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JOURNAL OF SCIENCE, Hue University, N
0
61, 2010 EXPLORING POSTNATAL DEPRESSION IN THUA THIEN HUE PROVINCE,
CENTRAL VIETNAM
Linda Murray, Michael Dunne, Nigar Khawaja
School of Public Health,

Queensland University of Technology (QU)
Cao Ngoc Thanh
College of Medicine and Pharmacy, Hue University
SUMMARY
Introduction: Postnatal depression (PND) is an important public health issue due to its
impact on maternal wellbeing, infant development, and family cohesion. The estimated
prevalence of PND during the first 12 months post-partum ranges between10-20% worldwide.
Whilst PND used to be considered a syndrome only occurring in western countries, there is now
evidence that it occurs throughout the world, and often at higher rates in low and middle-
income countries. To date, there has been little research into PND in South East Asia and only
two community-based surveys in Vietnam, one in Ho Chi Minh City in 1999 and one in Hanoi
and Ha Nam in 2009. This study will investigate health worker attitudes about risk and
protective factors for PND among women in Thua Thien Hue province in central Vietnam.
Methodology: In 2009, 23 health professionals participated in qualitative exploratory research
of postnatal depression in Hue. This included two focus groups with 12 health professionals who
completed a concept mapping process, and in-depth interviews with another 11 health
professionals. Results: Many factors relating to postnatal depression were identified including
socio-economic status, son preference, mother’s health, infant health, social support from family

reproductive health policy can create pressure to have a son within two births.
Studies of perinatal mental health have been conducted in both the north and
south of Vietnam. In a sample of 506 women in HCMC, 33% of women were found to
have PND, and 19% of participants acknowledged thinking about suicide. In the north
of Vietnam, a study of 364 postpartum women from Hanoi and Ha Nam province found
that 29.9% had a common mental disorders (CMD) and that CMD were more common
in rural areas. Other studies have found that 20% of mothers of one year olds had
anxiety or depression in Vietnam, and that between 8 and 16.9% of recorded perinatal
deaths could be attributed to suicide. There is currently no data on PND from central
Vietnam. The purpose of this research is to identify risk and protective factors that
health professionals in Thua Thien Hue, Vietnam, perceived to be related to PND in
order to plan for a larger epidemiological study of maternal mental health in the area.
2. Methodology
Methodological Approach: The theoretical approach of this research project
was community based participatory research (CBPR). CBPR aims to draw on multiple
sources of expertise when deciding what health risks matter, what causes them and what
can be done about them. In social epidemiology, CBPR is used to increase the rigor of
descriptive research through identifying social determinants of health through
collaboration with local stakeholders
Study Site: This study was conducted in Thua Thien Hue province in Central
Vietnam in collaboration with Hue University of Medicine and Pharmacy.
Participants: For the focus groups, a purposive sample of twelve maternal and
child health professionals were recruited from three commune health centres within
10km of Hue city, and one Provincial hospital. Nine midwives with 2-32 years 305
experience, and three doctors with 15-18 years experience participated in 2 two-hour
sessions. Another eleven experts in maternal health and mental health such as
Obstetricians and Psychiatrists participated in in-depth interviews.

3.1. Brainstorming: Participants brainstormed 46 statements to include in the
sorting and rating activities. A list of the statements is outlined in figure one.
3.2. Sorting: From the sorting exercise, a concept map was produced (see figure 306
two). Each of the 46 statements is located as a point on the map. Statements that were
sorted together more frequently appear closer to each other on the map and represent
similar themes than statements more distant from them. The statements fitted naturally
into eight thematic clusters, which are enclosed by the polygons on the map.
3.3. Rating: The next two maps show how the eight clusters were rated by
participants as ‘most likely to cause PND,’ and ‘most likely to protect against PND.’
The rating map depicts the relative average rating on a 5 point likert scale (where 1 =
least likely, 5 = most likely) in relation to being likely to cause PND. The number of
layers represents how strongly participants rated a statement as being likely to cause
PND. The more layers there are, the more participants rated statements in this cluster as
likely to cause PND. The layers represent a double averaging – across all participants
and all of the statements in each cluster.
Figure three clearly shows that the clusters ‘negative stressors,’ and ‘mother’s
emotions and worry’ were rated as highly likely to be risk factors for PND with average
ratings of 3.73 to 4.24. ‘Mother’s health’ and ‘baby’s health’ were also considered to be
risk factors with average ratings of 3.23 to 3.75, but were not rated as highly as the
previous two clusters. ‘Economics’ had an average rating of 2.73 to 3.23, which means
it was not considered as influential as other social and health factors in causing PND.
Figure four represents statements participants perceived as most likely to protect
against PND. Economics was moderately rated as a protective statement (average rating
of 2.72 to 3.08), although it should be noted participants put positive as well as negative
statements about economics in this category. Interestingly, ‘family aspects’ and ‘society
and friendship’ (average 3.82 to 4.91) were rated more likely to be protective than
factors explicitly categorised and labelled in focus groups as ‘protective factors.’ The

makes the woman feel bad.
4. Discussion
Overall, the concept mapping exercise allowed participants to identify risk and
protective factors of PND both individually and as a group. Participants naturally sorted
the statements into eight clusters, some which were previously in the literature on PND
such as maternal health, infant health, social relationships, economics and family
relationships. Interestingly, some of the statements that emerged are not previously
identified in the literature such as ‘good atmosphere,’ ‘worry about beauty and physical
appearance,’ ‘enough rest, sleeping late,’ ‘the grandparents not accepting the child and
sending it to an orphanage’ and statements regarding son preference. The fact infant
gender was mentioned in five separate statements highlights its importance. This is
congruent in other literature from Asia but is yet to be explored in - depth in. Other
statements in the ‘emotion and psychology’ cluster such as ‘physical appearance,’ ‘low
self esteem within the community,’ and ‘gender of the baby the husband didn’t want’
have also not been explored in relation to each other before.
Mother’s health, baby’s health and economics are routinely mentioned in the
literature about PND from other countries, but were not considered as important as
categories including social support. Rating social factors more highly than economics as
a risk factor for PND is also consistent with the literature on risk factors for PND in
developing countries. Vietnamese mothers have very high levels of social support, with
one study showing 85% of mothers received support from two or more sources. Strong
social support positively affects maternal coping, child nutritional status and cognitive
development. The benefits of supportive nurturing family relationships can override
even severe economic adversity in protecting against common perintatal mental 308
disorders.
In-depth interviews added depth to the themes mentioned above. They also
highlighted that many women suffering mental health issues in Hue were unlikely to

Medicine, 64(1), (2007), 5-20.
5. Fisher, J. R. W., Tran, T., Buoi, L. T., Rosenthal, D., Kriitmaa, K., & Tuan, T Common 309
perinatal mental disorders in women in the north of Vietnam: Community prevalence
and interaction with health care use. Bulletin of the World Health Organsation, In
Press, (2010).
6. Gupta, M. D., Zenghua, J., Bohua, X. Z. L., & Chung, B. H. W. (2003). Why is son
preference so persistent in east and south asia? A cross-country study of China, India
and the Republic of Korea. World Bank Policy Research Working Paper no.2942. The
World Bank. Retrieved 29 November 2009, from http://ssrn.com/abstract=636304
7. Harpham, T., & Tuan, T. . From research evidence to policy: mental health care in
Vietnam. Bulletin of the World Health Organization, 84(8), (2006), 664-668.
8. Kane, M., & Trochim, W. M. K Concept Mapping for Planning and Evaluation.
Thousand Oaks: SAGE, (2007).
9. Kleinman, A Global mental health: a failure of humanity. The Lancet, 374, (9690),
(2009), 603-604
10. Wong, J., & Fisher, J The role of traditional confinement practices in determining
postpartum depression in women in Chinese cultures: A systematic review of the
English language evidence. Journal of Affective Disorders, 116(3), (2009), 161-169.
Figure One
Cluster Statements
Economics 2 Worry about losing employment (applies to professionals)
11 Lost opportunities for promotion (e.g after third child)
1 Economic difficulty
9 Loss of income post delivery
10 Sufficient financial resources
4 Less time for social activities
Family Aspects 25 Informational support from relatives and family

Baby’s Health 6 Stillbirth
15 The baby has a congenital disability
18 Poor health of the baby
32 Baby difficult to nurse
17 Worry about enough milk for the baby
42 Healthy baby
24 The baby is feeding well
Mother’s Health 19 The mother has a history of mental illness
8 Obstetric complications (e.g postpartum haemorrhage)
37 Caesarean wound infection
12 Other physical disease during pregnancy and delivery
36 Pain and fatigue after delivery
7 Pain during delivery
Protective Factors 16 Sleeplessness due to the baby
28 Regular diet
29 Sufficient relaxation, wakes up late 311
27 Physical activity for avoiding stress
41 Mother doesn’t smoke or drink coffee or alcohol
23 The mother has enough time to take care of the baby

Figure 2

Figure 3 312


1. Introduction
Overweight and obesity is currently considered a global public health issue. In
2005 the WHO estimated that at least 400 million adults (9.8%) are obese, with rates
being higher among women than men. Once considered a problem only of high-income
countries, rates of overweight and obesity are rising worldwide. From 1980 to 2002,
obesity has doubled in adults and overweight prevalence has trippled in children and
adolescents. In 2003-2004, 17.1% of children and adolescents were overweight and
32.2% of adults were obese. The only remaining region of the world where obesity is
not common is sub-Sahara Africa.
In Vietnam, it was reported that the prevalence of overweight-obesity among
primary school pupils in a district of Hanoi had increased from 4.1% in 1997 to 7.9% in
2002, and in District 1, Ho Chi Minh City was 12.2% (1998). In Hai Phong City, nearly
9% of primary school pupils were overweight, and up to 6% were obese (2000). In Hue,
the rate has increased from 2.4% in 2002 to 6.4% in 2005. 314
The fact that identifying risk factors of overweight and obesity for prevention
and effective intervention plays a key role in the effort of reducing incidence as well as
its consequences. The aim of this study was to identify risk factors of overweight and
obesity among primary school pupils in Hue city.
2. Methodology
2.1. The subjects were divided into 2 groups
- Overweight and obese group: includes pupils who were determined either
overweight or obese in a previous cross-sectional study based on weight/ height > +
2SD or BMI ≥ 85 percentile.
- Control group: a similar number of normal weight pupils were randomly
selected with the same age, sex, geography, ethnicity, excluding underweight.
2.2. Methodology
2.2.1. Study design: A case-control study was conducted to determine the cause-

Weight at birth (grams) 3183.74  472.39 3125.49  402.71 > 0.05
Increased maternal weight
10.39  3.41 10.10  3.63 > 0.05 315
during pregnancy (kilograms)
Duration of Breast feeding
(months)
16.827.41 16.275.53 > 0.05
Time of supplementing food
(months)
4.32  1.75 4.61  1.42 > 0.05
In this study, the relationship between factors related to feeding such as weight
at birth, increased maternal weight during pregnancy, duration of breast feeding, time of
supplemental food and the overweight and obesity status of children has not been
determined. (p>0,05).
Table 3.3. Relationship in weight between parental obesity and children
Overweight
(BMI ≥ 25)
Case group Control group p OR
n % n %
Father
Mother
44
18
16.5
6.7
18
7

Trader
71 26.6 31 11.6
< 0.01
98 36.7 60 22.5
< 0.01
OR = 2.76 (1.7-4.5) OR=2.10 (1.41-3.12)
Manual
Laborer
31 11.6 63 23.6
<0.01
34 12.7 57 21.3 <0.01
OR=0.43 OR=0.52
Total 267 100 267 100 267 100 267 100 316
The risk of overweight and obesity of children whose parents are traders was 2
times higher than others. This may be due to their busy business and high income which
consequently leads to children being given a variety of foods, snack, and sweetened
beverages. Then the children often eat between meals without parents’ control and
monitoring.

Figure 3.4. Relationships between average food consumed and overweight and obesity.
Overweight and obese children eat more oil, greasy food and sweets than the
others (figure 3.4). The caloric increase will be increased when food consumption
increases. Redundant calories (70calo) each day over a long time will be the cause of
children being overweight. Furthermore, eating a lot of flour, sugar, sweets, and meats
may be the causes of overweight and obesity because protein, lipids, and glucose may
be metabolized into fatty reserves in the body.
Table 3.5. Relationship between eating habits and overweight and obesity of Hue primary

0

20

40

60

80

100

120

Average

Oil

Fat meat

sweet

Soft drinkTP group

Case

Control

group
Control group OR
No action
Daily excerise
149 74
3.29
(2.26-4.80)
A sedentary lifestyle is considered as watching TV, and playing computer games.
The mean sedentary time of the overweight and obesity group is 141.35 minutes/ day,
higher than that of the control group (111.92 minutes/day) as showed in Table 3.8
(p<0.001).
Watching TV, and playing games means as stationary activities increase and
physical activity decreases and consume calories. Nowadays, a sedentary lifestyle
including watching TV has increased with the use of remote controls, whereas computer
games are getting more and more attractive and abundant. Moreover, children can
watch or play games while eating fatty and sweet foods. Another important factor is
lack of physical activity, causing an increase in caloric intake but a reduction in calorie
consumption. Excessive calories are then converted into fat and are stored in the body.
There is a shortage of playgrounds for as a result of fast urbanization. Children today
have to spend much time studying and doing homework. In addition the habit of going
to school on foot has been replaced by other means of transport such as cars, motorbikes, 318
and buses. In the past, after school, children used to help parents do housework like
taking care of siblings, sweeping, house cleaning, and cooking meals, which make them
physically active. Recently, parents tend to do housework themselves, or employ
servants rather than letting their children participate. These lifestyle changes contribute
remarkably to the risks of childhood overweight.
Table 3.7. Relationship between awareness of parents and overweight and obesity in school-
319
founded that:
4.1. The overweight and obesity situation: the rate of overweight was 6.4%;
obesity was 3.1%. male (7.5%) is higher than female (5.1%) (p< 0.01), the light rate of
obesity was 74.2%; average and heavy rates of obesity were ? The highest overweight
or obesity was detected in children aged 10.
4.2. Some risk factors of overweight or obesity in school children: Family
factosr: the risk of overweight or obesity in children who have a father or mother who
are overweight and traders, was 2-3 times higher than normal. the risk of being
overweight or obesity was 2- 3 times higher than in children who have a sedentary
lifestyle and eat fatty foods, eat between meals and fast than the others. The awareness
of the parents of overweight and obese children requires improvement.

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