinking.” (mother) For postnatal depression, this advice was only mentioned by two mothers. 4. Discussion The interviews with health workers and mothers in Ba Vi, Vietnam have yielded illness explanatory models of depression and postnatal depression, with rich descriptions of the causes and advice. Unlike research done with Vietnamese immigrants in Perth, Australia (McKelvey et al., 1999), our results showed a very narrow tendency of the lay informants to seek biomedical help for the depression per se. This was despite the interviews having been conducted at the district hospital, which may have been thought to influence the interviewees toward a more biomedical orientation of their responses. However, our results cannot be directly compared with those obtained in Perth, where the research question addressed how lay people would seek treatment for mental illness. In our study, we did not pose such questions, and left it to the interviewee to decide whether depression was a mental illness. Most of our informants did not regard it as such, which

is in line with findings from Perth. Health workers in our study, on the other hand, were likely to recommend biomedical health care for depression. Often, however, this was associated with an uncertainty as to the type of health care that should be sought. Some of the respondents suggested that traditional medicine would be a good way to treat the root cause of the depression — to treat the mind. Traditional medicine has a long-standing strong position in the Vietnamese health care system, and the government has given much attention to its promotion and integration into the health care of Vietnamese people (Thuy, 1999). Our results corresponded well with what has been found by Tung (1980), who has described that Vietnamese people carry depression stoically alone. This aspect of personal responsibility for the causation and treatment of depression was very prevalent in the explanatory models given by the mothers. This has also been found in studies of depression explanatory models among older people in the USA (Switzer et al., 2006), and is thus not particular to the Vietnamese. The health workers in our study did not often assign personal responsibility for depression, but often recommended help from health workers. Thus, health workers felt responsible for caring for depression, which can therefore be assumed to indicate that they considered it a medical problem. We also found that causes for depression and postnatal depression were often described as unknown, and this was due to lack of communication from the person suffering. Indeed, others have shown that depression diagnosis in primary care is impeded by the reluctance of patients to communicate emotional symptoms (Docherty, 1997). The explanatory models that were elicited for depression were more extensive and showed more variation than those for postnatal depression. However, this may have been an artefact of the study methods, as interviewees were first asked about depression and then postnatal depression, and could thus have felt as if the two were similar and thus their answers had already been given. Most informants did not label the ailment described in the case vignette as depression, and none labelled it as postnatal depression. This corresponds with findings by Nguyen et al. (2005) where among 115 people diagnosed with depression at a mental health clinic in Ho Chi Minh City only four of the individuals reported that they had known the term depression prior to diagnosis. However, the case depicted in the vignette was recognisable and had been encountered by many informants. The depression was often labelled by both health workers and mothers as something pertaining to thinking, i.e. thinking illness, thinking problems or negative thinking. This may be explained in part by the traditional Vietnamese attitude toward mental ailments, where mental illness has been stigmatised (Nguyen et al., 2005). Thinking problems may be considered less stigmatising than emotional or mental problems, and the Vietnamese have been described to not discuss personal emotions openly with others (Nguyen et al., 2005). The Confucian roots of Vietnamese culture and communist values have resulted in a sense of community where the well-being of the collective is valued over that of the individual, and repression of emotional expression has functioned to maintain fluidity in relationships (Ngoc, 2004). Interestingly, some of the health workers and also some mothers labelled the depression and postnatal depression as

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neurasthenia (shown in Table 3). This corresponds with findings from China, where neurasthenia was commonly diagnosed by psychiatrists until the early 1980s, and still remains a common idiom among the lay Chinese (Lee, 1998, Kleinman, 1982). At a psychiatry outpatient clinic in China, 87% of those who were diagnosed as neurasthenic were found to suffer from a major depressive disorder (Kleinman, 1982). This acceptance of neurasthenia in China may be due to it being a less stigmatising diagnosis than depression, as subjects with neurasthenia are by definition not deranged in mind or dangerous to others (Kleinman, 1982, Lee, 1998). Such an attitude toward neurasthenia as a diagnosis has not previously been found in Vietnam, though a case study of a Chinese Vietnamese immigrant woman in USA has suggested that neurasthenia may be a more acceptable label than depression even among the Vietnamese (Cheung and Lin, 1997). Neurasthenia has been discussed to suit the somatosocial orientation of Chinese people (Lee, 1998), and can thus be expected to be acceptable as a diagnostic label for the Vietnamese in our study, who often assigned either somatic problems, illness, or social problems as causes. Studies in other parts of Asia have strongly implicated the pressure to conceive a male child as a cause of postnatal depression (Patel et al., 2002, Rahman et al., 2003). The relevance of this finding for the Vietnamese setting was supported by our present study, where almost all informants mentioned that giving birth to a daughter when a son was desired was a cause for depression. The sex of the infant was even ascribed by some as a cause for depression when the interviewee did not ask about postnatal onset specifically, thus suggesting a strong implication of this cause for depression. In a demographic health survey conducted in Hanoi (Thinh, 1998), the preference for sons was found to be prevalent, and the trend is toward sex selection becoming increasingly common (UNFPA, 2007). The primary reason for son preference has been suggested to be rooted in the strong Confucian patriarchal traditions of the country (Kisekka and Mere, 2007). Especially in rural settings, traditional, multigenerational households are still predominant in Vietnam, where women after marriage move into the house of their in-laws, and thus have very little autonomy (Ngoc, 2004). In line with this, participants mentioned social causes for depression, including problems with the core family or with in-laws. Other social causes included economical problems, as well as intimate partner violence. This mirrors previous findings that social and economical disadvantages of women, and lack of control over their life situation play an important role in causing higher prevalence rates of depression among women than among men world-wide (Astbury and Cabral, 2000). Male-to-female violence is prevalent in Vietnam, and is supported by patrilinear social hierarchy, Confucian virtues, as well as cosmological beliefs of men as ‘hot’ and bad tempered and women as ‘cool’ enduring characters, and the country's violent history of war (Rydstrom, 2003). 4.1. Methodological considerations The results of this study cannot be generalised beyond the group studied, or the context of Ba Vi, though we believe that analytical generalisation to other contexts can be made (Kvale, 1996). The small sample size of the study can be seen as a

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limitation, but is not necessarily so as saturation was achieved through the course of the interviews, where new interviews no longer yielded new information. Another limitation of the study design was that health workers were only asked about their EMs, and they were not observed in practice. Kleinman (1980), in his presentation of the illness explanatory model framework has noted that what health workers say they do, and what they actually do in practice may differ to a large extent. Our results can, however, be considered informative and valid with concern to the labelling and clinical knowledge of depression of the health workers. What the health workers would do if they met a person with depression and postnatal depression in their practice may differ from what we have found in our interviews. The validity of the study was strengthened by the fact that the content analysis of the interviews was checked by several researchers, one being a Vietnamese expert in the field of paediatric psychiatry. In this checking process, the points of disagreement were few, and when found, they were discussed in the research team and adjusted accordingly. It has been discussed that translators are not neutral conveyors of messages, but rather read and translate from their own perspective and thus are active producers in research (Temple, 2002). This was partly addressed by that the interviews were translated by one person, and analysis of the Vietnamese versions of the interviews was performed by another person, and then compared to the results of the English language analysis. However, the effects of translation on the interpretation of findings cannot be completely ruled out. The use of a DSM-IV based vignette in our study can be questioned, because the symptoms of mental illness have been said to vary between cultures (Good, 1992). Thus, it is possible that the symptoms that were described in our case vignette were not recognised as symptoms of depression by our informants simply because depression in Vietnam may not be expressed in this manner. We attempted to address this problem in our study design by consulting a Vietnamese psychiatrist and medical doctor about the suitability of the case vignette for the Vietnamese setting. However, these medical workers have a biomedical, western-oriented schooling, and thus may not be adequately informed about local Vietnamese symptomatic expressions of depression. However, a post hoc analysis of the case vignette used in our study in comparison with the symptoms of the Phan Vietnamese Psychiatric Scale (Phan et al., 2004) showed that almost all the symptoms described in the vignette are also found in the Phan scale. This was true for all other symptoms apart from “not being able to look after her house and children”, which may not make sense in the setting of the multigenerational household, where younger women often lack autonomy. In addition, our vignette did not include the description of symptoms that are specific to the Vietnamese context, characterised by e.g. undifferentiated reference to affective and physical symptoms or cosmological beliefs, as described by Phan et al. (2004). We can expect that the case vignette used corresponded fairly well with depression symptoms among Vietnamese, though some specific culturally relevant descriptions which may have rendered it more recognisable to the informants were lacking. Of course, some of the advice about what should be done to the depression and postnatal depression consisted of advice to focus on one's family and

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children, and it cannot be ruled out that this advice may have been triggered by the culturally abnormal symptom of not focusing on one's family described in the vignette. 4.2. Implications for practice This study carries implications for the planning of effective and available health care for depression and postnatal depression in Vietnam. The strong sense of personal responsibility for the conditions as well as the lack of communication from the person suffering should be taken into consideration already at a primary care level. In addition, mothers' lack of considering depression/postnatal depression as something that should be treated by specialist psychiatric care highlights the importance of the ailments being diagnosed and treated already in primary care. However, there was notable lack of knowledge among the health workers in this study of the depression symptoms and appropriate care, and this problem should be tackled through improved education on psychiatric diagnosis among non-psychiatric health care personnel (Paris, 2008). Yet, an approach to mental health management that focuses solely on individual pathology will fail to address the prevalent social causes of depression. Since a number of studies have implicated a wider social causation model for depression in females (Astbury and Cabral, 2000), we recommend a cross-sectoral approach for the prevention of depression in Vietnam, which takes into account the following: Assisting women in attaining control over determinants of their mental health, such as eliminating discrimination, and developing policy and legislation to improve the material well-being of women (Astbury and Cabral, 2000). Also, women should be empowered by being involved in decision-making about events and decisions that affect their lives, and social networks and communities should be strengthened to provide emotional support (Astbury and Cabral, 2000). 5. Conclusion This study has elicited illness explanatory models of depression and postnatal depression from lay mothers and health workers in order to understand how cultural and social structures in Vietnam may affect the patient–practitioner relationship and care-seeking behaviour of patients. The EMs elicited were predominantly somatosocial in nature, and mothers assigned a strong personal responsibility for caring for depression. On the other hand, preference for a male infant and other social factors were described as predominant in causing depression or postnatal depression. Psychiatric health care was seldom recommended, and when biomedical treatment was recommended, it was mainly in order to treat a physical illness, which was considered to be the cause. Lack of communication was described as an important factor concealing depression, and together with the lack of psychiatric care-seeking can be expected to impede effective depression treatment. Role of funding source Funding for this study was provided by the Health Care Sciences Postgraduate School, Sweden; the Postgraduate School had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest All authors declare that they have no conflicts of interest.

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