Mental Health and Psychosocial Wellbeing Among Children and Young People in Selected Provinces and Cities in Viet

I am happiest when I have my friends around. In-depth interview, boy aged 16, An Giang

Mental health and psychosocial wellbeing among children and young people in selected provinces and cities in Viet Nam Overseas Development Institute 203 Blackfriars Road UNICEF Viet Nam London SE1 8NJ Add: Green One UN House, 304 Kim Ma, Ba Dinh, Ha Noi

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Cover photo: UN Viet Nam\2011\Shutterstock

With special thanks to Vu Thi Hai Ha, Youth Programme Officer, UNESCO Ha Noi and Mako Kato, Education Project Assistant, UNESCO Ha Noi, Nguyen Nhat Linh, Education Project Officer, UNESCO Ha Noi, for their contribution to the illustrative photos in this report. Mental health and psychosocial wellbeing among children and young people in selected provinces and cities in Viet Nam Acknowledgements

The Study on ‘Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam’ was carried out as part of a broader collaboration between UNICEF Viet Nam and the Ministry of Labour, Invalids and Social Affairs (MOLISA), with research and technical expertise provided by the Overseas and Development Institute (ODI). The Study aims to provide an overview of the situation of mental health and psychosocial wellbeing of children and young people in Viet Nam.

The Study researching team consisting of Fiona Samuels, Nicola Jones and Taveeshi Gupta from ODI and Thuy Dang Bich and Le Dao Hong from the Institute for Family and Gender Studies. The researching team would like to acknowledge support from their external peer reviewers, Bassam Abu Hamad and Martha Bragin, for the helpful and detailed comments on early drafts. And they would also like to thank the numerous respondents in all the study locations for providing them with time and answering many questions. The research team would highly appreciate the Social Protection Department of MOLISA in supporting the research including organization of consultations on the drafts.

The Study benefited from financial and methodological support from UNICEF Viet Nam. And finally, the research team would like to acknowledge the great contribution from the Child Protection team of UNICEF Viet Nam for their tireless efforts in reviewing, providing comments on the drafts and proof-reading the full report as well as briefing documents.

4 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam Abbreviations

ADHD Attention deficit hyperactivity disorder CBCPS Community based child protection system DCPC Department of Child Protection and Care DOH Department of Health DOLISA Department of Labour, Invalids and Social Affairs F Female FGD Focus group discussion GCC Grand Challenges Canada GSO General Statistics Office HCMC Ho Chi Minh City HHWs Hamlet health workers IDIs In-depth interviews JICA Japanese International Cooperation Agency KI Key informant KII Key informant interview LMIC Low- and middle-income countries LSS Lower secondary school M Male MICS Multiple Indicator Cluster Survey (UNICEF) MOET Ministry of Education and Training MOH Ministry of Health MOLISA Ministry of Labour, Invalids and Social Affairs PHAD Institute of Population, Health and Development PTSD Post-traumatic stress disorder RTCCD Research and Training Centre for Community Development SAVY Survey Assessment Vietnamese Youth SDGs Sustainable Development Goals SDQ Strengths and Difficulties Questionnaire SPC Social Protection Centres SWCs Social Work Centres UNICEF United Nations Children’s Fund USS Upper Secondary School VUSTA Viet Nam Union of Science and Technology Associations

Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 5 6 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam Contents

Acknowledgements Abbreviations Executive Summary

25 33 41 55 81 97 105 113 1. Introduction and 2. Methodology 3. Magnitude and 4. Risk and 5. Mental health and 6.Challenges in 7. Political economy 8. Recommendations background prevalence of protective factors for Psychosocial Care service provision of mental health mental health and mental health issues service delivery systems and psychosocial psychosocial issues and psychosocial support in Viet Nam in Viet Nam distress amongst children and young people in Viet Nam

Acknowledgements Abbreviations Executive Summary

References 119

Annex 1: Data on suicide in Dien Bien province 124

Annex 2: Background on School Psychological Consulting/Counselling in Viet Nam 126

Annex 3: Findings of Statistical Analysis of SDQ and Self-Efficacy Scale Scores 129

Annex 4: Policies and legal documents related to mental health, social work and children 147 Tables Table 1: Respondent types and numbers by location 36

Table 2: The age of children as the whole qualitative sample 36

Figures Figure 1: Demographic characteristics of the children took part in assessment (N=402) 37

8 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam Boxes Box 1: Some definitions 27

Box 2 - Key Statistical Analysis Findings of SDQ and Self-Efficacy Scale Scores 44

Box 3: Reasons/causes for suicidal ideation 48

Box 4: Mental health services through the government hospitals in Hanoi 83

Box 5: Mental health services through the government hospitals in HCMC 84

Box 6: Systemic counselling in schools (a case of Olympia School in Hanoi) 92

Box 7: Shamanism and the Hmong according to Hmong Shaman 94

Box 8: Limitations in policies 109

Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 9 Executive Summary

Introduction and and environmental factors. It is the important set of findings which will latter group of causes i.e. the social inform recommendations on how Background factors and environmental, to which to address the challenge of mental this study contributes. Thus a range ill-health and psychosocial distress Mental health has been recognised of social and environmental factors amongst children and young as an integral part of broader including rapid social change, people, also feeding into existing definitions of health (see e.g. WHO, migration, unemployment, poverty national level programmes. 2001), wherein mental health is and changes in traditional values, not equated simply as the absence have been recognised as being Four overarching research of mental disorder, but includes key drivers of mental ill-health questions guided the study: subjective wellbeing, self-efficiency, and psychosocial distress and autonomy, competence, and particularly amongst young people. • What is the prevalence of realization of one’s potential. mental health and psychosocial The purpose of this study is problems, including suicide Widening out the discussion to also to provide an overview of the among Vietnamese children, include the notion of psychosocial situation and context of mental adolescents, and youth? wellbeing, a body of literature health of children and young across various disciplines explores people in selected provinces and • Which factors in the Vietnamese the causes of both mental ill-health cities in Viet Nam. It does not seek context place children, and psychosocial distress showing to be representative of the whole of adolescents, and youth at that it is multifactorial and includes Viet Nam. Nevertheless, findings are risk and which factors act as biological, psychological and social valid in themselves and provide an protective factors for mental

10 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam and psychosocial distress at the milder end of the mental health Magnitude and disorder spectrum, also referred prevalence of mental to as common mental disorders (CMDs), and largely to what have health issues in been defined internationally as internalising/emotional problems Viet Nam such as anxiety, depression, loneliness, sadness and somatic Findings from the secondary complaints, all of which can have literature. A review of the fledgling a range of negative outcomes, evidence base on mental health including suicide. issues in Viet Nam found that the prevalence of general mental To situate and present our findings, health problems in Viet Nam ranges we adopt a socio-ecological from 8% to 29% for children and framework, with children/young adolescents, with varying rates people at the centre, which across provinces, by gender and explores factors at different levels by respondent and depending of the social ecology – individual, on the study methodology. A family/household, school, recent epidemiological survey of a community, institutional – and nationally representative population the ways in which they interact from 10 of 63 provinces found that and contribute to both drivers or the overall level of child mental risk factors of mental health and health problems was about 12%, psychosocial well-being as well as suggesting that more than 3 million protective factors. children are in need of mental health services. The most common types Two main approaches were used for of mental health problems among this study: a regional and national children studied in Viet Nam are review of secondary data and those of internalizing (such as qualitative primary data collection. anxiety, depression, loneliness) (A total of 110 interviews were and externalising problems (such carried out, respondents included as hyperactivity and attention service providers, parents, children deficit issues). and young people). Additionally, health and psychosocial two internationally validated scales While there is increasing concern problems, including suicide? for measuring wellbeing were used with the rates of suicide among with 402 school children (aged young people in Viet Nam, Viet Nam’s • What laws and policies exist 11-14 and 15-17) : the Strengths and reported suicide rate is remarkably around mental health and Difficulties Questionnaire (SDQ) and low compared to global estimates. psychosocial wellbeing in Viet the Self-Efficacy (SE) and Resilience In a 90-country study, among all Nam? Scale. adolescent deaths the suicide rate was 9.1% (Wasserman et al., 2005), • What kind of mental health and Primary data collection took place while in Viet Nam it was only 2.3% psychosocial service provisions in Ha Noi and Ho Chi Minh City and respectively (Blum et al., 2012). and programmes exist for in the provinces of Dien Bien in the Substance abuse, which includes children and youth in Viet Nam? north and An Giang in the south; using drugs, abusing alcohol, and in these provinces data collection smoking, can also be a driver or a It is important to note, and as was took place in both urban and rural risk factor for mental ill-health and reflected in the research team areas. psychosocial distress; tobacco use composition, and following the especially was common among focus discussed above on social Vietnamese adolescent males and environmental drivers of (almost 40%). Though co-morbidity mental ill-health and psychosocial is not a risk factor by itself, the distress, the study does not focus literature indicates that one form of on severe mental disorders. Rather mental illness may act as a risk factor it focuses on mental ill-health for another. Moreover, concerns

Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 11 12 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam are emerging that these mental thought that stigma towards people mutually inclusive, with many issues are indicative of additional facing mental health challenges was coexisting and one often resulting psychosocial challenges below the declining, it was also mentioned in another. Similarly, manifestations surface that may require further that while people might not can also be risk factors, also further study going forward. outwardly stigmatize, they do so driving mental ill-health and inwardly and/or show indifference, psychosocial distress. Thus in terms Findings from the qualitative and it was suggested that as a of the psychological state of study primary data collection. Despite result of prevailing stigmas, people participants, two main feelings the relatively low incidence of are reluctant to access services. were expressed: on the one hand, mental health problems reported in Emerging strongly from many optimism about the future, and on the secondary data there is a general narratives was the fact that mental the other hand sadness and worry. perception amongst all study health issues are not well understood respondents that both psychosocial with this lack of understanding Children of all ages, particularly and mental health problems are also leading to fear of those with the younger age categories, had both widespread and increasing, mental ill-health. Narratives around great optimism and aspirations for with some saying they felt that ‘social evils’ were heard amongst the future. Worries, sadness and children face a greater mental health study respondents, often linked to general pessimism was expressed burden than adults and that different discussions about substance abuse more frequently by older children. age groups face different kinds and addiction to internet games and The reasons for worry and sadness of problems. However, they also gambling, which in turn can also ranged from parents fighting, mentioned that challenges remain in have implications for mental health a family member being unwell, terms of estimating more precisely and psychosocial wellbeing as well performance in school, fear of these numbers and particularly in as other anti-social behaviour such dropping out of school, uncertainty relation to children. as stealing. about the future and early marriage. The older age group, particularly girls Respondents spoke about people In keeping with the literature who had dropped out of school and with mental health difficulties in on mental health, narratives are who were already married, worried various ways: they were seen to be presented based on the following about their financial security and ‘unknowledgeable’, ‘negative’, or broad areas: psychological state of that of their child as well the marital ‘different.’ Similarly, respondents participants, cognitive disorders, discord they were facing with their believed that ‘their way of thinking emotional disorders, somatic husbands. Symptoms of this sadness is different’, they have some kind complaints, behavioural disorders and worry include stress, which led of ‘disease’, are ‘an exception’, or and substance abuse. Clearly, these to skipping meals, headaches and are ‘unstable’. While respondents disorders and complaints are not anger.

Emotional disorders, under and early marriage of drug addicts’ literature on mental health issues which depression and suicide fall, children. in Viet Nam tends to be highly were prevalent amongst study medicalized, and thus we try to draw respondents. Generally, girls were Preliminary analyses of the SDQ and more attention to these socio- perceived to be more susceptible SE Resilience Scales found that in economic factors in our analysis of to emotional problems than boys. terms of mental health problems, the primary data which we discuss The way children and young people of the four domains of behavioural especially at the household level spoke about and perceived suicide and emotional problems, this study (see below). There are also likely to appeared to vary according to age found that the rate of children be a range of other factors which and gender: while the younger age scoring ‘Abnormal’ in the Emotional influence the mental health and group (11-14) had heard of ‘many’ problems Scale is more than twice psychosocial wellbeing of children people who had attempted suicide, as high as those in other Scales, and young people in Viet Nam by the time they got to the next age which suggests that emotional including factors such as trafficking, group (15-17) there were several cases problems are what children struggle sexual abuse and violence. These of suicidal ideation and amongst with the most during adolescence. issues were not explored in the the older age groups, and some The rate of children having conduct literature review since these are respondents also reported having problems in this study also appears topics in themselves and worthy of tried to commit suicide themselves. to be quite high; the most common separate studies. The primary data There was a general perception that symptoms include getting angry collection also did not focus directly it was mostly young people and and losing temper easily, and lack on these issues, though some of girls who committed or who tried to of self-control. The majority of these issues did emerge indirectly commit suicide, and the availability the children in the survey sample e.g. through stories of isolated young of poisonous la ngon or ‘heartbreak’ showed problems or symptoms mothers being at the mercy of their leaves in Dien Bien makes suicide of hyperactivity. Very few of the husbands. relatively easy. Reasons for suicidal children were confident that ideation and attempted suicide they possessed good attention, for males and females include judgement and ability to analyse Risk and protective failure of romantic relationships, and complete tasks effectively. In marital discord, problems at school, terms of children’s self-efficacy factors for mental problems at home, and reluctance and perceived self-efficacy, to share feelings. For men, additional analyses revealed a relatively positive health issues reasons include not being able to live perception of self-efficacy among up to expected masculine attributes the children in the sample, both in The report explores both risk and and behaviour, including the ability unexpected/unforeseen situations protective factors (including coping to maintain the family/household. and especially when actively strategies) of children and young facing difficult problems, although people at four levels: individual, household, school and community. In Somatic complaints - headaches, the number of children having the following sections we focus on the loss of appetite, poor sleep and good self-efficacy in coping with primary data; for further findings from nightmares - were mentioned by unexpected events is a bit lower. the literature review please see the full many respondents. Reasons for Particularly, in the face of difficulties report or the literature review report these were largely related to the and challenges, many of the children (Samuels et al, 2018). stress associated with academic believed in their coping abilities. pressure, but also, particularly for They could keep calm to solve the Individual level girls, as a result of stress from having problems, and were confident in to do housework. Finally, substance their own efforts and abilities to Risk factors. Three main individual abuse – alcohol, smoking and focus on pursuing and achieving risk factors emerged for young drugs - was also mentioned by many their goals. people, with some age and gender- respondents in our study and was specific variations. First, emotional largely associated with boys, young It is important to note that isolation / self-isolation was men and husbands. According to overall, while the global literature an important source of risk, with respondents, substance abuse results highlights the importance of children often reporting choosing from peer pressure to ‘drink to forget poverty, adversity, migration not to share their feelings with their troubles’ or from sadness and and family separation as causes anyone, often because they wanted general social pressure. Substance of mental ill-being, these are not to protect their parents from abuse can also lead to violence strong themes in the secondary worrying. For older adolescents, literature on Viet Nam. The existing especially girls, feelings of social 14 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam isolation result from early marriage. brothers, teachers, uncles — who with less time to do schoolwork Other girls in this age group also have qualities that they admire and and fewer means for extra-tuition attributed their social isolation to who have been good to them. classes, or force them to drop out dropping out of school against of school altogether. This leads to their choice and/or to the burden Negative coping strategies high levels of stress for children, who of domestic responsibilities. A included crying alone, substance are not able to achieve their future second driver of psychological abuse (especially drinking alcohol), aspirations. Parental migration, ill-being is linked to access to vandalism and suicidal ideation also due to financial reasons, can modern technology and the risks — most commonly mentioned in also have a negative effect on of addictive online behaviours, Dien Bien and in relation to pressures children’s mental health, with with this access posing a threat to around school drop-out and early children left behind facing sadness wellbeing since children tend to marriage. All of which can in turn and depression. In addition, early “use it too much”. Boys tend to spend further fuel mental ill-health and marriage, often associated for girls more time online, playing games psychosocial distress. with school-leaving, was also found in the internet shops and their to lead to sadness and depression. sadness is attributed to losing games Household level online. Over time, online gaming Household tensions arise from a also appears to have negative Drivers/risk factors. Three broad number of sources including: family spill-over effects on scholastic sets of factors at household level pressure on children to excel in achievement. Respondents stated were identified: overly restrictive school, a general feeling that parents that boys are more likely to play family rules (especially with don’t understand children, marital computer games than girls, but girls regard to scholastic achievement conflicts (which often spill over are more at risk from cyber bullying and marriage), poor or declining onto children), divorce, domestic and stalking. A third key risk factor household socio-economic status, violence from husbands, and lack of relates to negative perceptions of and intra-household tensions. In communication between parents adolescent physical appearance. terms of family rules, younger and children, often as a result of These concerns begin in early children emphasised that they faced changing family structures and adolescence, especially among girls, high expectations from parents the pressures facing parents in a who are anxious about menstruation in terms of carrying out domestic competitive labour market leading to or who are perceived to be chores and caring for younger them often neglecting their children. overweight. Other physical concerns siblings and were afraid of being revolved around being too short, ‘scolded’ by parents for not doing Protective factors and responses. which leads to teasing, name calling them adequately. Similarly, children Two sets of protective factors and discrimination in school sports are also fearful of parents criticising were identified: relatively better activities. them for poor marks at school, and off household socioeconomic there have been some instances status mitigated some sources Coping strategies. A range of in which scolding for academic of stress experienced by young both positive and negative coping performance has led to suicide people, thus it was mentioned that strategies was identified for dealing attempts. For mid-adolescents (i.e. children in better-off households with mental and psychosocial ill- around 14-16 years of age), when were more likely to complete being. The first key protective factor young people are increasingly trying twelfth grade. And emotionally mentioned was active participation to define an independent identity, healthy family relationships or in leisure activities (e.g. sports, parental “control” was seen as a family connectedness were also martial arts, reading, watching key source of stress, with children a key positive factor in mitigating movies, joining school clubs or trips, reporting that their parents do not psychosocial stress and ill-being — learning through the internet). A allow them to go out with their children felt loved the most by their second critical protective factor friends, disapprove of romantic parents and grandparents, and felt was having or being part of good relationships, monitor their cell happy when they were able to share social networks. The importance phone use, and make them do their feelings and concerns with of having friends was noted across chores around the house. them. all interviews, irrespective of gender. There were also several examples of Poor or declining household School-level drivers children having good role models socioeconomic status, can limit to follow, although this was more opportunities for socialising Risk factors. Three main sets of risk commonly cited by boys. These are with peers, limit their scholastic factors were identified: academic generally adults they know — older achievement by leaving them stress, inadequate support and/ Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 15 or shortcomings of the school environment, and challenges faced in romantic relationships. Respondents agreed that the academic pressure they face is one of their main worries – concerns related largely to performance, with children placing very high expectations on themselves to do well, which was further exacerbated when comparing themselves with their peers and by pressure from their families to do well. While the secondary literature has paid considerable attention to the problem of after-school tuition putting additional pressures on adolescents (e.g., see Ko and Xing, 2009), in our sample, this did not emerge as a significant concern, likely due to very high levels of poverty and marginalization. Shortcomings within the school environment were manifested by high levels of bullying and peer conflict. Being away from family and in boarding school, is an added stressor, as is the lack of leisure activities and often unsupportive teachers. Romantic relationships, which often start in the school environment, were often associated with stress since, on the one hand, they have to remain hidden from parents and teachers who would forbid them and , on the other hand, break-ups and unrequited love lead to sadness, depression and sometimes even suicidal ideation or © UNICEF Viet Nam\2017\Colorista\Hoang Hiep attempts.

Responses and coping strategies. training and citizen education to economic opportunities; and A number of schools, largely in that children receive in school helps harmful norms. Easy access to urban areas, have psychological them deal with stress, as do clubs, harmful substances was particularly counselling units, and girls access other extra-curricular activities and prevalent in Dien Bien province, them more than boys. Shortcomings the internet. Teachers are also an where access to drugs and to of these units ranged from students important part of students’ coping poisonous (la ngon) leaves was not knowing about them and repertoires, particularly in relation to widespread. Alcohol abuse was also therefore rarely accessing them, studying and sometimes with family prevalent. Reasons for abuse range to variability in the capacities of related issues. from people wanting to use them, counsellors, to the location of to being tempted by their friends, the unit in a public space with no Community level to having cheap and easy access to privacy, to the fact that there are substances. Since opportunities (in sometimes only male counsellors Risk factors: Three main categories terms of employment/future jobs with whom girls may be reluctant to were identified: easy access to and leisure activities) in rural areas share their feelings. The life-skills harmful substances; lack of access are limited, and limited knowledge 16 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

of vocational options, this also a number of ministries, including Service provision through MOH causes potential stress for children the Ministry of Health (MOH), the and young people, with narratives Ministry of Labour, Invalids and In Hanoi mental health services in urban areas highlighting higher Social Affairs (MOLISA), and the are provided through a number of level career aspirations of children Ministry of Education and Training hospitals, including the National and young people. Harmful norms (MOET). Each ministry has a different Institute of Mental Health, National appear to be more prevalent in rural paradigm of administration, with Psychiatric Hospital No. 1, Hanoi areas and largely in the impoverished different areas of responsibility, Psychiatric Hospital and the Mai northern highlands. These include roles and functions, and has their Huong Daytime Psychiatric Hospital. norms around early marriage for own programmes, proposals and In HCMC mental health related girls - usually also resulting in a girl models for dealing with mental services are also provided through leaving school at an early age – what health and psychosocial issues. several hospitals, including the a girl should do with her life, how she For example, MOH is in charge of Paediatrics Hospital No. 1. should behave and look/dress and health-related matters, hospitals the domestic roles that she needs and health centres. Health centres In Dien Bien Province mental to take on. All of these can affect and hospitals diagnose and provide health services are provided through the mental health and psychosocial treatment primarily for serious and the government and through two wellbeing of girls. persistent mental illness stemming hospitals in Dien Bien Phu City: from neurological conditions and the provincial general hospital, Protective factors and coping. developmental disabilities. In which has a mental ward and a Where there are opportunities or contrast, MOLISA, through its vertical psychiatric hospital. While there services focusing on mental health system of DOLISAs in 63 provinces are a large number of private and psychosocial wellbeing, these and cities, social protection and clinics and health care providers have a positive effect on children social work centres, deals with social in Dien Bien Phu City, according to and young people. Respondents support policies for social protection study respondents, none provide also note the importance of holding beneficiaries and provides services mental health services. Although positive attitudes and beliefs, for serious cases. MOET provides there is no psychiatric hospital in many of which can be taught in psychosocial counselling units An Giang, DOLISA supports the schools. in schools and life-skills training. hospital wards and health centres A growing number of non- by providing them with financial governmental oranisations (NGOs) support to accept referrals of serious Mental health service delivery are also providing mental health and mental health patients. The national psychosocial related services programme on mental health care The provision of mental health for community and children is also services falls within the remit of being implemented in An Giang and Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 17 the Women’s Union there has also preventing mental disorders and services; (vii) Organize rehabilitation been providing support to those with contributing to improved general and occupational activities; assist mental health needs. social security. beneficiaries in self-management, cultural, sport activities and other Commune health centres and the Social protection institutions include: activities suitable for the age and hamlet health workers (HHWs) Social protection institutions taking health conditions of each group of are usually the first port of call in care of the elderly people; Social beneficiaries; (viii) Take the lead and communes and remote areas for protection institutions taking care coordinate with relevant institutions people with any kind of health-related of children in special circumstances; and organizations to provide concern. While mental health issues Social protection institutions taking academic and vocational training are usually not part of the remit care of people with disabilities; Social and career guidance to promote of HHWs, a sub-group of HHWs in protection institutions providing comprehensive development of Keo Lom (Dien Bien) attended a care and rehabilitation to people beneficiaries, physically, intellectually training session in which they were with mental illnesses and disorders; as well as in terms of personality. taught how to identify mental health General social protection institutions (x) Provide social education and problems and access drugs for the taking care of beneficiaries of social capacity building services (Provide patients at the psychiatric hospital in protection or those in need of social social education services to help Dien Bien. The community mental protection; Social work centres beneficiaries develop problem- health programme appears to providing counseling services, solving capacity, including parenting have been running for around ten urgent care or other necessary skills for those in need; teach life years in Dien Bien province, whereby support for those in need of social skills to children and adolescents; the psychiatric hospital distributed protection; Other social protection Collaborate with training institutions medicines to the districts and the establishments according to the law. to organize education and social responsible officers at district level Social protection institutions have work training for staff, collaborators then distributed to patients in their the following responsibilities: or those working for social work coverage areas. service providers; Organize (i) Provide urgent services (receive training and workshops to provide Overall, however, there is very those in need of urgent protection; knowledge and skills to beneficiaries limited provision of mental health assess beneficiaries’ needs, screen who have demand. (xi) Manage services within the public health and categorize beneficiaries. When beneficiaries who receive social work sector, and what is provided is poorly needed, refer beneficiaries to health, services to all beneficiaries of social integrated – especially at provincial educational, police, judicial or other protection and those in need of hospital level. relevant institutions or organizations; urgent protection. ensure safety and address urgent Service provision through needs of beneficiaries such as: Up to now there are 45 Social MOLISA temporary accommodation, food, Protection Centres providing care clothes and transport); (ii) Consult and rehabilitation for people with Key institutions under MOLISA and treat mental disorders, psycho mental illnesses and Social Work through which mental health and crisis, and physical rehalibitation Centres that have implemented psychosocial wellbeing services are for beneficiaries; (iii) Advise and case management for 60,000 people provided include social protection assist beneficiaries to access with mental health problems institutions, social work centres, care social support policies; coordinate in communities. These centres and rehabilitation centres for people with other relevant units and provide social work services such with mental health, and hotlines. In organizations to protect and assist as organizing rehabilitation and 2011, the Vietnamese Government beneficiaries; search and arrange occupational activities. has approved a programme for social types of care services; (iv) Develop support and community-based intervention and assistance plans for Most of these establishments rehabilitation for people with mental beneficiaries; monitor and review collaborate with small businesses, health illnesses for the period 2011- intervention and assistance activities, organizations, and some individuals 2020 (Decision 1215). The programme and adjust plans if needed; (v) to provide production activities, aims at social mobilisation, especially Receive, manage, and care for social vocational training, create jobs and from families and communities, to protection beneficiaries who are in generate income for people with provide spiritual, material support seriously difficult situation, unable to mental illness through some simple and rehabilitation to people with take care of themselves and cannot occupations such as raising cattle mental illnesses and support them live in a family and community; (vi) and poultry, growing mushrooms, to integrate into the community, Provide primary medical treatment producing insent sticks and votive 18 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam paper, planting trees; contributing to environment; (ii) Support students the improvement of the beneficiaries’ to practice life skills, strengthen their material and spritual life. will, trust, courage and appropriate behaviors in social relations; While there have been a number exercise physical and mental health, of telephone hotlines operating contributing to the forming and in Viet Nam dealing with a range improvement of their personality. of topics, the most prominent, longest-operating one (since 2004) The quality of service provided that deals with young people and through these units, as well as the mental health issues is ‘the Magic level of training and commitment Buttons –18001567”. The number of of the counsellors appears to vary. this hotline has been changed to Units provided through government 111 from December 2017. Housed in schools and those outside of Hanoi MOLISA headquarters in Hanoi under and HCMC are generally of lower the Department of Child Care and quality, with students rarely using Protection, it operates 24 hours a the services. According to the day, 7 days a week and has 20 staff school psychologists, there are a and 10 collaborators /adjunct staff number of ways in which students with backgrounds in psychology are made aware of and can access and special education. There is an the counselling units. They can be advisory council of doctors and advertised during school activities, academics specializing in psychology teachers can identify students who and law to provide support in they think may be facing difficulties, difficult cases. Between 2014-2015, and the psychologists themselves the hotline received more than 2 may identify students through million calls from children and adults walking around the school area. At throughout the country. one school, a Facebook page was created for students. Service provision through MOET and schools Service provision through informal providers The mental health and psychosocial wellbeing of children and young The use of herbal medicines as people is potentially addressed well as shamanism appears to through schools by i) life-skills persist in some areas. Due to a range training and ii) psychological of interrelated factors including mental health challenges. For counselling units. Additionally, in remoteness from mental health example, a school in Hanoi provides some schools, particularly in Hanoi, service providers, lack of awareness, sessions for parents on parenting sessions on parenting skills are and adherence to ethnically based skills. Parents are also a focus in some starting to be provided to parents. community practices, people will of the hospitals in the cities. A health On 18 December 2017, the Ministry often take herbal remedies and worker in the national paediatrics of Education and Training issued a perform certain rituals before going hospital in Hanoi mentioned training circular guiding the implementation to formal healthcare providers – and classes held for parents with autistic of psychological counseling for this is true for mental health and and hyperactive children. students in general schools with other related problems, but possibly the purposes to: (i) Prevent, support more so for mental health challenges and intervene (when necessary) Challenges in service provision for students who are experiencing There is a sense that the family plays psychological difficulties in their an important role in the provision Supply side challenges study and life so that they can find of care for mental health patients approriate resolution and mitigate and could provide more if they were Generally, service delivery is negative impacts which may trained. In the cities there is a move mainly concerned with a group of possibly occur, contributing to the to both train and involve family people facing severe mental health establishment of a safe, healthy, members in improving parenting disorders, and pay relatively little friendly and violence-free school and dealing with children facing attention to the provision of services Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 19

for children and young people and policy implementation, distress issues. Similarly, the majority facing more common mental health improved coordination between of staff working at social protection disorders as well as psychosocial government departments is critical centres are not trained in social work, distress. Summarising the supply- in order to have effective policy or other relevant specialisations. side challenges: implementation. Moreover, the number of social workers is still limited, especially Limitations in coordination among Lack of qualified, sufficient and those working directly with patients. government departments. Our appropriate (gender) human findings suggested that there is a resources. The limited number Self-learning and on-the-job learning mixed level of coordination among of qualified staff was a challenge in relation to mental health appears government departments, and mentioned by all respondents, to be a coping mechanism given although there are some good particularly at district and provincial the lack of training provided. Even practices, there is still further levels and in relation to staff from where there were qualified staff, as is room for improvement. Similarly, a social work background and able the case in major cities, many were while the role of the DOH was to deal with less severe mental away on further training and short seen to be critical to coordination, disorders and psychosocial distress. courses, and others still often left it was also see to be lacking and Additionally, there was considerably upon receiving training. It was also in need of revision. According less capacity to deal with children noted that currently in Viet Nam as to study respondents, in order and young people presenting with a whole there are limited numbers to have effective programme mental health and psychosocial of students in the specialisations 20 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam that are needed. Lack of sufficient health doctors themselves that and availability, but even where (and qualified) staff also emerged mental health professionals do not there are appropriate services, as a problem in the provision enjoy the same status as doctors in people are reluctant to access them, of counselling / psychological the General Hospital. According to often because of the associated support in schools. In particular, one respondent, working in mental stigma. Even if they do access these when comparing public schools health is seen as a last resort, and services either they do not see their with private schools, it was noted according to another, ‘Psychiatrists importance or get disheartened that teachers were less willing to suffer from inferiority complexes’. when the individual does not appear take on and provide a counselling to be improving. service to their students because Infrastructure. Infrastructure- of their workloads and the fact that related challenges are more In remote areas, people will resort class sizes in public schools were frequently mentioned outside first to herbal medicines and perform so large (50-55 pupils, vs 25-30 in of Hanoi and HCMC. Challenges rituals, for both mental health and private schools). Additionally, it was range from having no provincial other related problems, which lead felt that there should be dedicated mental hospital, to having poor to delays in receiving efficacious and qualified psychologists or infrastructure and equipment, to treatment that can prolong the counsellors in schools, ideally of having insufficient space to expand course of recovery. The gender of each gender to facilitate confidence to accommodate more beneficiaries. providers also creates challenges among the students. With school counselling services, for uptake of services and stigma the office sometimes has remains a barrier to accessing Stress on existing mental health inadequate privacy assurances, thus services providers. Arguably mental health discouraging students from seeking providers face a double stress out the service. burden. First, because there are so Political economy of mental health few mental health providers, the Indeed, mirroring our respondent’s in Viet Nam existing ones have large workloads opinions, a report from the and, consequently, high levels of Department of Social Protection Currently Viet Nam has neither stress. Second, providers speak about (under MOLISA), found that an explicit mental health law, nor the high levels of stress because limitations of the social protection any specific legislation on mental of the subject matter. In terms of centres include poor quality services, healthcare for children. No policy remuneration, it was felt by some separation of the beneficiaries from dealing explicitly with children’s that their salary was not sufficient their families, poor infrastructure, mental healthcare has been put in compared to that of other healthcare and lack specialised equipment place, though general healthcare providers since psychologists have to and facilities, thus cannot meet the for children has been effectively devote much more time to a single special demands of beneficiaries encoded in the legal system, with patient. with regard to care, education, multiple policies and programs rehabilitation and psychosocial related to healthcare in place for Undervaluing /stigmatising of needs.. children. mental health services. Not only do people refrain from accessing mental Demand side challenges To strengthen the social support health services because of the stigma system, a wide range of legal associated with mental illness, but According to study respondents, documents has recently been there is also a sense coming from either people: i) do not recognise approved such as the Law on providers that mental health is mental health challenges; ii) even Children, the Law on Persons undervalued relative to other health if they do see that their child might with Disabilities, the Law on the areas. Given that mental health be facing difficulties, they do not Elderly, the Government Decree No. challenges are not as visible as are think they are important enough 136/2013/ND-CP dated 21 October physical injuries, people do not treat to seek assistance; iii) even if they 2013 regulating social support them as seriously; similarly, mental want to get help, they do not know policies for social protection health issues cannot be treated as where to get it; and iv) will only beneficiaries; Decree No. 103/2017/ quickly or straightforwardly as is access a service provider, rather ND-CP dated 12 September 2017 often possible with physical injuries, than caring for them at home, if providing for the establishment, whose treatments are concrete someone is seen to have a ‘serious organization, operation, dissolution and often result in rapid, visible mental health problem’. This is and management of social assistance improvement. There is also the particularly the case in areas where facilities; Decree No. 28/2012/ND-CP perception amongst the mental there are limited service options dated 10 April 2012 detailing and Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 21 guiding the implementation of a Additionally, in 2006, the Ministry with vision to 2030 expresses a number of articles of the Law on of Health issued the “National commitment to provide healthcare Persons with Disabilities; Decision comprehensive plan for protecting, coverage to all people, and it gives No. 1215/2011/QD-TTg dated 22 July caring and enhancing Vietnamese priority to poor regions, those 2011 of the Prime Minister approving teenagers’ and young people’s in difficult situations, and ethnic the program of community-based health for the period 2006-2010 minorities and other vulnerable social assistance and functional with vision to 2020”. Among other groups. The document uses a rehabilitation for mental illness things, “Mental trauma and other life-cycle approach in which policies, and mental disorders (2011-2020), issues related to mental health” are plans and mental healthcare services which has provided care, support seen as one of the main dangers to should be structured to account and rehabilitation to children with Vietnamese teenagers’ and young for the specific needs that arise in disabilities in general and children people’s health. There is also a push each life period (from newborns, with mental health problems in by the government to develop the to children, teenagers, adults and particular. social work profession with the Prime the elderly). Notably, the draft Minister Decision 32 in 2010 approved has a target related to mental The National Target Programme the Programme on development of health protection for children and on mental health started in 1998 Social Work profession period 2010- teenagers for prevention and early when the Prime Minister signed 2020. Thus, MOLISA has issued the detection of up to 50% of mental the inclusion of the Projectfor Circular (07/2013/TT- BLĐTBXH dated disorders by 2025. Community Mental Health 24/5/2013) to provide instructions on Protection into the National target how to improve commune/ward- According to study respondents, a programme on prevention and level social work collaborators. number of policy recommendations control of some social illnesses, have been put forth to improve upon dangerous epidemics, and HIV/ When study respondents were asked the national mental health program AIDS, now being a part of the their views on mental healthcare but are currently in draft phase. At National Target Programme for policy, particularly for children and the local level, our findings suggest Health. Since its operation, the young people, it was generally that there are also some specific project has developed a model for thought that it was lacking and plans for future implementation of the management, treatment and more attention needed to be paid programming and service provision care of people with schizophrenia to it, both within the health sector around mental health including and epilepsy in the community. and the schools. There was also more places to care for people facing Since 2001 up to now, the Project a sense that while there is policy mental health challenges. In other for the Community Mental Health on mental health, though not for places, it appears that the policies Protection has gone through three children, there was little or nothing and programmes have been agreed stages, each with different names. on psychological counselling. upon and they are just waiting for During 2001-2005, the Community investment, including staff. Mental Health Care and Protection When there are psychological Project (under the National Target services being provided, it is often Programme on prevention and through the private sector and is not Recommendations control of some social illnesses, regulated in any way. Generally, it dangerous epidemics, and HIV/ should be noted that current mental Based on our findings, the AIDS. In the period 2011-2015, the health-related policies are scattered report proposes a number of project is named as “Protection of in various legal documents in which recommendations: Mental Health for the Community mental health is mentioned to and Children”, which was under varying degrees. Additionally, mental 1. Better and more coordinated the National Target Programme health is generally not considered a policies on mental health on Health. The overall goal of the major issue in the provisions of these psychological counselling, for project is to develop a network documents. Even in the People’s children and young people and pilot a model for inclusion of Health Care Law, a very important mental healthcare with general legal document in the field of Consider improving the laws and healthcare of the commune/ward health, mental health issues are only policies related to mental health health station for timely detection, mentioned in a cursory manner. care in the social assistance and management and treatment so that social security systems in Viet Nam, patients can soon re-integrate into Looking forward, the draft document aiming at: 1) strengthening of human the community. of the National Strategy on Mental resources and 2) improving the Health in the period 2018-2025 quality of mental health care services 22 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam in social assistance establishments to ensure a holistic approach to The community health level model and in the community, and 3) supporting children and young appears to have been very successful development of specific policies people’s mental health and in general, although not yet at scale, explicitly targeting children and psychosocial wellbeing would indicating that there is a need to young people. This process would include the MOET’s Department of revisit and support retraining for need to be led by MOLISA and MOH Student Affairs, the Commission a cadre of community level health in collaboration with other key on Ethnic Minority Affairs, and the workers. ministries. Women’s Union. The content of the training School healthcare programmes Given the high level of unmet programmes need to be developed also need to address more specific demand for support services and jointly with mental health and issues related to mental health care treatment among children and psychosocial experts, drawing on and psychosocial support for school young people, capitalising on international best practice, but also children. existing NGO and private service ensuring that the particular realities providers by providing referrals of the Viet Nam context are taken It will be important for the as well as clear guidance on practice into consideration. Government of Viet Nam to approve standards will be an important short- the National Strategy on Mental term step. For all cadres of staff, it is important Health period 2018-2025, with its that on the one hand they are emphasis on providing healthcare 2. Increase quantity and quality incentivized to work in this sector, coverage to all people, giving priority of human resources and in particular in areas beyond to poor regions, those in difficult large cities. On the other hand, it is situations, and ethnic minorities There is an urgent need to enhance also critical that all these cadres are and other vulnerable groups. training to develop a cadre of provided with sufficient and good Adequate budget allocations from health workers, from nurses to quality supervision and guidance. the Ministries of Health, Education doctors, as well as specialist training. and Labour and Social Affairs (MOH, There is a strong need to pay 3. More and improved awareness MOET and MOLISA) will be required attention to developing training around young people’s to not only increasing the number of for more and better counsellors, psychosocial and mental health social workers, specialised medical social workers, psychiatrists, and care needs, as well as existing professionals, and community- and psychologists who could deal with support services school- based counsellors, but less severe types of mental health also to set standards and guidance problems and disorders. Moreover, Every year, MOLISA organizes for tailored training and periodic tailored training in each of these training to raise awareness among retraining. Additionally, synergies fields related to the needs of social work staff, collaborators and should be promoted through the children and young people is families about mental health care. implementation of the Master essential. There is, however, need to increase Plan for Social Assistance Reform these awareness raising activities and Development for 2017-2025, The role of the education sector in order to raise public awareness vision towards 2030 (MPSARD), and schools in particular is critical. around less severe mental which includes attention to social More training is needed to health and psychosocial needs assistance for particularly vulnerable establish a cadre of dedicated and of children and young people. In groups, including those with mental professional school psychologists particular, it would be important to health problems. In this regard, and counsellors, along with raise awareness about the linkages MOLISA will have a critical role to the appropriate infrastructure between discriminatory social norms play in ensuring integrated policy (counselling units /centres). and mental ill-health. and programme implementation. It is also essential to develop a cadre Awareness-raising can be done Policy implementation will also of professional of social workers. through: developing training necessitate providing clear In addition, there is an urgent need curricula for different carders of guidance and mandates to all to strengthen the knowledge and workers and relevant to their sector relevant agencies – MOH, MOET capacities of the staff at Social (health, education); developing and MOLISA – to ensure that goals Protection Centres. Finally, there communications activities of the national strategy are reflected could be important dividends in targeting communities; and through in their respective policies and developing a cadre of para-social providing information at service programmes. Additional linkages workers (commune collaborators). points. Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 23

This awareness-raising could be budget from MOH, MOET, and of knowledge children are expected done at various levels, starting MOLISA. to learn; iii) Invest in developing at the commune level, providing psychological counselling in all communities also with more (v) At the same time, establish schools, especially for children of information about the role of the collaborations and partnerships ethnic minorities; and iv) Equip social workers as well as hotlines. between line ministries for the parents with skills that can help The Women’s Union as well as provision of services to ensure ease the problems that children face other grassroots political and social complementarity and best use at school and at home. organizations at ward or commune of resources. A cross-ministerial level, could also potentially play a working group and collaboration 6. Further research and better role in raising awareness. regulations could be set-up to data facilitate this at national level, which Related to this, it would be beneficial could also be mirrored at provincial Broadening the geographical to support parents with parenting, and commune level. (iv) Capitalis scope in subsequent studies to caring and communication skills on the connectivity of many young cover a wider range of regions and training and support, including people, and ensure that there are ethnicities would be important. regular follow-ups in order to strong online sources of information Specific areas of research to address promote behavioural norm changes. and support that can be accessed paucity of data in this area include: by mobile phones or computers, It is also vital to ensure that the while at the same time ensuring that • Local level service mapping approach is inter-sectoral - at there are adequate safeguards in in order to inform local the commune level working with place to protect children from the communities about what teachers would be critical and negative dimensions of social media. services are available. Prior to training them to detect early Facilitate support groups for parents, that, it is necessary to assess the warning signs and to refer students especially for parents caring for quantity, quality, variety and to school counsellors and relevant children with specific and diagnosed density of service providers. healthcare professionals, commune mental health disorders; In addition, office staff, and social workers. there is a need to invest in systemic • National data collection on counselling, i.e. working closely manifestations and prevalence 4. More and better coordinated with families to help them provide of different mental ill-health and services throughout the country adequate attention and care to their psychosocial problems children. Through health and social protection • Improved monitoring and facility systems, MOH and MOLISA In order for these changes to happen evaluation reporting at all levels, should: a clear governmental champion from commune through to is needed to raise the profile of the central levels vis-à-vis service • Increase the number and specificity of children’s mental health provision for children and young quality of mental health and needs at national level and across people psychosocial-related services sectors. throughout the country, while • Improved data collection and at the same time ensuring that 5. Ministry of Education should databases on referrals and appropriate and dedicated take on role for championing follow-ups infrastructure is in place for children’s needs for better provision of specialized support mental health and psychosocial • Further analysis of the strong related to mental health and wellbeing linkages with underlying psychosocial wellbeing. gendered social norms that MOET has a key role to play through impinge on adolescents’ mental • Develop clinical diagnostics both primary and secondary schools, and psychosocial wellbeing standards and activities for to: i) Support a focus on prevention children and young people by teaching children the skills • Studies on a larger scale and thus allowing for the early needed to respond to emotional and among particular groups, such detection and treatment of psychological difficulties faced in as children and young people mental health challenges as relationships with parents, teachers, in special situations, or ethnic well as psychosocial distress. friends and others; ii) Relieve study minority groups. This requires active support and pressure by evaluating the volume 24 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

CHAPTER 1 Introduction and background 26 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

Mental health has been recognised group of causes i.e. the social factors ill-health and psychosocial distress, as an integral part of broader and environmental, to which this the study does not focus on severe definitions of health (see e.g. WHO, study contributes. Thus a range of mental disorders. Rather it focuses 2001), wherein mental health is not social and environmental factors on mental ill-health and psychosocial equated simply as the absence including rapid social change, distress at the milder end of the of mental disorder, but includes migration, social isolation, conflict/ mental health disorder spectrum, subjective wellbeing, self-efficacy, post-conflict environments, also referred to as common mental autonomy, competence, and unemployment and poverty, disorders (CMDs), and largely to what realization of one’s potential individual and family crises, changes have been defined internationally in traditional values and conflict with as internalising/emotional problems Widening out the discussion to also parents, have been recognised by a such as anxiety, depression, include the notion of psychosocial range of scholars as being key drivers loneliness, sadness and somatic wellbeing, a body of literature of mental ill-health and psychosocial complaints, all of which can have across various disciplines, though distress and particularly amongst a range of negative outcomes, largely from psychology, explores young people (e.g. Patel et al., 2007; including suicide. See also Box 1 for the causes of both mental ill-health Stavropoulou and Samuels, 2015; definitions of mental disorders and and psychosocial distress showing WHO, 2010) psychosocial distress. that it is multifactorial and includes biological, psychological and social It is also important to note, and as The purpose of this study, therefore, and environmental factors (see was reflected in the research team which was carried out by UNICEF Viet e.g. Chesney et al, 2015; WHO 2001; composition, and following the Nam, with research and technical WHO and Calouste Gulbenkian focus discussed above on social and expertise provided by the ODI and Foundation, 2014). It is the latter environmental drivers of mental IFGS, is to provide an overview of Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 27 the situation regarding the mental Ministry of Education and Training health and psychosocial wellbeing and other key stakeholders and Box 1: Some of children and young people/youth service providers working closely in selected provinces and cities in with children and young people definitions Viet Nam. The study was guided including social workers, teachers, According to WHO, mental by four overarching research health staff and parents. disorders are defined as “a questions: combination of abnormal This study also draws, builds on and thoughts, perceptions, • What is the prevalence of complements ongoing work carried emotions, behaviour and mental health and psychosocial out by ODI in partnership with IFGS relationships with others,” problems, including suicide on gendered social norm change whereas biologically based disorders can include among Vietnamese children and processes (e.g. around the value of depression, bipolar affective youth? girls’ education; the gender division disorder, schizophrenia and of labour and decision-making in the other psychoses, dementia, • Which factors in the Vietnamese household, marriage, gender-based intellectual disabilities and context place children and violence) with young people which developmental disorders youth at risk and which factors we believe is vital to contextualise including autism (WHO, fact act as protective factors for mental health and psychosocial sheet 2016). In addition to mental health and psychosocial wellbeing (Jones et al., 2013; 2014; biologically based disorders, problems, including suicide? 2015)1. Such discriminatory norms mental health can also be are typically influenced by multiple affected by psychosocial • What laws and policies exist contexts (global discourses and factors that cause distress. around mental health and international frameworks, national According to the Capetown Principles, ‘psychological psychosocial wellbeing in Viet political ideologies and development effects' are defined as Nam? trajectories, subnational context), those experiences that but are also reframed through affect emotions, behaviour, • What kind of mental health and individual and community thoughts, memory and psychosocial service provisions experiences and perceptions (see learning ability and the and programmes exist for e.g. Munoz Boudet et al., 2012; Mackie perception and understanding children and youth in Viet Nam? and LeJeune, 2009; Petesch, 2012). of a given situation” (Capetown Principles, UNICEF Findings from the study do not 1997). These include social purport to be representative of the effects on well-being as a result of various factors such whole of Viet Nam; nevertheless, 1. There are many different definitions of as poverty, war, migration, they do represent the situation in social norms, but all of them emphasise famine, climate change and certain areas of the country. The age the importance of shared expectations or informal rules among a set of people (a so on. group of 11-24 was selected given reference group) as to how people should the focus of UNICEF work relating to behave. Most also agree that norms are held in place through social rewards for people children and youth but also given who conform to them (e.g. other people’s the understanding that this is an approval, standing in the community) and social sanctions against people who do age group facing particular mental not (e.g. gossip, ostracism or violence). health and psychosocial challenges Harper and Marcus (2015) define norms both globally and in Viet Nam. as the informal rules governing behaviour, distinguishing these from underlying Findings from this study will inform values and from practices – regular recommendations on how to address patterns of behaviour – which they see as challenges around mental health the manifestation of norms, values and of other factors. To understand the ways that and psychosocial distress and will different factors contribute, they suggest feed into the existing national level that it can be helpful to distinguish between three closely linked, but distinct elements: programmes including the National i) Underlying values – such as ideologies of Programme on Social Support male superiority, of men’s right to women’s and Rehabilitation for People with bodies, and of girls’ and women’s place being in the home; ii) Norms of behaviour – Mental Illness as well as the National such as it being acceptable for men to leer, Targeted Programme on Health. The wolf-whistle, make sexually explicit remarks or to touch women (without their consent) main audience for these findings and iii) Practices (or regular patterns of will, therefore, include MOLISA, the behaviour), which are manifestation of Ministry of Health, the norms and other drivers – in this case, sexual harassment. 28 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

In the remainder of this section we to understanding mental illnesses. al., 2010; WHO, 2015a). It has been present an overview of the global Therefore, living in a home with a predicted that over the next two and regional literature on mental caregiver who suffers from mental decades mental illness will account health and psychosocial wellbeing, illness may place a child at risk since for the largest proportion (35%) of and also a short conceptual he/she will learn behaviours that are global economic losses from non- framework through which to maladaptive and will consequently communicable diseases (Bloom et al., provide an understanding on how perceive the world in maladaptive 2011), with an estimated $16.3 million we present and analyse findings ways. Finally, psychodynamic cumulative global loss of economic from the study2. In Section 2 we theories underscore the dynamic output between 2011 and 2030 (World present the study methodology interrelationship between the Economic Forum, 2011). and a description of the study sites. biological, psychological and Sections 3 to 7 present the bulk of social dimensions of life, with each the primary fieldwork findings, also continually influencing the other 1.3 Mental health and psychosocial referring to findings particular to (Capetown Principles, UNICEF, distress affecting children and Viet Nam from the literature review 1997). Biological dimensions include young people where relevant. Therefore, in Section genetic and physical factors with 3 we explore the manifestations which each human being is born; and prevalence of mental health psychological dimensions include Serious and persistent mental and psychosocial challenges facing emotions, behaviour, thoughts, illness and developmental delay children and young people; in memory and learning ability, as affect all populations and roughly Section 4 we examine the risk and well as capacity to perceive and 20% of children and adolescents protective factors at different levels; understand everyday situations. globally (WHO, 2016). Psychosocial in Section 5 we describe the service Social dimensions refer to people’s distress – which can lead to suicide, environment around mental health, relationships to each other, their substance use, and poor educational and in Section 6, we cover challenges community and the world around outcomes – disproportionately in service provision. In Section 7 them from culture and belief systems affects vulnerable populations, we discuss the political economy to economics. including ‘members of households environment within which mental living in poverty, people with chronic health programming and services are health conditions, infants and situated. We end in Section 8 with 1.2 Global mental health children exposed to maltreatment conclusions and recommendations. and neglect, adolescents first Mental health problems, (see exposed to substance use, minority definitions in Box 1), affect more than groups, indigenous populations, 1.1 Theoretical underpinnings of one in four persons, with disorders like older people, people experiencing mental health depression affecting more than 350 discrimination and human rights million people globally (WHO, 2015a). violations, lesbian, gay, bisexual, and Several theoretical paradigms Indeed, common mental disorders transgender persons, prisoners, and underpin understandings of mental (CMD), which this study focuses on, people exposed to conflict, natural illnesses, and the most commonly comprising anxiety and depression, disasters or other humanitarian cited theories fall under three are the most prevalent psychiatric emergencies’ (WHO, 2015c: 7). schools of thought: behavioural illnesses among adolescents and Children and adolescents are theories, cognitive theories, and young people worldwide (WHO, particularly vulnerable – 10%-20% of psychodynamic/developmental 2001a). Additionally, suicide, linked children and adolescents have been theories. Behavioural (e.g. Skinner, strongly in high income countries with found to experience psychosocial 1938; Pavlov, 1902; and Watson, depression, claims the lives of over problems (Kieling et al., 2011). 1913) approaches suggest that all 800,000 people annually across the Indeed, suicide rates are increasing; behaviours are acquired through globe (WHO, 2015b). Between 1990 young people are now the group at conditioning, i.e. that learning occurs and 2010, the burden of mental and highest risk of suicide in one-third through repetition of behaviour. substance use disorders increased by of all countries, both developed and Cognitive theories suggest that 37.6% globally (Whiteford et al., 2013). developing (WHO, 2007). In fact, how people think, perceive, This burden has a significant impact suicide is a leading cause of death remember, and learn are central on the individual and has major among young people in China and social, human rights and economic India (Patel et al., 2007). Apart from consequences at country level as mortality, mental health problems 2. See Samuels, et. al. 2016 for a full literature well (Bloom et al., 2011; Levinson et have other negative consequences review. Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 29 for young people, such as lower prevent mental health problems Thus, the Sustainable Development educational achievement, as a result of psychosocial causes Goals (SDGs) declared the need substance abuse, violence, and poor have had positive outcomes to strengthen mental health by reproductive and sexual health. (Kieling et al., 2011). Similarly, there promoting “physical and mental has been growth in community health and well-being…for all” The cause of mental illness and based psychological support that (Paragraph 26) with specific mental psychosocial distress in children complements psychiatric services, health goals in targets 3.4, 3.5, and and young people is multifactorial including medication (Bragin, 2014). 3.83. In Southeast Asia, the World with several identified contributory Health Organization (WHO) has biological, psychological and social Many of these improvements are begun to collect data on youth factors. Biological factors that are focused on developed nations, mental health – especially as a result known to underlie serious mental while mental illnesses are largely of psychosocial factors – in countries illnesses (such as schizophrenia, neglected, or even ignored in many such as Thailand, Sri Lanka, and India developmental delays, and autism) developing countries (WHO, 2001b). (WHO, 2005), but there is limited and persistent mental illnesses Moreover, issues around mental information on child and adolescent (susceptibility to depression, anxiety, health illnesses are absent from the mental health in Viet Nam. Moreover, and paranoia) can include genetic Millennium Development Goals while suicide rates in the 15-19 age background and brain abnormalities. (MDGs) and other development- group is higher for males than Brain abnormalities may stem related health agendas (Samman females (e.g., in Kazakhstan, Russian from abnormal brain growth and & Rodriguez-Takeuchi, 2013). Federation, Belarus, Estonia, Ukraine underconnectivity among brain For adolescents in developing to name a few). This is not the case regions, brain injury (prenatal or countries, mental health needs are in China and Sri Lanka (Wasserman post-birth), and exposure to toxins, neglected and unmet as a result of et al., 2005), suggesting that the such as lead. Social factors include poor government mental health Southeast East Asian contexts need rapid social change, migration, social policy, inadequate funding, a to be further examined. isolation, unemployment and poverty, shortage of professionals, the low increasing social pressures to perform capacity of non-specialist health well, peer pressure, individual and workers and the stigma attached 1.5 Rapidly changing context of family crises, changes in traditional to mental illness (Patel et al., 2007; Viet Nam values and conflict with parents (Patel Kieling et al., 2011). For both medical et al., 2007; WHO, 2010). Physical health treatments and psychosocial care, Since the 1980s, there have been and nutrition problems, maternal governments spend on average less vast economic changes in Southeast depression and lack of psychosocial than $2 per person annually and Asia, and Viet Nam has transformed stimulation, caregiver loss, deficiencies less than$0.25 per person in low- from a socialist economy to a in the psychosocial environment, income countries on mental health market economy over the past 40 exposure to toxins, violence care, and the majority of funds is years. This has resulted in, amongst and conflict, migration or forced allocated to psychiatric hospitals other things, an annual gross displacement, gender inequality, and institutionalised care (Whiteford domestic product (GDP) growth abuse and neglect have also been et al., 2013; WHO, 2011). As a result, of approximately 7.4% between identified as causes of mental health WHO estimates that over 75% of 1991 and 2009 (Giang, 2010). Viet problems (Kieling et al., 2011). the global burden of disability due Nam’s rapid poverty reduction to depressive disorders occurs in is recognized globally; current 1.4 Mental health treatment and developing countries (WHO, 2008). indicators suggest that only about There is, however, a significant gap psychosocial support responses in the knowledge base concerning children’s mental health despite the 3. From SDG paragraph 26: “3.4 – By 2030, Over the past 25 years, treatments fact that almost 9 out of 10 children reduce by one third premature mortality from non-communicable diseases through for mental disorders in young people live in LMIC (Kieling and Rohde, 2012). prevention and treatment and promote have improved. Several forms of mental health and well-being. 3.5 – psychosocial interventions that With rapid economic changes, Strengthen the prevention and treatment of substance abuse, including narcotic focus on the individual, family or psychosocial factors are leading to drug abuse and harmful use of alcohol. group have also been shown to high burdens of disease and mental 3.8 – Achieve universal health coverage, including financial risk protection, access have encouraging results (Patel health conditions (Dzator, 2013), to quality essential health-care services et al., 2007). For instance, various so the need to focus on mental and access to safe, effective, quality and school-based programmes to health has became more urgent. affordable essential medicines and vaccines for all. 30 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

11.3% of the population is below care. Children and adolescents are teachers and peers, and academic the poverty line, and there is a yet another vulnerable group, and pressure. The next tier up is that of primary school enrolment rate of since 23% of Viet Nam’s population is the broader community; at this level 100% (Databank, 2016). However, under the age of 15 (World Bank 2013), factors such social norms related to similar to other LMICs that are there is an urgency to understand the for instance early marriage, as well rapidly developing, Viet Nam’s needs mental health and psychosocial as income-generation opportunities transformation appears to have support needs of this population. for men and women and the broader been limited largely to physical environment are all likely to play a infrastructure directly connected role in effecting the mental health to economic development while 1.6 Conceptual framings and psychosocial wellbeing being of sectors aimed at social development children and young people (chapter such as health have garnered To situate and present our findings, 4). relatively little attention (Stern, we adopt a socio-ecological 1998). Moreover, economic reform framework which explores factors at The next tier is conceptualised as coupled with widespread social different levels of the social ecology the institutional level which includes change has put increasing pressure – individual, family/household, both the service environment and on families, which has contributed to school, community, institutional – provisions (chapters 5 and 6) as well emotional distress in a context that and the ways in which they interact as the policy and legal environment lacks social infrastructure support. and contribute to both drivers or and frameworks (chapter 7). These This is quite similar to other fast risk factors of mental health and can also be seen as the institutions, developing nations, such as China, psychosocial well-being as well as structures or routes through where ‘Rapid social and economic protective factors. Given the focus which national-level resources change has been associated with is on children and young people, and priorities for addressing a loss of social stability, and with it they are placed at the centre of the mental health and psychosocial a rise of depression and suicidality’ framework surrounded by a range of wellbeing are refracted. Thus formal (Blum et al., 2012, pp. s37). Similarly, influences that affect their individual institutions include policy, legal and the overall neglect of the health mental health and psychosocial justice frameworks for addressing sector has included lack of care for wellbeing including and ranging mental health and psychosocial children and adolescents suffering from their education status, their wellbeing as well as formal service from mental and neurological relationship with their parents provision through government and disorders and developmental delays. and peers, their body image, their NGO. Informal service providers access to modern technology and or institutions may include family Finally, with the increasing pressure social media and the extent of their support or traditional or faith of uncontrolled urbanisation in a support networks as well as other healers. All these institutions will largely rural country and inadequate coping strategies (both positive also affect the mental health and support for those in need of mental and negative). Individual mental psychosocial wellbeing of children health services, mental health health and psychosocial wellbeing and young people. problems appear to be on the rise. is also influenced by the family or household level dynamics and status, Finally, all these tiers are located Moreover, despite the social and the next level of the socio-ecological within broader national and global economic progress made as a result framework. Variables here might contexts. At national level, country of the Doi Moi programme4, there include the economic status of the priorities, national level allocation remain large disparities in access to household, the extent of parental of resources, as well as national and social and health services among control, relationships between regional contextual factors (e.g. different geographical regions parents and intra-household population dynamics, migration, and income groups (Dang, 2010; dynamics and tensions. Given that climate change, etc.) may all affect Vuong et al., 2011). Dang (2010) schools settings play a central role the ways in which mental health and notes, for instance, that as a result of in the lives of children and young psychosocial wellbeing-related laws commercialising healthcare, those in people, this is the next level up or and policies are prioritised and then poverty and of ethnic minority status tier when exploring both risk and operationalised in national agendas. have limited access quality health protective facts for the mental Global-level conventions and policies health and psychosocial wellbeing of as well as donor attitudes and children and young people. Variables investments in responding to mental

4. The name given to the economic reforms affecting children and young people health and psychosocial wellbeing initiated in Viet Nam in 1986 with the goal are likely to include the school also are likely to play an important of creating a socialist-oriented market environment, relationships with role in fostering an enabling economy. Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 31

environment. This latter dimension, the ways in which mental health and however, was not explored in this psychosocial wellbeing-related laws study and would be interesting to and policies are prioritised and then explore further in a separate study operationalised in national agendas. distress in a context that lacks social Global-level conventions and policies infrastructure support. This is quite as well as donor attitudes and similar to other fast developing investments in responding to mental nations, such as China, where health and psychosocial wellbeing ‘Rapid social and economic change also are likely to play an important has been associated with a loss of role in fostering an enabling social stability, and with it a rise of environment. This latter dimension, depression and suicidality’ (Blum however, was not explored in this et al., 2012, pp. s37). Similarly, the to study and would be interesting to quality essential health-care services explore further in a separate study. and access to safe, effective, quality and affordable essential medicines and vaccines for all. overall neglect of the health sector has included lack of care for children level, country priorities, national level allocation of resources, as well as national and regional contextual factors (e.g. population dynamics, migration, climate change, etc.) may all affect 32 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

CHAPTER 2 Methodology 34 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

The study consisted of two stages: •• What is the prevalence of 2.2 Primary data collection the first was a review of secondary mental health and psychosocial materials, the second entailed problems, including suicide To complement and triangulate primary data collection in a number among Vietnamese children, findings from the literature review, of sites in Viet Nam. adolescents, and youth? and to address possible information gaps, primary qualitative data •• Which factors in the Vietnamese collection was carried out in selected 2.1 Secondary data review context place children, provinces and cities in Viet Nam adolescents, and youth at- between March and June of 2016. The aim of the literature review risk and which factors act as was twofold: i) to provide an overall protective factors for mental 2.2.1 Site selection and picture of the situation and causes health and psychosocial description of mental health issues, including problems, including suicide? suicide, focusing on children and The selection of sites was carried out young people in Viet Nam and •• What laws and policies exist in close consultation with the UNICEF ii) to inform the preparation for around mental health and Viet Nam team. Broad site selection the primary data collection and psychosocial wellbeing in Viet criteria included: i) the importance analysis, including identifying Nam? of obtaining both an urban and information gaps. Further details rural perspective, given that there of the methodology used for the •• What kind of mental health and are likely to be differing risk factors literature review can be found in psychosocial service provisions in these areas and arguably, as Samuels et al, 2018. The first step and programmes exist for the literature also shows, higher of the literature review, conducted children, adolescents, and youth risk factors (e.g. substance abuse, between January and February in Viet Nam? unemployment, violence) in urban 2016, was to develop a clear search areas; ii) the importance of ensuring protocol that identified research Databases searched included: that the north and south of Viet questions, inclusion/exclusion EBSCO, MEDLINE, PubMed, psycINFO, Nam and their unique features are criteria, appropriate databases, Social Sciences Index, Proquest, and captured; and iii) the need to ensure combinations of search strings to JSTOR. Sources for reviews included a selection of areas where a priori retrieve articles, and a key informant peer reviewed journal articles and there appeared to be relatively high interview protocol. A combination books, policy documentation from levels of mental health issues or risk of key words on topics related to our government and international factors and/or where there are high review that were used in different agencies, and grey literature levels of poverty, which, based on combinations of AND/OR/NOT in (including NGO, government reports our previous work in Viet Nam, tends the database search function was and evaluations). For peer- reviewed to translate into high levels of stress, also drafted. Keywords included: journal articles, we also conducted anxiety, and other mental health risk psychiatry, mental health, mental a search in journals that were factors (Jones et al., 2014; 2015). illness, mental disorder, psychosocial identified by experts in the field to wellbeing/ill-being, mental disorders be most relevant and credible to the With the above broad criteria in diagnosed in childhood, mental topic. In addition, a search for articles mind, it was decided to first focus retardation, ADHD, anxiety disorder, was conducted on websites relevant on the two largest urban centres in posttraumatic stress disorder to the topic. Finally, we interviewed Viet Nam: Hanoi and Ho Chi Minh (PTSD), depression, mood disorder, (through Skype or email), eight City (HCMC) and then to select a suicide, substance abuse, personality experts in the field, to seek their northern and southern province – disorders, stress, maternal opinion on seminal resources on Dien Bien and An Giang, respectively. depression, paternal depression, mental health, both globally and in In both of these provinces, again in bullying, peer pressure, services, Viet Nam. order to get a rural and urban/peri- clinics, programmes, interventions, urban dimension, interviews in the trials. provincial capitals of each province took place (Dien Bien Phu city in Specific research questions guiding Dien Bien and Long Xuyen city in An the review, and which were also Giang) as well as interviews in the derived from the original proposal, rural areas (Keo Lom in Dien Bien and are outlined below: Phu My town in a rural district of An Giang). Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 35

Hanoi, the capital of Viet Nam, has Dien Bien is a mountainous province were older people who committed its own particular situation given the in the Northwest region of Viet Nam. suicide by hanging themselves or government presence. According to The only province in the country that taking pesticides; the remaining the 2014 mid-term population census shares borders with both China and victims were aged 24 or younger and (Ministry of Planning and Investment Laos, Dien Bien’s total population took poisonous “heartbreak” leaves. (General statistics Office), 2015), the is divided into 10 district-level Annex 1 contains suicide data from city’s total population is just over 7 administrative units, including one Dien Bien Province, including at million, divided amongst 12 urban city (Dien Bien Phu), 1 district-level district and commune levels. districts, 17 rural districts, and 1 town, town and 8 rural districts, with a total for an average population density number of 112 wards and communes An Giang in the Mekong Delta of 2,126/km2. Hanoi has a high and commune-level towns. Presently, region of Viet Nam, shares a border number of public health facilities Dien Bien is home to 21 different with Cambodia, and is the 4th largest and the non-public health facilities ethnic groups, of which Thai people province in terms of geographical are also well-established, including make up the majority (about 42.2%), area with a total population of international hospitals. In recent followed by H’mong (27.2%), Kinh 2,155,381 persons and a density of years, considerable investments (19%) and Kho Mu (3.9%)(ibid). 609 people/km2. An Giang has 9 have been made in healthcare, rural districts, which are further including medical equipment and Keo Lom commune in Dien Bien subdivided into 156 communes and the construction of hi-tech medical Dong district (one of the country’s wards (including 120 communes, 20 areas. Over the last decade or poorest districts) was chosen as wards and 16 commune-level towns). so, citizens, including vulnerable the rural site in Dien Bien Province. Long Xuyen city is the province’s children and social welfare Keo Lom commune has 25 villages, capital. The field study was carried beneficiaries, have been enjoying with 6,378 persons living in 1,210 out in Phu My town (one of the two better access to medical services. households. The four main ethnicities commune-level towns of Phu Tan However, the healthcare needs of include Hmong (59%), Kho-Mu (20%), district). The town has 9 villages, with people are still greater than the Thai (20%) and Kinh (1%). The distance 5,617 households and a population of capacity of the hospitals, resulting from the commune centre to the over 21,000 people. The majority of in frequent overloading of these most remote village is 20 km, with the population are followers of Hoa facilities. many villages only accessible by car Hao Buddhism. The primary source in the dry season. Services are limited of income is agriculture. The service HCMC in the south, is culturally and the poverty rate was 77.3% in 2015 sector remains underdeveloped. Due distinct from Hanoi and more (ibid). In the commune, there is one to agricultural mechanisation and ethnically diverse given very high health station, one ethnic minority limited farming land resources, many rates of internal in-migration. The secondary boarding school, two families have moved away, mostly to largest city in Viet Nam in terms of primary schools, two kindergartens HCMC or Binh Duong to work in the both population size and growth, its and a number of satellite primary industrial parks, or become masons nearly 8 million residents are divided schools and kindergartens in remote or seasonal labourers (ibid). among 19 urban districts and 5 rural villages. districts, for a population density of 2.2.2 Methods and respondent 3,796/km2 (ibid). HCMC is the key Most children manage to complete types economic, financial, commercial and secondary education, but some service centre of the country, its GDP still drop out due to family financial A range of qualitative data comprising one-third of that of the constraints or lack of motivation. methods were used including whole nation. It is also the nucleus of While child marriage has started In-depth interviews (IDIs), focus the southern economic area – one of to decline in the past few years, it group discussions (FGDs), and key the three largest economic areas of remains a common practice. The informant interviews (KIIs). Purposive Viet Nam – and an important driver commune has a high rate of drug sampling was used to ensure that behind socioeconomic development users and also recorded the highest the kinds of study respondents in the south and the country as number of child and youth suicide required to meet the overall study a whole. Regarding healthcare, cases in Dien Bien Dong, a district objectives were included in the large investments in healthcare known as a hotspot of child suicide sample. IDIs were carried with infrastructure and modern often hi- in the province. According to the children and young people, mostly tech medical equipment have been commune health station’s data, there recruited through lower and upper made. Private healthcare services are were 40 suicide cases between 2007- secondary schools. FGDs were also also increasingly being developed in 2015, including 35 Hmong, 3 Thai and carried out with children and young HCMC. 1 Kho Mu. Four out of these 40 cases people, again mostly recruited 36 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam through schools, with some cases Table 1: Respondent types and numbers by location of attempted suicide and early marriage recruited through KIIs and snowballing; additionally, a Location IDIs KIIs FGDs Total Total of number of FGDs with parents were people undertaken at community level as well as with service providers. Finally Hanoi 4 26 4 34 57 KIIs were carried out with mental HCMC 4 14 4 22 40 health and psychosocial service providers at central level and in the Dien Bien Province different provinces (psychiatrists, Dien Bien Phu city 3 9 2 14 28 counsellors, mental health doctors); government officials from different Keo Lom Commune 6 9 3 18 34 line ministries (social welfare, health, An Giang Province education) at central level and in the provinces; and community level Long Xuyen City 2 5 1 8 14 stakeholders (community leaders, Phu My Town 4 4 6 14 37 village elders). Total 23 67 20 110 210 A total of 110 interviews were carried out and included 23 IDIs with children, 67 interviews with KIs and As mentioned above, 23 IDIs along with 16 group discussions were held with 20 FGDs (16 with children, 2 with children. The total number of children included in the qualitative study was 113, parents, and 2 with officials). In terms of which 39 were in the age group of 10-14, 69 in the age group of 15-17, and 4 of location, there are 57 participants were 18 years and above. In terms of gender, approximately equal numbers of in Hanoi, 40 participants in Ho Chi boys and girls were interviewed: 56 girls and 57 boys (See Table 2). Minh City, 62 participants in Dien Bien province, and 51 participants in Table 2: The age of children as the whole qualitative sample An Giang province (See Table 1).

Location 10-14 15-17 18-29 No of No of Total yrs yrs yrs girls boys

Hanoi 13 14 1 15 13 28 HCMC 12 13 10 16 26 Dien Bien 1 30 2 18 15 33 An Giang 13 12 1 13 13 26 Total 39 69 4 56 57 113

Interview guides were developed by the study team in a participatory manner, drawing on existing tools and best practice in this area, but also adapted to the Viet Nam context. The interview guides were also piloted and refined following this pilot.

In addition to undertaking the above interviews, rapid assessment tools were carried out with school children across all study sites. A total of 402 children across the different site took part in this assessment. In each site, the team selected children at two education levels – Secondary (age 11-14) and High school (age 15-17) - 46.3% of the children were in secondary school, and the rest, 53.7%, were in high school. Girls make up 60.2% and boys 39.8%. Figure 1 contains a detailed demographic characteristics of children included in the assessment. Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 37

Figure 1: Demographic characteristics of the children took part in assessment (N=402)

Southern Viet Nam (n=196) 48.8

Region Northern Viet Nam (n=206) 51.2 Ho Chi Minh (n=78) 19.4 An Giang (n=118) 29.4 Dien Bien (n=104) 25.9

CityProvinces Ha Noi (n=102) 25.4 Rural (n=229) 57

Areas Urban (n=173) 43 Upper Sec. School (n=216) 53.7

Grade Lower Sec. School (n=186) 46.3 Girls (n=242) 60.2 Boys (n=160) 39.8 Gender 16+ (n=216) 53.7

Age <=15 (n=186) 46.2

The aim of these tools was to obtain, read by the in-country study lead to in a fairly fast and efficient way, a scales and Annex 3 contains a detailed ensure quality and consistency. relatively large number of responses analysis of the findings. from children on what they think After the translation, a preliminary about their own mental health and 2.2.3 Sample size coding structure was developed psychosocial wellbeing. based on the interview guides Table 1 below identifies the kinds and emerging findings. Interviews After consultation with a number of of respondents and tools by site. As were then coded using MAXQDA 12 experts, it was decided to use two mentioned above, recruitment of software (a qualitative data analysis tools: the Strengths and Difficulties respondents was carried out through software package) following this Questionnaire (SDQ) and the Self- schools, snowballing and KIIs. The preliminary coding structure, with Efficacy and Resilience tool. The SDQ large sample size was determined by a additional sub-codes developed had already been used in Viet Nam combination of resource parameters, from the interviews as coding as part of the Young Lives Study,5 the importance of triangulating progressed Once all interviews were and while the latter tool had not findings across diverse informants coded, the codes were reassessed previously been used in Viet Nam (to as well as the principle of research based on emerging themes, the the knowledge of the researchers), saturation, i.e. reaching a point where broader literature and the areas of the content and ways of framing/ no new insights were being garnered interest for this study, after which asking questions were deemed by additional interviews. several codes were grouped together more appropriate for the study, its and a set of meso-level codes respondents, and the Vietnamese 2.2.4 Analysis of qualitative data were identified. Following this, the context than other tools. Both tools interviews were analysed by reading were reviewed for language related After obtaining informed consent coded portions of interviews across issues and some minor changes were from research participants, all participants. made. According to respondents, IDIs, KIIs and FGDs were recorded, the tools were easy to understand transcribed and translated. When For the first layer of analysis, we and complete. Box 2 below contains possible, two persons attended each created groups of participants, a summary of findings from these interview which allowed for better that were based on a review of debriefing and reflection after the preliminary findings, areas where end of each interview. A subset the researchers though interesting of the transcripts (both in local differences and similarities may languages and translated) was also emerge and in order to ensure that 5. 38 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam the study was reflecting context- some limitations. Due to limited identify children that they thought specific issues emerging from research in the area of mental health exhibited unusual behaviour at the transcripts. Thus groups were in Viet Nam and the review’s focus school. created based on: age of respondent on the mental health challenges – 3 age categories were developed, of Vietnamese children and young Additionally, given that our prior also corresponding to schooling people, the pool of sources from research had shown that early divisions, 11-14 (lower secondary which we could draw was relatively marriage caused much anxiety and school), 15-17 (upper secondary limited. Additionally, while we stress particularly amongst girls and school) and 18+ (upper secondary tried to ensure that our inclusion/ young women, we sought help from school and beyond); gender of exclusion criteria were neither too community level key informants to respondent – male or female; and broad nor too rigid, we may have identify these cases. location – rural (Keo Lom {Dien Bien}, missed some grey literature that Phu My town {An Giang}), semi urban could add nuance to the trends that Finally, given relatively high rates of (Dien Bien Phu city {Dien Bien}, Long we discuss. suicide and the particular interest in Xuyen city {An Giang}) and urban this phenomenon in this study, key (Hanoi and HCMC). For each group, In terms of the primary data informants also helped us identify all coded segments were analysed, collection, we also faced a number respondents who had attempted paying particular attention to how of limitations. Firstly, given that we suicide. Clearly, the selection of all patterns are emerging within each carried out fieldwork in selected these respondents was influenced group. Wherever patterns pertaining locations in Viet Nam, findings from by biases of the person selecting to the above variables (age, gender this study are not representative and relied on their interpretation and location) became apparent in of the whole of Viet Nam, nor of ‘unusual’ behaviour, for instance. the analysis they were highlighted do they intend to be. Similarly, Nevertheless, we sought to lessen and discussed. However, it should be because qualitative methodologies this potential bias through careful noted that in many instances not a were used, again, the aim of such in Viet Nam and the review’s focus large amount of variation was found approaches are not meant to be on the mental health challenges across these different variables. representative of an area, let alone probing during the interviews Counting the number of words a whole country. Findings are, related to a particular theme, in this nevertheless, valid and present As mentioned above, given the case mental health and psychosocial an important perspective of the composition of the research team wellbeing, is another approach mental health and psychosocial and the focus of the research, the to analyzing qualitative data. environment particularly facing aim was not to collect and identify However, given that this language children and young people in different kinds, and particularly was not necessarily used by study present day Viet Nam. severe mental health disorders. respondents, developing the coding Rather it was to explore the drivers and sub-coding structure described Secondly, initially we wanted to as well as risks and protective above was a more appropriate and carry out interviews with children factors of more common mental nuanced way of undertaking the and young people who had health disorders and psychosocial analysis. accessed/used mental health and distress as well as the policy and psychosocial related services. Given service environment. As such, a Unlike quantitative data, best the highly medicalised nature of full spectrum and details of mental practice in qualitative data advises this sector in Viet Nam, with mental health disorders is not provided here that it is not appropriate to count health associated largely with and would be the task for another number of responses to a certain severe mental disorders and severe study. topic or question. This is because developmental delays (or severe qualitative data is not meant to learning disabilities), and relatively In the areas in which the study be representative from the start little attention given to psychosocial team was working, there were very so counting responses becomes distress, accessing the kinds of few NGOs and other civil society irrelevant (see e.g. e.g. Bazley, P., 2004 respondents we were interested in organisations working on mental and Abeyasekera, S., 2005) proved extremely difficult. As such, health and psychosocial wellbeing- rather than be presented with young related issues. As such, we are people with learning difficulties so aware that we may be missing more 2.3 Study limitations and ethics severe they were unable to respond information related to this sector. to our questions (as happened in one A further exploration of existing Despite the step-by-step approach urban site), we widened our scope services provided by the NGO sector taken in the literature review, it has and sought support from teachers to Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 39 would be an important addition to this study.

Finally, in terms of the terminology used to discuss the concept of mental health and psychosocial wellbeing in Viet Nam, it is important to note that existing studies on mental health in Viet Nam often cite the WHO definition when referring to the concept of mental health.

However, both in daily language and written materials, the exact Vietnamese wording of this term has not been agreed upon; it can be worded as “suc khoe tam than” (literally “mental health”), “suc khoe tinh than” (health of spirit/mind), or “suc khoe tam tri” (health of mind). Dang Hoang Minh et al. (2015) note that the terms “suc khoe tinh than” and “suc khoe tam than” are used interchangeably, though both refer to the same concept of “mental health” in English. They also argued that in the Vietnamese language, the word “mental” carries with it a lot of prejudice, because it is often associated with serious mental disorders such as schizophrenia and epilepsy. Therefore, psychologists tend to use the other wording, “suc khoe tinh than” (health of spirit/ mind) in an attempt to soften the social biases towards mental health. Fieldwork interviews confirmed that the word “suc khoe tam than” (“mental health”) suffered prejudice; as such, sometimes the research team had to use the expression “suc khoe tinh than” (health of spirit/mind) in conversations, so that the interviewees would feel more comfortable to share more information about their common mental health problems.

The research proposal and instruments were reviewed and approved by the ODI research ethics committee. The study was also cleared by the Institute for Family and Gender Studies ethics review board. © UNICEF Viet Nam\2017\Truong Viet Hung 40 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

CHAPTER 3 Magnitude and prevalence of mental health and psychosocial issues in Viet Nam 42 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

to collect the data. For further details of different study findings please see Samuels et al., 2018.

The most common type of mental health problem among children studied in Viet Nam is that of internalising and externalizing problems. Several studies have attempted to account for the magnitude of these problems in Viet Nam. In 1999, McKelvey et al., found that in a sample of 1,526 children living in two neighbourhoods of the Dong Da district in Hanoi, 5.3% of boys and 7.7% of girls aged 4 through 11, and 9.5% of boys and 10.1% of girls aged 12 -18 years scored in the clinical range suggesting that they had behavioural difficulties (i.e. on a composite score of the subscales Attention Problems, Rule-Breaking Behaviour, and Aggressive Behaviour). A few years later, using the Strengths and Difficulties Questionnaire, Anh et al., (2006) found that among high school students in Ho Chi Minh City, 16% were experiencing significant affective problems, and 24% behaviour problems. More recently, Nguyen et al., (2013b) found that in their sample of 1159 school going children, 23% of students reported anxiety symptoms at a clinically significant level. Female students had three times the odds of having anxiety symptoms as © UNICEF Viet Nam\2017\Colorista\Hoang Hiep compared to male students. High levels of depression were also found. Measuring depression using the In this section we start with a brief and adolescents, with varying Centre for Epidemiology Studies overview of findings from the rates across provinces and by Depression Scale (CES-D), they literature review on the magnitude gender (Samuels, et al, 2016). A found that the prevalence of being and prevalence of mental health and recent epidemiological survey of a in a category at risk for clinical psychosocial issues in Viet Nam. We nationally representative population depression (a CES-D score of ≥ 16) then turn to explore primary data from 10 of 63 provinces found that was approximately 41.1% (ibid.). findings in this area. the overall level of child mental Of these, 26% were identified as health problems was about 12%, having elevated levels of depression. suggesting that approximately more According to the Survey Assessment 3.1 Findings from literature review than 3 million children are in need Vietnamese Youth (SAVY I), 32% of mental health services (Weiss et of 14-25 year olds reported feeling Findings from our literature review al, 2014). These different rates can sad about their life in general show that the prevalence of largely be explained by the different (MOH, 2005).). The results of SAVY general mental health problems sample sizes, the different research II, conducted in 2009 indicated that range from 8% to 29% for children approaches and different tools used 73.1% of those aged 14–25 had ever Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 43 felt sad, 27.6% had ever felt so sad An increasing concern with suicide neighbours, with higher rates of or helpless that they stopped doing among young people has given rise tobacco and alcohol use among men their usual activities, and 21.3% had to research on the topic, including compared to women (Pham et al., ever felt really hopeless about their suicidal ideation, (thoughts about 2010). future (WHO, n.d.; MoH, WHO, and committing suicide) and suicide UNICEF, 2010). More recently, in their attempts. Compared to global Though co-morbidity is not a national representative study, Weiss suicide prevalence (9.1% of all risk factor by itself, the literature et al., (2014) found that there were deaths of young people across 90 indicates that one form of mental more cases of internalising problems countries) (Wasserman et al., 2005), illness may act as a risk factor for such as anxiety and depression than Viet Nam’s suicide rate is remarkably another. Thus, studies revealed that externalising problems. low. In a cross-country comparison those feeling depressed and sad among Vietnamese and Chinese were also likely to report suicidal One determinant or driver of adolescents, Blum et al.’s (2012) study thoughts (Huong, 2009; Nguyen et mental ill-health is that of child of over 17,000 adolescents and young al., 2013b; Thanh et al., 2006). With maltreatment. According to MICS people found that the prevalence respect to suicide, alcohol and data on over 11,000 households (GSO, of suicidal ideation in the past 12 cigarette use was found to be a risk 2011), 73.9% of children in Viet Nam months was 2.3% in Hanoi (n = 6,191), factor (Blum et al., 2012). Finally, aged 2–14 had experienced violent the lowest in their sample compared studies identified co-morbidity discipline, meaning they were to 8.1% in Shanghai (n = 6,212) and between substance abuse and other subjected to at least one form of 17% (n = 4,706) in Taipei. Similarly, disorders, especially depression (Huy psychosocial or physical punishment less than 1% of Vietnamese youth et al., 2015; Kaljee et al., 2005; Tho et by their parents/caregivers or other had attempted suicide, compared to al., 2007). household members. Moreover, 1.3% in Shanghai, and 6.9% in Taipei. 55.4% of children were subjected SAVY I also found low rates of suicide Given our focus on psychosocial to psychosocial aggression. Severe in Viet Nam — approximately 3.4% of wellbeing as well as mental health, punishment of children is more the respondents reported that they we also explored indicators related common in rural areas, as well had contemplated suicide in 2003. to it, one of which is self-esteem. as in less educated, poorer and Six years later, SAVY II documented While it is a commonly monitored ethnic minority households. In a a suicidal ideation rate of 4.1% of indicator, there is relatively little cross-sectional study of over 2,700 those aged 14–25 suicidal ideation. information on this factor in Viet school children aged 13-17, 40% of In 2009, Huong conducted a study Nam; available literature is restricted the sample reported emotional on 2,737 students from Vietnamese largely to the SAVY data. Thus SAVY abuse, 47.5% reported physical public lower secondary schools and I assessed feelings of self-esteem abuse, and 19.7% reported sexual found that 6.1% of the sample had by asking participants about their abuse (Nguyen et al., 2009). Males attempted suicide in the past 12 self-worth and optimism regarding were more likely than females to be months. the future (MoH et al., 2010a). The classified as experiencing physical findings indicated that overall, abuse as a child, while females Another common problem relates young people have high positive reported more emotional abuse and to substance abuse, which includes self-assessments. On a scale of 1-5 the physical or emotional neglect (ibid.). using drugs, abusing alcohol, and majority of the participants attained Several household characteristics smoking, can also be a driver or a relatively high scores, averaging are associated with lower likelihood risk factor for mental ill-health and 3.5 across all groups, with a score of child maltreatment in Viet Nam, psychosocial distress. According to of 3.4 for young people of ethnic including an older mother, parents the Global Adult Tobacco Survey minority. Over 94.7% felt they were with more education, greater in Viet Nam (MOH, Hanoi Medical valuable to their parents, 98.4% felt income, and fewer children (Trang University, GSO, CDC, & WHO, 2010b), they had good qualities and 71.3% and Duc, 2014). Other studies in Viet the prevalence of current users of felt that they can help other people. Nam found that among children, any cigarette (i.e. manufactured SAVY II found similar trends, where child maltreatment is associated and hand-rolled cigarettes) among on a scale of 1-5, the average score with higher levels of sadness respondents aged 15–24 was for self-esteem of youth was 2.76, (Huong, 2009; MoH, 2005), anxiety, 11.9%. SAVY II found that 20.4% of with higher scores for older and depression and low self-esteem (Le respondents aged 14–25 had ever more educated youth. There were et al., 2009), suicide attempts and smoked tobacco (39.5% of men and also high levels of optimism found suicidal thoughts (Huong, 2009), and 0.6% of women). With regards to risk among the youth surveyed. Within smoking and drinking (Huong, 2009). behaviours, Viet Nam is very similar the 14–17 age group, more than 70% in many ways to other regional agreed that they would like to have 44 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam their own happy family, a job that they liked, and the opportunity to Box 2 - Key Statistical Analysis Findings of SDQ do what they wanted, though only and Self-Efficacy Scale Scores 54.6% agreed that they would have a good income. Preliminary analyses from a sample of 402 children aged 12-17 from secondary and high schools have allowed the authors to reach a number of conclusions as follows: It is important to note that overall, while the global literature highlights In terms of mental health problems the importance of poverty, adversity, Of the four domains of behavioural and emotional problems, this study recognised the rate of children scoring ‘Abnormal’ in the Emotional problems Scale stood at migration and family separation as as high as 19.7%, and this Scale’s mean score (4.34; SD = 2.32) is also the highest causes of mental ill-being, these are among all Scales and is more than twice as high as those in other Scales, which not strong themes in the secondary suggests that emotional problems are what children struggle with the most during literature on Viet Nam. Through our adolescence.. [primary data collection we try to The rate of children having conduct problems in this study also appears to be quite draw more attention to these socio- high. The percentage of children having ‘Abnormal’ scores is 7.5% in the Conduct economic factors (see particularly problems Scale. On the contrary, the number of children scoring in the ‘Abnormal’ at the household level (see below). band in the Peer problems Scale made up 7%. Nevertheless, what is the most There are also likely to be a range noteworthy about this survey sample is that the percentage of children having Borderline scores in the Peer problems Scale was 2-3 times as high as that in other of other factors which influence Scales (30.6% as compared to 10-15% in other Scales). This indicates that a sizeable the mental health and psychosocial portion of the children were on the threshold of suffering difficulties in developing wellbeing of children and young social relationships. The most common symptoms include getting angry and losing people in Viet Nam including factors temper easily, and lack of self-control. The majority of the children in the survey such as trafficking, sexual abuse sample showed problems or symptoms of hyperactivity. Very few of the children were confident that they possessed good attention, judgement and ability to and violence. These issues were not analyse and complete tasks effectively. explored in the literature review since these are topics in themselves The behavioural and emotional problems mentioned above differed according to and worthy of a separate study. The the children’s demographic and social characteristics. The children of the older age group and higher education level face more problems than those of the younger primary data collection also did age group and lower education level; girls appeared to have more difficulties than not focus directly on these issues, boys. The girls faced more emotional problems than the boys, while in contrast, though some of these issues did the boys have more peer problems than girls. Hyperactivity seems to be more of a emerge indirectly e.g. through problem among older children and in urban areas and big cities. stories of isolated young mothers Concerning Prosocial behaviours, the majority of the children in the survey sample being at the mercy of their husbands. had positive social relationships (80.6% scoring in the ‘Normal’ band), while only 14.9% and 4.5% were in the ‘Borderline’ and ‘Abnormal’ bands, respectively. There are significant differences between children living in different areas. The Prosocial 3.2 Findings from primary data score is higher among children in rural areas than urban areas (7.15 versus 6.71), and higher in Dien Bien and An Giang provinces than the rest, and in the North than in the South In this section we focus on the manifestations of mental health and Children’s self-efficacy and perceived self-efficacy psychosocial wellbeing by exploring The children’s perceived self-efficacy levels were on a scale of 0-10, showing that children’s self-efficacy is relatively high, with a mean score of 6.66 (SD=2.23). Only the narratives of children and young 18.2% of the children have lower-than-average self-efficacy scores (0-4), 41% have people in our study sites. We start average scores (5-7), and 40% have mean scores of 8-10. These numbers imply a by providing a brief overview of fairly high level of self-efficacy among the children, both in unexpected/unforeseen perceptions around prevalence of situations and especially when actively facing difficult problems, although the mental health issues in the study number of children having good self-efficacy in coping with unexpected events is a bit lower. Particularly, in the face of difficulties and challenges, many of the children sites; we then explore some of the believed in their coping abilities. They could keep calm to solve the problems, and terminology that people use when were confident in their own efforts and abilities to focus on pursuing and achieving describing mostly others’ mental their goals. When faced with unforeseen/unexpected situations, only about half health problems; and then turn to of the children believed in their abilities to handle the problems that arose: 45.3% thought they ‘could deal efficiently with unexpected events’, and 53% believed that explore the kinds or manifestations ‘Thanks to my resourcefulness, I know how to handle unforeseen situations. of mental health and psychosocial Correlation analysis results found statistically significant differences between self- wellbeing facing these children efficacy levels of children by sex, province and region. The boys seemed to have and young people. Box 2 gives a higher self-efficacy than the girls. Self-efficacy also appeared to be higher among summary of findings from the SDQ children in urban areas than those in rural areas, and in the South than in the North. and Self-efficacy scales. Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 45

3.2.1 Prevalence / increase / health problems, with different for about 60%. The men often have decrease of mental health and age groups facing different types such issues as autism, mental diseases, psychosocial wellbeing in the study sites of problems: ‘The 6 years old or oppositional defiant disorder, and younger usually have developmental conduct disorder. Women mainly have All KIIs agree that both psychosocial challenges, for example retardation, anxiety disorder or depression’. and mental health problems are autism, hyperactivities or eating widespread across Viet Nam and disorder or sleeping disorder. Or at The numbers of mental health increasing, but challenges remain the early schooling age, 6 years, 7 patients vary across sites. However, due to ‘insufficient or no data on years or 8 years have the problem of as reporting does not differentiate children’ (KII, DOLISA, Phu Tan hyperactivities, fear of studying, fear between serious and persistent District, An Giang). Yet the consensus of going to school, anxiety disorder mental illness and the type of is “the rate of children in school and regarding separation from relatives. psychosocial ill-being discussed preschool having illnesses in this field Teenage children’s issues often relate to in our study, further work may be has increased. It’s more common depression, anxiety, poor adaptation needed to get a more accurate in urban areas…maybe too much to the society, studying environment baseline for the purpose of service exposure to information technology (the wider exposure, the more provision. For instance, a KII with such as the internet, games, and other relationship they have), or behavioural a member of staff of the Division elements in school, such as stress, also disorder, resistance and learning bad of Social Protection and Poverty affects children. In rural areas, perhaps habits. And they also have sex-related Reduction in An Giang described a factor that needs to be taken into issues. Teenagers have such as issues the number of cases of mental consideration is the attention of as Facebook, social network, making health problems as ‘Very large. We’ve parents to their children, with cases friends online and idolization, the got more than 3,000 subjects in An of neglect especially among Hmong issues are diverse and numerous’ (KII, Giang province, of which 10-20% people. The attention paid to children Paediatrics Hospital No 1, HCMC). are children – people under 16 years is still limited.” (KII, DOH, Dien Bien of age. The most obvious forms Phu city). This same KI reports that he sees include schizophrenia and other mild about ‘250 patients a week; the symptoms. But through my visits Other KIIs also state that children number of men is a bit higher than in some local areas, I see that the face the major burden of mental the number of women, accounting risks to children’s mental health are 46 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

psychological shocks due to living situations and life stresses’ (KII, Social Protection Division, DOLISA, Long Xuyen city, An Giang). Similarly, in Dien Bien, a KII with the Division of Social Protection of DOLISA indicated, ‘At of the end 2015, there are 5,081 people with disabilities in the province, including 2,881 males and 2,200 females. The law on disability defines six types of disabilities: movement, communicating, hearing, low vision, mental health, cognitive and others. The mental health people with disabilities accounts for the biggest proportion of 1,019. The people with cognitive disabilities account for 510’ (KII, DOLISA, Dien Bien Phu city).

3.2.2 Ways of speaking about / defining mental health / perceptions of mental health

There was a range of different ways that respondents spoke about and described people with mental health difficulties. There did not appear to be a large variation in these definitions according to age, gender, or location. Thus people who were mentally ill were seen as ‘unknowledgeable’, others spoke about them as being ‘negative’, or ‘their way of thinking is different’, or they are seen as ‘different’ with some kind of ‘disease’, are an exception’ and as being ‘unstable’. In Dien Bien a KI from the psychiatric hospital mentioned that people use the concept of ‘madness’ or people ‘wandering around’ to describe those with mental health issues: ‘Actually people have always called them “mad”; those don’t know anything and keep wandering around, or walk around naked are called lunatics. As ‘Once in a while when we meet them, they say they’re for those with minor problems, maybe people don’t know; they just call them stable now. In some cases, they still come for medicine “abnormal”’ (KII,Psychiatric Hospital for maintenance’ of Dien Bien, Dien Bien).

(KII, Psychiatric Hospital of Dien Bien, Dien Bien). Children also used the word ‘depression’ as it is taught, according to girls in Dien Bien (FGD, F, 15,

© UNICEF Viet Nam\2017\Colorista\Hoang Hiep Dien Bien Phu city) in biology and citizenship education. Depression is Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 47 also mentioned in the newspapers stigmatize, don’t get close to them This lack of understanding can also and television, which is also the and discriminate. They don’t speak lead people to fear as this narrative reason why children know this much, but they tend to alienate and shows: term: ‘We hear about depression avoid.’ Such stigma often results, many times in newspapers and on as the same respondent states, ‘A child with mental illness lives in the television that some children confine in a reluctance to access services: house opposite to mine. He has had themselves in their rooms and blame ‘In general, the community stigma the illness for about 10 years, I don’t both parents of indifference. They constrains the children from coming know if neighbours stigmatize or not, are under psychological pressure, to hospital. People often worship but they are scared of him. He is gentle suffer depression, so they can’t live or consult a fortune-teller before much of the time, but sometimes when in harmony with other people and consulting a doctor’ (Health Worker, irritated he becomes so frightening. confine themselves in their rooms’ National Hospital of Paediatrics, The person in my neighbourhood is (FGD, M, 17, An Giang). Hanoi). an example. Several nights he holds the lamp and his neighbours have to There were differing responses Also brought out strongly in the stay awake to keep eyes on him. Then concerning the extent to which narratives, particular amongst KIs was he chases after his grandmother and stigma around mental health exists. the fact that mental health issues are beats other family members. That’s In an FGD with 15-year-old boys in not well understood by a majority why people often feel scared of people Dien Bien Phu City it was reported of people and that similarly, levels with mental illnesses’ (FGD, provincial that ‘some’ people stigmatise those of awareness are dependent on officers, Long Xuyen city, An Giang). with mental health problems, but educational levels, which are often ‘most people treat them normally’. In linked also to place of residence and Narratives around ‘social evils’ were Hanoi, 16-year-old boys explain that ethnic minority status: heard amongst study respondents, those with mental health problems often linked to discussions around are viewed as ‘having a disease’, as ‘The public’s awareness depends on substance abuse and addiction to the following narrative from a KII their intellectual standards. If a family internet games including gambling, in Dien Bien also highlights: ‘They has children whose levels of education which, as seen above, also have are not discriminated against. Local are mostly 12th grade or above, implications for mental health and people consider that they have a through their access to newspapers psychosocial wellbeing as well as disease and report the case to the and radio and such, they will know if other anti-social behaviour such as authorities. The special cases will their children are having problems or stealing. ‘Sometimes after they’ve be sent to get proper treatment. In not. But the rest, the majority of the sold their houses to play pool, they 2014-2015, we’ve sent seven cases to population are poor families who have even steal from other people’ (Village Viet Tri psychiatric hospital’ (KII, Dolisa, to struggle to make a living, so they Patriarch, Keo Lom commune, Dien Dien Bien). On the other hand, and mostly don’t care about their children’s Bien District). For most, the narrative also in Dien Bien, while people mental health. The children are left about social evils was learnt at might not outwardly discriminate, a to grow up on their own, especially school via life skills education. A male KI reports that people tend mostly among ethnic minorities. People respondent in Hanoi sums up what to show indifference: ‘So far, there is rarely care about prevention of mental social evils are as follows: ‘Acquiring still a lack of sharing and empathy in disorders; they just care about how to bad habits from other people, like the community’s perception of mental have good physical health’ (KII, Social smoking, having ideas of dropping patients. They don’t discriminate Protection Division- DOLISA, Long out of school or skipping class hours against these people, but it’s quite Xuyen city, An Giang). to play online games’ (FGD, M, 13, common to turn an indifferent eye Hanoi). In Dien Bien Phu City an an or consider it something abnormal’ ‘I think that people’s awareness has FGD with girls notes that ‘Gambling, (DOH, Dien Bien Phu City , Dien been better. In fact, it should be divided drugs, drinking, theft, and domestic Bien). In Hanoi, however, there was into two groups, one of which lives in violence’ (FGD, F, 15, Dien Bien Phu a relatively strong sense coming the urban area with a high education City ) are seen as social evils. There from KIIs that stigma was still level. To this group, psychological is a sense that more boys than girls present, and particularly in relation issues need treatment. While the group are addicted to gaming: ‘More boys to substance abuse and game in remote areas or who has a lower are addicted to it (gaming), because addicts as the following narrative education level doesn’t understand boys are more eager to win. It means shows: ‘The community still keeps how diseases can be cured by using that they want to conquer everything, stigma toward substance addicts and words’ (KII, Paediatrics Hospital No 1, surpass everyone, so they embark in game addicts, as well as people with HCMC). playing games. Games are seen as mental health issues in general. People the only way to upgrade their virtual 48 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

Box 3: Reasons/causes for suicidal ideation .. because of problems in school ‘Back then, I was often made fun of by a classmate; when they teased me, back then I was crying a lot. When I cried, they laughed, and so I felt self-pity and sad, so I didn’t want to communicate with them much. When he teased me, I reacted by telling him off. But he kept teasing me. And so I kept feeling sad, and I cried. From the 5th grade, whenever he teased me, I avoided him completely. And so I felt really sad because I thought everyone was just like him; they all liked to bully me and so I had the suicidal thought.’ (IDI, M, 16, Hanoi)

‘Back when I was young, I always went to school on foot. I didn’t have any vehicle; many of my friends are good friends, but some of them spoke ill of me, saying I was too poor. They said many things that annoyed me, and so I went home and asked my parents to buy me a bike. But my mom said our family couldn’t afford it. And then I said many things, and then my parents also told me off. I was upset, saying “I’d rather die than be so miserable”. Therefore, I took them (poisonous leaves). After taking them, I realized I was afraid of dying, so I told my parents and then they took me to the emergency room.’ (IDI, M, 28, Keo Lom commune, Dien Bien)

‘..Maybe they went to school and had problems with their friends, and so they took “heartbreak grass” leaves; their parents didn’t know and it was already too late when they found out about it.’ (FGD, F, 15, Dien Bien Phu city) .. because of problems at home ‘In my area, usually the children suffer a lot of family-related stresses, [such as] violent fathers, or parents divorced, so they feel there’s no one to protect them; they feel lonely.’ (FGD, F, 15, Dien Bien Phu city).

‘In general, if he says something and I disagree with him, he will say, “If you don’t like it, leave.” Sometimes I think because I came to live with him, he doesn’t respect me. And I’m not sure if I mean anything or if I am of any importance to him; after 1-2 sentences, he will say “just leave”, and “such kind of person you are is nothing. I can just stand here and whistle, and they [women] will line up for me.” I feel pity for myself, and then I think perhaps I’m like what he says. I came to live in his house, so that’s perhaps why he doesn’t respect me. I do have such thoughts. Sometimes I think I’m stuck with no way out, maybe I should just die. But I also think that if I were not here anymore, maybe my two children would suffer even more. If he married someone else, maybe he would have a wife, but my children wouldn’t have a mother. Therefore I keep trying to live. I just hope that when he gets a bit older, he will change. Otherwise, if he doesn’t change, I don’t know what the future will be like.’ (IDI, F, 18, Keo Lom commune, Dien Bien)

..Another problem is that they committed suicide when they couldn’t talk to (convince) their parents.’ (FGD, F, 15, Dien Bien)

‘The suicides mainly relate to the quarrels with family members and parent’s addictedness. The second reason relates to love. Parents don’t agree for their child to get married to this girl or boy, the child will attempt suicide’ (KII, Hamlet Head, Keo Lom commune, Dien Bien) .. because of love related problems ‘In my area, many people in 8th or 9th grades committed suicide, mostly because of love-related problems, or their parents had many wives, their family members didn’t get along, they didn’t have a happy life, or any hope about the future, so they committed suicide.’ (FGD, M, 15, Dien Bien)

‘Many cases of suicide due to emotional issues from intimate relationships.’ (FGD, F, 15, Dien Bien Phu city) .. because of norms around expected masculine behaviour ‘Another reason cited is masculine ideology around men being breadwinners that leads to financial pressure. Most men are under pressure from the responsibility to feed their wives and children, while in fact some are incapable of doing that.’ (FGD, M, 17, An Giang)

.. because of reluctance to share feelings ‘Local people say children should not act like that, that there are many ways to cope, that you should find a solution other than dying. You could have shared [your feelings] with other people. I think, in such a situation, when we felt too much pressure, if we shared [our feelings] with other people, we’d be afraid that they wouldn’t believe us, and we’d feel that we would be no longer valued by the others around us.’ (FGD, F, 15, Dien Bien Phu city) Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 49 characters, prove their class, instead of reintegration into society, instead of with girls in HCMC: ‘I think that young studying or doing something in reality’ trying to put them into institutions people are strong, enthusiastic to (FGD, M, 17, An Giang). Possible like it used to be in the past, isolating work, they are creative, they follow explanations could include more them from society. When patients are their passion, they are dynamic at access, and the fact that culturally successfully brought back into the work; young people have much time boys tend to have more free time, community, the perceptions of mental and dare to think and dare to act, more autonomy and control over illnesses become less serious. In the they have many big thoughts and big their lives. past, mental institutions just kept dreams’ (FGD, F, 16, HCMC). Across serious patients in there, so [people] all the sites, children spoke about The gendered pattern of gaming only watched them from far away; wanting to become a maths teacher, addiction was confirmed by a they didn’t dare go near because a construction engineer, working in psychiatric doctor from Dien Bien: they were afraid. Now when mental the medical field, a doctor, a sports patients can return to their families coach, policeman and hairdresser. ‘Gaming addicts are teenagers, and and local communities, and receive In the rural areas there was also a I have seen only boys.’ He added, medicine from the local health staff, sense that the cities represent more however, that lasting recovery is their images improve, which helps opportunities and excitement as possible. reduce discrimination’ (KII, Psychiatric the following quote from a boy in Hospital, HCMC). Dien Bien shows: ‘It’s always more fun ‘Once in a while when we meet them, they near the city, and children can enjoy say they’re stable now. In some cases, they 3.2.3 Manifestations of mental a good educational environment and still come for medicine for maintenance’ health and psychosocial the living conditions are better’ (IDI, M, (KII, Psychiatric Hospital of Dien Bien, wellbeing 15, Keo Lom commune, Dien Bien). Dien Bien). In the urban areas, children also In keeping with the literature on stress the importance of studying It was also noted in Dien Bien mental health, in this section we for a good future, including further that whilst there has not been present the narratives according studies as the following quote from much change in either the types to the following broad areas: a boy in Hanoi shows: ‘Maybe just or prevalence of mental health psychological state of participants, like everyone else, I don’t want a tough issues, when it comes to games and cognitive disorders, emotional life in the future, I want to become a substance abuse, there has been disorders, somatic complaints, successful person, so I’m trying to study an increase: ‘Since the hospital’s behavioural disorders and substance so that it will be easier for me in the establishment, I haven’t seen many abuse. Clearly, these disorders university entrance exam, and I’ve also changes in this issue… (however) and complaints are not mutually been learning about many things, so Children’s addiction to [computer] inclusive, with many coexisting that when I make my way into society, games is tending to increase, and and one often resulting in another. I can familiarise myself better’ (IDI, M, addiction to drugs, American weed, Similarly, manifestations can also 16, Hanoi). marijuana, in general addictive be risk factors, also further driving substances, is tending to increase as mental ill-health and psychosocial The flipside of this optimism was well. Actually, we’ve treated such cases distress, as also discussed in section worry and sadness and general here, but there are still a considerable 4. pessimism, with older children number of patients out there who arguably mentioning this more haven’t been treated at the hospital’ Starting with the psychological than younger children, or being (KII, Psychiatric Hospital of Dien Bien, state of study participants, many more quick to point out that despite Dien Bien. of the feelings discussed under this optimism, worries were also often broad category may clearly link to present. This can be explained by the Though the overwhelming other disorders and complaints. fact that the older a child gets, and consensus was that those with Two main feelings were expressed particularly girls, the more likely they mental health problems continue by respondents: on the one hand, are to have domestic responsibilities to be stigmatised, one KII in the optimism largely in relation to or experience early marriage, which psychiatric hospital in HCMC shares the future, and on the other hand may, amongst other things, interfere that approaches to care for those sadness and worries. Children of all with schoolwork and negatively who are mentally ill are improving: ages, though perhaps particularly impact on their optimism and ‘The way of caring for mental the younger age categories, had aspirations for the future. Moreover, patients nowadays has changed; great optimism and aspirations for for both boys and girls, the pressure they now bring patients back to their the future, summed up effectively of school work increases, making communities, to their families for in the following quote from an FGD them question their abilities as a 50 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam student to be successful in the future head and spoke to him.’ After this, her listen to them’ (IDI, F, 16, Dien Bien (discussed in Section 4). The reasons son was hospitalised for 18 days and Phu city). for worry and sadness ranged from was diagnosed with ‘acute psychosis parents fighting, a family member disorder’. While behavioural disorders do being unwell, to performance in not appear to be very common in school, fear of dropping out of Though there were no other our sample (only one boy’s actions school, uncertainty about the future, cases of thought disorders, there could perhaps be likened to him and early marriage. For the older age were quite a few references to have behavioural problems, as group, particularly for girls, there neurodevelopmental disorders such he shared that he was pressured was sadness and worries amongst as autism, including by two 16-year- to ‘make trouble’ by ‘ringing the those who had already dropped out old respondents themselves (one boy doorbell, running away or sometimes of school and were married – they and one girl in urban and semi-urban by throwing a stone in a room where worried about their financially locations), who wondered whether people are sitting and running security and that of their child as well they may be autistic. However, across away’ (IDI, M, 16, Long Xuyen city, the marital discord they were facing all of these categories, it is unclear An Giang), emotional disorders, with their husbands. Symptoms the extent to which respondents under which depression and suicide of this sadness and worry include understand what it is, and there is a fall, were much more prevalent. stress, which leads to meal skipping, general sense that when someone Generally, girls were perceived to headaches and anger: ‘When I’m is behaving differently or unusually, be more susceptible to emotional angry, I often smash things’ (IDI, M ,16, for instance not speaking much or problems (including suicide) than Dien Bien). Another girl states that, engaging with other children, the boys as the following two quotes ‘I smash my phone if I am holding it’ common and current response is that from boys, one from Dien Bien and (FGD, F, 17, An Giang). Another shares ‘they have autism’. This was further another from An Giang highlight: that when he gets angry, he ‘Should emphasised during discussions with keep calm. If I get angry, it’s not good key informants — there seems to be Q: Do you think there are many other and [I can] inflict damage to myself’ a national push now to recognise children around you who often face (FGD, M, 16, Keo Lom commune, autism as a mental health problem, depression, stress and disappointment Dien Bien). Findings from an FGD though it’s unclear whether this is in life? in An Giang with girls suggest that a result of an increasing number of respondents feel that girls and boys cases or whether this push comes A: I see many are like that. deal differently with anger. While from the fact that it is a relatively boys may be more likely to turn their easily identifiable mental health Q: Are there more boys or girls like anger outward and ‘beat something,’ disorder. Clearly, these reasons are that? they also seem to have more socially not mutually exclusive. Furthermore, acceptable refuges from negative during the data collection period A: Both boys and girls. feelings, including ‘games, football, World Autism Awareness Week was or sport’ (FGD, F , 17, An Giang). celebrated, and the media picked Q: But who face such problems more up on this quite widely, all of which often, boys or girls? A More girls. In terms of cognitive disorders, resulted in quite a few people (IDI,M,16, Dien Bien Phu city). there was only one case of a mother speaking about it. of a child with a cognitive disorder A: "In terms of emotions, girls are more in the study sample. She described In another case, a child was taken to likely to get moved than boys" (FGD, M, the onset of her son’s condition: ‘At see a psychological doctor because 12, An Giang). first, he was studying in Hanoi when he he had struck his head and his phoned me and said he felt something mother was worried he had autism The way children and young people wrong in his body; he got goose (cite); in another case a girl was taken spoke about suicide appeared to vary bumps and felt shivering cold. Since to a psychiatrist because her mother according to age and gender. Thus then, he kept feeling anxious; he said had been worried that her ‘living in while the younger age group (11-14) he felt unwell. When he called, I was in silence without willingness to talk with had heard of ‘many’ people who had Dien Bien so I couldn’t visit him. Two anyone’ was a sign of autism (FGD, attempted suicide, by the time they days later, I went to see him and took F, 17, An Giang). Finally, a girl in Dien got to the next age group (15-17) there him to hospital. He said there were Bien stated that her peers call her were several cases of suicidal ideation voices in his head; he said there was autistic because ‘I often play with my as noted in the exchanges below in someone who could read his thoughts phone in the classroom; I rarely talk An Giang and Dien Bien: and threatened him. Many people. to them. I’m very stubborn, and I don’t He said many people jumped into his Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 51

Q: Did you feel so disheartened that you no longer wanted to live? (noise)

A: I did in the past.

Q: What happened the last time?

A: That time people around me didn’t listen to my idea, I felt angry, so I questioned myself, ‘nobody listens to me. Does my life have any meaning?’(FGD, F, 17, Phu My town, An Giang)

Q: Did some people take “heartbreak grass” leaves to commit suicide?

A: Yes.

Q: Can you tell me about a case you know?

A: In my area, usually the children suffer a lot of family-related stresses, [such as] violent fathers, or divorced © UNICEF Viet Nam\2017\Colorista\Hoang Hiep parents, so they feel there’s no one to protect them; they feel lonely. They’ll no longer have a goal to live’ (FGD, F, 15, Dien Bien Phu city). more than boys’ (KII, DOLISA- Dien as girls do. Girls share [their feelings] Bien Phu city). Other boys added more often, because they’re more Amongst the older age groups, that girls are more likely to commit sensitive, while boys don’t want respondents reported having tried suicide because of ‘superficial to share with other people; they to commit suicide themselves thinking because they live in remote only want to be stronger, to prove (interviews were selected with this areas, they don’t have much contact themselves, to show that they’re men. characteristic in mind). There was also with the society’ (FGD, M, 15, Dien (FGD, F, 15, Dien Bien Phu city). a general perception from both girls Bien Phu city). And similarly, as the and boys as well as key informants following narrative from an FGD with The poisonous leaves, known also that it was mostly young people and girls in Dien Bien shows: has ‘heartbreak’ or ‘la ngon’ leaves, girls who committed or who tried to according to respondents, are commit suicide, as this quote from a Q: Those who committed suicide, were abundant and are available to any boys’ FGD in An Giang shows: ‘There they boys or girls mostly? age group as they grow in the forests are more girls among those who in the surrounding areas: commit suicide and do harm to their A: Both boys and girls. bodies like chopping their hands or Q: How did you come to know about confining themselves, as girls are more Q: Were there more boys or girls? “la ngon” leaves? sensitive to their emotional issues. Their hearts are easy to be hurt, meanwhile A: More girls. A: Back when I was little, my parents boys are more steadfast and calmer took me with them when they went to when encountering a problem. So there A: I rarely hear about boys’ cases. work; I didn’t know they were the “la are more girls in this group" (FGD, M, 17, ngon” leaves then. I pluck some to play, An Giang). Q: But girls tend to take poisonous and then my parents said they were “la leaves more often. Is it because of your ngon” leaves; that was how I came to As a KII in Dien Bien states ‘…children traditional culture and practice, or know about them. and young people account for a larger why? proportion (of suicides) because they Q: Do they grow a lot around here? Are are easy to have conflicts with their A: No. Maybe it’s because boys don’t they easy to find? friends. It happens amongst girls share [their feelings] with their friends 52 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

A: Yes, a lot. (IDI, M, 28, Keo Lom even succeed in taking their own availability of poisonous leaves: ‘Not commune, Dien Bien) lives. Moving beyond these more all the ethnic minority groups are the immediate reasons/causes of suicide same. It occurs only with the Hmong Reasons for suicidal ideation and and suicide attempts, respondents people. I haven’t got the report of other attempted suicide include failure of spoke about lack of knowledge ethnic minority groups. Hmong people romantic relationships (e.g. being and awareness, as stated by have a bad custom of eating la ngon abandoned/discarded usually by a 15-year-old boys in Dien Bien Phu [poisonous] leaves to kill themselves. boyfriend), marital discord, problems city, and ‘shallow thinking’ (FGD, M, It happens a lot in Dien Bien Dong. at school (including bullying, teasing 17, An Giang) as possibly being an The reason relates to the superiority and getting low scores), problems underlying cause of this ideation. complex of Hmong people. When at home (e.g. being scolded by a child has an urgent matter with parents, lack of communication with Interviews with key informants classmates or disagrees with their parents, parents disagreeing with added a further dimension to this parents, he or she is easy to commit choice of marriage partner, early — according to their perceptions, suicide. And, it is also convenient to marriage also leading to school ethnicity was also a possible driver of do so because there are plenty of drop-out, conflict between parents, a suicide, with the Hmong in particular poisonous leaves in the area. Only one violent father, financial pressure and being seen as haughty and proud or two leaves can kill a person. Only parental addiction), and reluctance and thus easily tempted into suicidal if someone knows about it, the child to share feelings. For boys, reasons actions. The availability nearby of [who eats poisonous leaves] is cured also include not being able to live poisonous leaves, particularly for the in time. In Dien Bien Dong, there have up to expected masculine attributes Hmong in Dien Bien, facilitated the been campaigns to root up poisonous and behaviour, including an ability process of committing suicide. The plants, but it has yet to be done’. (KII, to maintain the family/household following narrative from a KII in Dien DOLISA, Dien Bien Phu city). (see also Box 2). All this leads to Bien captures both the perception young people feeling sad, upset of the Hmong people as being more Somatic complaints were and frustrated, which in turn leads prone to suicide than other ethnic mentioned by many respondents, them to attempt and sometimes groups as well as the issue of the irrespective of gender, age and

‘There is also a kind of e-cigarette costing 60,000 dong (approximately £2). Some children here use designer drugs which also affect their mental health. They inhale glue, the ‘dog’ glue (a brand of glue), which is used to fix rubber tires but it smells like banana extract. Now the children inhale deep into their lungs’

(FGD, Parents, An Giang).

© UNICEF Viet Nam\2017\Truong Viet Hung Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 53 location. These consisted largely of Q: When do you feel headaches? A city). Similarly, as a young man in An headaches, though loss of appetite, When I do a lot of tasks. Giang recounts more in relation to poor sleep and nightmares were drugs: ‘I think that sadness leads them also mentioned. These somatic Q: What do you do when you have a to look for the substance to relieve complaints are also mentioned by headache? their sadness. After the substance has a psychologist in the Paediatrics stopped working, they feel sad again, Hospital in HCMC who shares that A: Relax. so they begin to use it as an instrument ‘A group we see here, which is quite to relieve their sadness, they get used important is children with physical Q: How do you relax? to the habit; and regularly using it, they disorders, in simpler words, pains – for become addicted to it unintentionally. example, belly pains, headaches, or A: I call some friends to my house to There are many causes for it. A child arm or leg pain… basically pain in play. Playing with them, I feel better. may follow someone’s example to some part of the body, which can’t (IDI, F, 13, An Giang) become classy, “Hey, you can do it, I can usually be explained by physical do it, too.” It is a normal thing’ (IDI, M, 17, examination – I mean they can’t Substance abuse – alcohol, smoking An Giang). be explained medically, or there is and drugs – was mentioned by many not enough evidence of a disease, respondents in our study, and was Substance abuse can also lead to but usually there are associated largely associated with boys, young violence, with husbands seen to be psychological problems.’ men and husbands, though largely ‘shouting and swearing nonsense’ at in the rural and semi-urban areas. In their wives as well as children (IDI, According to respondents, reasons An Giang, parents report a dangerous F, 18, Dien Bien), while another girl for these headaches were largely trend among teenagers that involves in Hanoi recounts a story of a father related to the stress associated with smoking drugs: ‘The children are who got drunk throwing a tray at his academic pressure (school tests, bad smoking USA grass, which is aromatic daughter when she made a mistake: marks), but also, particularly for girls, and tasty, so several children can’t ‘When I was in the 9th grade, there as a result of stress from having to do recognize their parents. When their was a girl who was living in the same housework. These headaches were parents talk to them, they ask “Who are village as mine. She was a child of a relieved through playing with friends you?”. Such things seriously affect the family who were doing ok (financially), (for the younger children) and children’s mental health in An Giang.’ but in the family, she got scolded all through taking painkillers (the older the time by her parents and then her children / young people) as seen in ‘There is also a kind of e-cigarette boyfriend broke up with her. Once I the following exchanges. costing 60,000 dong (approximately heard that she went to buy tofu, while £2). Some children here use designer her father had told her to buy alcohol. Q: Do you often have headaches? A drugs which also affect their mental When she came home with the tofu, Yes. health. They inhale glue, the ‘dog’ glue her father threw a whole tray of food (a brand of glue), which is used to fix onto her face. After that, she didn’t Q: Do you take any medication for your rubber tires but it smells like banana want to live anymore, and bought a headaches? extract. Now the children inhale deep bottle of pesticide and killed herself. into their lungs’ (FGD, Parents, An The next day, her friends attended her A: Yes, I do, but it only reduces them a Giang). funeral’ (IDI, F, 18, Hanoi). little bit. I’ve been having headaches lately. According to respondents, substance Another consequence of substance abuse results from, on the one hand, abuse was early marriage ‘According Q: When are the headaches the most peer pressure to ‘drink to forget to the Government, men get married serious? their troubles’ or from sadness (also at 20 years old and women can get because of failed love relationships) married at 18 years old, [but] this is A: When there are tests; 15-minute or 45 or feeling pressure from society. The not the case for children of parents minute tests. Q Since when have you following quote from an FGD with who are addicted to drugs, where had the headaches? girls in Dien Bien sums up the reasons daughters often get married at 13-14 why men predominantly drink: ‘(Men years old and sons get married at 16-17 A: Only when I have to study too much. drink to) forget their troubles, when years old’ (KII, Hamlet Head, Keo Lom (IDI, F, 16, Dien Bien Phu city) they are having fun or when they commune, Dien Bien). have guests, when they’re sad about Q: Do you ever have a headache? their family, when they can’t talk to anyone; or lovelorn or when the family A: Yes. breaks up’ (FGD, F, 15, Dien Bien Phu 54 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

CHAPTER 4 Risk and protective factors for mental health issues and psychosocial distress amongst children, and young people in Viet Nam 56 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

Following our review of the to SAVY results, younger cohorts according to study respondents, secondary literature, which were more likely to report suicidal emotional isolation was an important highlights that psychosocial ideation. source of risk (though it, along with dimensions have received the the other risk factors described least attention in terms of research Even though being a migrant itself here, can also be a manifestation and practice in the Vietnamese is a risk factor, there were no studies of psychosocial distress). A number context, and also reflecting our that found links between migration of children reported choosing not fieldwork methodologies, we focus and internalising symptoms or to share their feelings with anyone, primarily on the largely neglected substance abuse. Migrant status preferring ‘not to look for anyone’, psychosocial issues facing children emerged as a risk factor however, in especially with respect to sharing and young people.We acknowledge Blum et al’s (2012) work for suicide. family issues or troubles with friends that additional data collection on Youth in rural areas who had never or extended family members. This more serious neurological-related migrated reported a lower likelihood is true even in situations where mental health disorders would of suicidal ideation compared with children are upset as a result of require a more specialized and urban natives in Hanoi in Blum’s conflicts at home such that the child resource-intensive data collection study of 6,000 adolescents and youth. who was crying after being scolded approach. In each of the following Having more family income was but did not want to share his feelings sub-section we firstly present a protective factor and associated with his grandmother (IDI, M, 13, An findings from the secondary data, with decreased likelihood of Giang). followed by findings from the probable mental health problems for primary data. It should be noted internalising symptoms (Amstadter et In other cases, the desire to not that findings from the secondary al., 2011). For externalising symptoms, share stems from wanting to protect and primary data do not necessarily in Weiss and colleagues’ (Weiss et.al parents from worrying about the mirror each other. Similarly, the 2014) study of children aged 6-16, child. This seemed to be particularly analysis of the primary data can only higher family income and more the case with mid-adolescents be based on information received parent education acted as risk in our sample where a number from study respondents. factors for both parent reported of respondents noted that they and adolescent reported attention/ intentionally isolate themselves hyperactivity problems. With respect when dealing with sadness or 4. 1 Individual level risk and to suicide, in a study of 200 girls, Le distress. For instance one boy stated: protective factors (2009) found that parents’ education ‘I just like to be by myself; I like keeping level and occupation are associated [my feelings] to myself’ (IDI, M, 15, Keo A number of variables at the with children’s suicide behaviour. The Lom commune, Dien Bien). Another individual level were identified in majority of children (approximately boy who was bullied felt suicidal and the literature on Viet Nam as being 79%) who have thought of suicide live refused to share his sadness with either risk or protective factors for in families in which parents have low anyone, choosing to sit in a closet mental health and psychosocial levels of education. in his home to dream an ‘Imagined ill-being. For instance, being female, world where everyone loved me and living in urban areas, and being 4.1.1 Individual level risk factors no one bullied me’ (IDI, M, 16, Hanoi). of ethnic minority status was a risk of mental and/or psychosocial ‘Self-isolation’ was particularly factor for internalising emotional ill-being prevalent among respondents in problems (Chan & Parker, 2004), HCMC who commonly noted that externalising problems (McKelvey’s Three main individual risk factors they felt their distress emotions were 1999; Stratton et al., 2014), suicide emerged for young people from too private to share with others. (Blum et. al., 2012; Huong, 2009; the primary data, with some age One mid-adolescent child noted: Thanh et al., 2005), and substance and gender-specific variations. It ‘I am a bit isolated from the outside abuse (Diep et al., 2013). Age effects is important to note at this stage, world, because I find it difficult to were also found: being older acted as that risk factors and manifestations communicate’ (IDI, M, 17, HCMC), a protective factor for externalising are not mutually exclusive: and another confided that he felt symptoms, suicide and substance manifestations can become drivers ‘abandoned’ when his friend left town abuse, while conduct problems or risk factors for mental ill-health (FGD, M, 16, Hanoi). and hyperactivity scores decreased and psychosocial distress, and with age, suggesting a possible often it is unclear what came first. For older adolescents, and especially maturation effect (Stratton et al., Arguably, however, the order is girls, feelings of social isolation 2014). Similarly, being younger was not so significant, what is more result because of marriage at an a risk factor for suicide, as according important is that they exist. Thus, early age (and while the legal age Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 57 of marriage in Viet Nam is 18 for girl connectedness as the root of their during Tet: ‘They don’t have a ground and 20 for boythe reality in places psychological illbeing. ‘Overall I just to play sports, and because their such as Dien Bien, is that girls marry stay silent, I don’t dare say anything. I families mostly work in agriculture, earlier). A number of girls noted also cry, but overall, I just try to finish there’s no time for children or people that their husbands do not allow the work, and then go up to my room my age, or older people; they have to them to return back to their natal and sit alone in silence, feeling sad, work in the fields; and in the evening, homes to meet with their parents or and lying in bed crying; I don’t know they don’t have much time either, to meet others socially, suspecting what else to do (IDI, F, 19, Hanoi).’ so they have fewer chances to play. their wives of possible infidelity. As a Similar patterns of isolation and And music and sports events are not result they lack a trusted confidant to feelings of depression were also organized, either. Only during Tet whom they can turn. As one young highlighted among respondents holidays are music and sports event wife explained, ‘When I’m sad, I often in Dien Bien. ‘Pressures from other held’ (FGD, F, 15, Dien Bien Phu city). go somewhere to sit alone. I’ll feel more people around make that person feel comfortable when I’m by myself’ (IDI, that he/she is not cared about, that he/ Overall, boys tend to spend more F, 22, Keo Lom commune, Dien Bien). she is isolated, as if he/she has fallen time online, playing games in the Another described her situation into a world where he/she is all alone’ internet shops and their sadness is as follows: ‘I have no friends. If I go (FGD, F, 15, Dien Bien Phu city). Some attributed to losing games online. somewhere, I only visit my parents; I girls also reported that they were ‘They [boys] are different from us don’t visit my neighbours often. If I go unable to sleep well if they are sad. [girls]. They go to the internet shops to them too much, they will say I’m and so on’ (IDI, F, 13, Long Xuyen city, an annoying woman. Up there they A second driver of psychological ill- An Giang). In some cases, children don’t like people who wander about being is linked to access to modern emphasised that online games everywhere, so it’s best not to go’ (IDI, technology and the risks of were their only way to interact with F, 18, Keo Lom commune, Dien Bien). addictive online behaviours. There peers: ‘As no one is around to talk, so The desire to have someone to talk is a consensus among respondents I have the only way of playing game, to is there, although she lacks social that access to modern technology I mean the electronic game. It makes networks: ‘If there was someone I poses a threat to wellbeing since me more dependent on the phone could talk to, I would feel relieved. But children tend to ‘use it too much’. and computer’ (IDI, M, 17, HCMC). there is nobody…because my parents In fact, one KII with a director of Another explained: ‘It takes about don’t have the rights to talk to him a mental health hospital likens 30 minutes of playing games online’ [her husband]. Because in our ethnic game addition to drug addiction, to forget their ‘feelings of sadness’ tradition, once I’m gone (married), stating that both are a serious form (FGD, M, 13, Hanoi). Indeed, in many the husband’s family have more of addiction. As one 15-year-old of the interviews, children do not rights’ (IDI, F, 18, Keo Lom commune, girl in HCMC describes, ‘It is the era report being interested in other Dien Bien). Substance abuse can of internet. The majority of children leisure activities, stating that they further exacerbate this situation entertain themselves on the internet ‘rarely go out with my friends. I just as husbands may emotionally and more than going out’. stay at home and do my homework, physically abuse their wives when or watch TV’ (IDI, F, 12, HCMC). Part under the influence of alcohol. Other Other respondents also recognise of the problem is also attributable girls in this age group also attributed the dangers of the internet and to limited leisure time infrastructure their social isolation to dropping suggest that parent monitoring can for children. Sometimes children are out of school against their choice keep a child from ‘falling into traps’ also hindered in their pursuit of non- and/or to the burden of domestic of the ‘social network’, but others online leisure activities by the fact responsibilities. One young woman emphasised that there is a gaming that their friends live far and they are noted that in her ‘free time’ she sows addiction in the community. Almost unable to afford the financial cost the field, plants vegetables, and everyone who can ‘afford it’ owns a required to travel. waters and tends the crops – if she smartphone according to an FGD doesn’t her husband ‘scolds’ her (IDI, with 15-year-old girls in Dien Bien Over time, this focus on online F, 18, Keo Lom commune, Dien Bien). Phu city, and children find ways to games also appears to have negative use the internet even though the spill-over effects on scholastic While the sense of isolation for older school ‘forbids it’. This FGD also achievement as highlighted by this married girls was most acute, girls in reveals that there is a need for more quote from a young adolescent girl this age bracket more generally put music (and sports events in the in HCMC: ‘There’s a student who sits a strong emphasis on lack of social community which only take place next to me; he’s a little bit addicted to 58 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam computer games, but he doesn’t look about menstruation. One 12-year-old 4.1.2 Individual level coping strategies tired; he still looks normal, but his girl in HCMC, for example, reported performance in school has declined’ that her parents asked her to ‘eat less’ Young people in our sample (IDI, F, 12, HCMC). This propensity because she is ‘too fat’. Others in Dien identified a range of both positive towards addiction is not helped by Bien lamented that they could be and negative coping strategies when the fact that, ‘Even though the game teased for being ‘fat as a pig’ (FGD, F, they are suffering from mental and shop owner signed a commitment to 14, Dien Bien). A mid-adolescent boy psychosocial ill-being (whether it be close at 9 PM, in fact it is not closed also explicitly linked over-eating to related to self-image, lack of social until 11 PM or 12 AM because game feelings of sadness. He explained that connectivity, or due to the addictive players are still there, it means that he was called ‘fat’ by his peers and properties of online activities). The they wait until the last player leaves to that although he wants to improve first key protective factor mentioned close’ (FGD, M, 17, An Giang). his physical appearance he ‘eats not was active participation in only to fill stomach, but also to drive leisure activities, e.g. sports such Gender differences also emerged: sadness out of my heart’. Similarly, fear as swimming or football, martial respondents stated that boys are around being fat is compounded arts, reading, or watching movies. more likely to play computer games with fears of being bullied: ‘Fear A 16-year-old girl in An Giang, for than girls: ‘More boys are addicted that friends say that I am as fat as a example, highlighted that martial to it, because boys are more eager to pig’ (FGD, F, 14, Keo Lom commune, arts gave them ‘joy’ and ‘better spirit’. win’ (FGD, M, 17, An Giang). However, Dien Bien). Other physical concerns A 16-year-old boy noted feeling girls are at risk from cyber bullying revolved around being too short, ‘very happy when they score a goal and stalking. Negative comments on which leads to teasing, name calling in football’ (IDI, M, 16, An Giang). Facebook from peers or unwanted such as ‘dwarf’ and discrimination in A 13-year-old girl explicitly stated messages on Zalo (a messaging school sports activities. Boys were that she engages in activities to feel application) from unidentified also teased for being physically weak, better: cyberbullies can make adolescent as the following narrative from a boy girls feel angry and sad. One in An Giang highlights: Q: When you feel upset, where do you 12-year-old girl in Hanoi explained often go to forget about it? her experience as follows: ‘I was Q: What are negative features about playing on my phone when suddenly yourself? A I am not handsome. Like a A: First, I’ll go on the internet and a message was sent to my number, pan cake. maybe play [online] games, or when and I replied. At first I was having a I’m too angry, I can do physical proper conversation, but suddenly he Q: What do you mean by “a pan cake”? exercises, really tough ones. I’m not asked me about other stuff. I didn’t much into the habit of throwing like it, and told [him] to stop sending A: I am not as strong as other boys. (IDI, objects, because I find it costly and messages to me; it was bothering M, 16, An Giang). it’s also a nuisance to clean up. Now me; but that person kept sending me when I exercise, it helps me not only messages. And then I was afraid my Another boy focused more on his release my stresses but also build good mom would find out, so I deleted all lack of confidence in front of a group: health and a better body, so when those conversations, and then I asked ‘When I speak or stand up in front I’m too angry, or when I play, when my friend if there was a way to block of a crowd, I often feel that my body I feel too excited, like hyperactive, I’ll that person. My friend said yes, that I temperature rises, and then my face also do exercises, or play shuttlecock should click the “Block” button on Zalo becomes red, and I feel very shy. I have kicking, or do something that is highly to block [him]. And so I’ve managed to that many times’ (IDI, M, 16, Dien physically active. I find it quite difficult block [him]’ (IDI, F, 12, HCMC). Bien). Finally, several girls mentioned to sit still in such situations' (IDI, F, 13, fears around menstruation with girls Hanoi). A third key factor that emerged from worrying that they will stain their our interviews related to negative trousers. However, in a focus group Others also mentioned joining perceptions of adolescent physical discussion, one 12-year-old girl in An school clubs or trips (e.g. to the appearance. Some of these concerns Giang stated that she was not afraid botanical garden, zoo, gardening) were related to poor self-image and of ‘red light days’ since her mother or keeping a diary about their in other cases they were externally ‘bought books and newspapers day-to-day activities and emotions. triggered by peers and/or adults. to read’ and gives her advice on Some children also emphasised These concerns began in early menstruation. their proactive use of technology to adolescence, especially among find support – for instance, reading girls who were perceived to be articles on the internet to help learn overweight, and in relation to fears how to deal with feelings of sadness Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 59 or anger, watching entertaining friends is ‘more practical’ and ‘faster’ There were also several examples of videos or reading stories on ‘science than sharing on Facebook (FGD, M, children having good role models and technology’ to relieve stress, 16, Hanoi). Children also explained to follow, although this was more and connecting with friends on that they share feelings on Facebook commonly cited by boys. These are Facebook. (‘Q: Where did you find but do not post ‘big issues or generally adults they know — older information related to mental health? problems’, choosing instead to seek brothers, teachers, uncles — who Where can you find it if you want? A out advice from friends or teachers have qualities that they admire and It is available on the internet’ {FGD, F, instead (FGD, F, 16, HCMC). Similarly, who have been good to them: ‘It was 16, HCMC}). Using cell phones to call students also noted that they partly my own initiative, and partly parents when feeling sad or lonely preferred to talk to people their own because of my older brother. He was at boarding school was also another age about concerns rather than send ahead of me, so I’ve observed him’ commonly cited coping strategy. an anonymous letter to the school’s (IDI, M, 16, Hanoi). Another looked mailbox, which is a channel to solicit up to his uncle for support and A second critical protective factor advice from an adult counsellor or advice: ‘My uncle, because everyone against psychosocial ill-being teacher. respects him. He’s nice to everyone. was having or being part of a He often helps other people; he loves social network. The importance Among the 18+ age group, there his family’ (IDI, M, 16, Dien Bien Phu of having friends was noted across were fewer examples of young city). A man in his 20s similarly noted: all interviews, irrespective of people feeling that they could turn ‘Some older men in the village; their gender. Children turn to friends to friends and relatives. Girls in economic situations are ok, enough to share ‘happy and sad things’, to particular noted that they do not to feed themselves, and they can talk ‘forget’ feelings of sadness that share family issues directly, but (well-spoken) so that we can follow result from family conflict or from instead ‘Just talk in a vague way, just their examples’ (IDI, M, 28, Keo Lom teacher-student conflict and to to make people care, and see how commune, Dien Bien). confide concerns about puberty and they will explain to me. I just collect relationships. In fact, most children [advice], but later I will think about Not all responses to periods of believe that ‘having friends’ is what what is the best thing to do’ (IDI, F, 18, stress or sadness were positive and makes them happy in life. Some Hanoi). Girls also talk to their family included a number of negative choose to confide in their friends members such as mothers and older coping strategies which could also about their troubles, believing that siblings, but are often cautious about further fuel psychosocial distress. their friends ‘understand’ them. In showing their parents their sadness A number of children highlighted one case, a 13-year-old girl in An so as to not provoke parental crying alone to release their Giang felt that her stress headaches worry. However, one girl who had feelings. One child feels that he is go away when she plays with her attempted suicide because her unable to share his feelings with friends (quote in Section 3). Among parents made her drop out of school anyone and ‘goes to sleep’ when he the mid-adolescent age group, was saved because she told her is sad because ‘My parents are busy irrespective of location, friends friend that she had eaten poisonous all day. My relatives go to work. No one were seen as pivotal to psychosocial leaves. ‘She visited me, saying “I heard is available. My friends I don’t trust’ wellbeing: ‘I am happiest when I have that you’re very sad, right?”, and so (IDI, M, 17, HCMC). There were also my friends around, right now’ (IDI, M, I cried, and told her that I had taken considerable mentions of substance 16, An Giang). ‘If we lose our friends, “la ngon” leaves already, and so my abuse, especially drinking alcohol, we’re done’ (FGD, M, 16, Hanoi). parents took me to the emergency as a negative coping mechanism And indeed children were quite room’ (IDI, F, 22, Dien Bien). Another for some young people. ‘One way to conscious of what a dearth of friends male states that he turns to his deal with "troubles" is to drink alcohol, could mean in terms of dealing with friends both to discuss future plans though boys tend to drink more than psychosocial stress: ‘Those who can’t and when he is angry since his girls. On the other hand, girls tend confide in anybody, they often look for friends ‘comfort’ him and he feels to take poisonous leaves more often quiet places to cry alone. After crying, ‘happy again’. ‘Even if I’m very angry, because girls are "more sensitive’ (FGD, they stand up and pretend to be I will just go with my friends; they are F, 15, Dien Bien Phu city). FGDs also happy, despite their pain and sadness’ close to me and so they comfort me; highlighted that substance abuse (FGD, F, 13, Hanoi). after a while I will feel happy again was more likely to be part of the and go back to my family. I let the coping repertoire in less well-off Interestingly, children were aware past be the past’ (IDI, M, 28, Keo Lom households, while children from that online forms of support could commune, Dien Bien). better-off families tended to opt for have their limitations. One child online gaming as it requires relatively explicitly stated that sharing with more resources. 60 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

Another negative coping strategy divorced parents, was a risk factor expectations from parents in terms mentioned several times was for both internalising symptoms and of carrying out domestic chores and vandalism. A number of child suicidal ideation (Nguyen, 2006), caring for younger siblings and were respondents reported smashing and sibling conflict was linked with afraid of being ‘scolded’ by parents things in anger. For example, one increased alcohol consumption for not doing them adequately. child from Hanoi explained that (Phuong et al., 2013). Having a In Dien Bien in particular, parents’ ‘Many times, I can’t confide delicate positive relationship with parents rules around helping in the fields is issues in my family in friends or emerged as a protective factor normal and expected, as a hamlet parents or teachers, I will destroy my against internalising symptoms head in Dien Bien noted: ‘At the age belongings’ (FGD, F, 13, Hanoi). (Weiss et al., 2014), externalising of nine or ten, girls start working in symptoms (Weiss et al., 2014), and the family fields. Boys at nine to ten At the more extreme end of negative suicide (Blum et al., 2012; Phuong et often tend cows or buffalo. At 12-15 coping repertoires of young people al., 2013). For example, in their work or 16 years old they start work in the was suicidal ideation. This appeared with 972 school students, Phuong et fields.’Other domestic responsibilities to be most commonly mentioned in al. (2013) found that father- bonding include ‘Cleaning the dishes, sweeping Dien Bien and in relation to pressures acted as a protective factor against the floor, feeding the chickens and around school drop-out and early thoughts about suicide for male and pigs, and watering the vegetables’ marriage. FGDs highlighted that in female students. Notably, female (IDI, F, 12, Keo Lom commune, Dien Dien Bien girls who are pressured participants who did not receive Bien). Another girl from Hanoi to drop-out and marry against their emotional support at home had noted that ‘"Daughters have to do choice may even resort to suicide. higher risk of suicidal ideation than this work, daughters have to be good In cases where it is against the girl's those who sought emotional support at doing housework, and sons are wish to marry, eating poisonous from mother/father or brother/sister responsible for important work, so leaves becomes the alternate route: (ibid.). Further details and nuance to they don’t have to do housework’ ‘In my area, there was a family who some of these findings are provided (FGD, F, 13, Hanoi). Girls report that forced their daughter to marry a man through the primary data collection they do not go outside with friends she didn’t love. Therefore she sought carried out for this study. because they have to ‘stay at home death; she took “heartbreak grass” and do housework’ (IDI, F, 12, Keo leaves but didn’t die, because she Some factors, such as family Lom commune, Dien Bien). Another was discovered and then taken to the composition, can be both a risk explained: ‘Parents force me to stay at emergency room’ (FGD, F, 15, USS, and a protective factor. For example, home, to look after younger siblings Dien Bien Phu city). One respondent adolescents with higher numbers and not to go to school. After school also noted that there is a fear of of siblings were more likely to suffer I have to work on the farm. I have no ‘being kidnapped’ into marriage in anxiety and somatic problems. For way other than obeying. I am tired of the area and recounted a story of a young children however, having working on the farm, as it is far from 16-year-old girl who was kidnapped more siblings was associated with home’ (FGD, F, 14, Keo Lom commune, and then committed suicide because fewer attention problems, aggressive Dien Bien). In fact, even some boys she was so unhappy in her new behaviours, and fewer social were subjected to such family norms marital home. problems (Weiss et al., 2014). as noted: ‘I’m afraid of not fulfilling my duties as an older brother in my 4.2.1 Household level factors family, not being able to look after 4.2 Household level risk and my younger siblings’ (FGD, M, 12 An protective factors Three broad sets of factors at Giang). household level emerged from the The literature identifies a number primary data as putting children As discussed further in the section of aspects at household level that at risk of psychosocial ill-being on school-based factors, children are are either risk or protective factors – overly restrictive family rules also fearful of parents criticising poor of mental health and psychosocial (especially with regard to scholastic marks in school. In some instances, wellbeing. Family living achievement and marriage), poor or FGDs show that being scolded arrangements, i.e. living outside the declining household socio-economic by parents for performing poorly parents’ home, was a risk factor for status, and intra-household tensions in academics has led to suicide suicide (Blum et al., 2013; Nguyen – either between parents and/ attempts. et al., 2010) as well as for high levels or parents and children. In terms of alcohol consumption (Diep et of family rules, younger children For mid-adolescents when young al., 2013). Moreover, indicators of – especially girls in rural sites – people are increasingly trying to family conflict, such as having emphasised that they faced high define an independent identity, Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 61 parental ‘control’ was seen as a key Q: Do your parents ever talk to you Q: Have you ever talked to your parents source of stress. ‘They [young people] about reproductive health, for example about what you want in using your are under strict control of their families. about contraceptive methods? A: No. phone? It seems that extreme control deprives them of freedom to do what they Q: Never? A: Yes, because my phone is not a want" (FGD, M, 17, An Giang). There fancy one. I only use it for a number are several examples of children A: [They] only tell the girls. of purposes; it doesn’t really affect reporting that their parents do not anything. I also told my parents that allow them to go out with their A: My mother often talks to my older I’m a grownup now, they shouldn’t friends, monitor their cell phone use, sister; she rarely talks to me [about it]. check [my phone] like that. My parents and make them do chores around think I’m still a child. (FGD, M, 16, the house. One girl responded that A: My parents don’t talk [about it]; they Hanoi) her parents are ‘Often afraid of me only say that “whatever you do, you must going out with my friends, so they know when to stop, otherwise etc.” For the older age group, there were don’t let me go out much’ (FGD, F, 15, fewer concerns expressed by boys, Dien Bien Phu city). Another from A: Parents mostly just talk to daughters, but older girls cited their domestic Hanoi complained, ‘Housework. For such as my older sister. (FGD, M, 16, Hanoi) burden and care responsibilities as example, they make me climb up and the most stressful. One 18-year-old clean spots that nobody sees. They Children, and especially girls, felt girl in school in Hanoi, who takes make me clean them every week; or my that their parents would disapprove care of her young siblings and cooks mother, for example, I like things to be of romantic relationships and thus often gets reprimanded for making in a mess and to tidy them up later at refuse to tell them about any love mistakes in her chores. For example, the weekend, but my parents always interests. In extreme cases, children she says that if the food is not require my study desk to be clean. It’s stated that girls who commit suicide cooked properly, she gets scolded. the same at home; I clean the floor only may do so if their parents refused to As a result of her care responsibilities, once every two weeks, but my parents let them marry their boyfriends. she has had to miss school and even tell me to do it once a week, otherwise it wrote a letter to the teacher herself will get dirty. And there are some other However, parental monitoring of explaining her challenges. Another things, for example they even control technology use – which was limited pointed out quite emotionally that what time I take a shower’ (FGD, M, 16, to urban areas – seemed to be less she would sacrifice her own school Hanoi). Family pressure to study and gendered. For instance, children attendance out of responsibility do well also means forgoing other state that parents ‘pass by’ to see towards her younger sisters who, hobbies as one girl passionately what the children are doing on without her, would be left home explained: ‘There are some things that I Facebook. Similarly, with regards to alone. ‘I’m very sensitive in the sense want, but my family doesn’t want me to cell phone use: that, honestly if my younger sisters do. It seems that they try to stuff me in a stay at home and play by themselves, mould which I don’t choose’ (FGD, F, 16, Q: Whose phone is under control of I won’t feel at ease; I’m also worried, HCMC). This high level of monitoring other people? and so, for example, when I go to was also observed in the case of a girl school, on the way to school, I’m whose grandmother did not allow A: Mine. just worried about them staying at her to go alone to visit her mother home by themselves, so I’ll just skip who had migrated. A 16-year-old boy A: My father used to do that, but now the class in the end; I don’t want from Hanoi confided that he would maybe my parents have realized that them to stay at home alone (getting like to run away from his parents as a I’m already a grownup. In the past, emotional); my mother works at the result of this monitoring. they allowed me to use a phone, but market, so sometimes the teachers forbade me to use a new password, called and asked why I was absent Interestingly, while part of this and I must let [him] control it. from class, and so I said that I skipped parental control was linked to the class because I had something concerns about their offspring’s A: Keep the screen unlocked. to do at home; I stay at home to play sexual and reproductive health, with them; if I let them stay home by this was primarily directed towards A: They even take the phone away themselves, my mind is not at peace daughters. The following exchange from me at night, to prevent me from (Crying)’ (IDI, F, 18, Hanoi). Another between a mid- adolescent boy and texting at night. They still do that now. girl shared that her mother did not the interviewer highlight this point: allow her to continue her education because ‘My mother said there was nobody to help her; as a daughter, I 62 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

must help her, so I was very sad’ (IDI, F, Giang). Education took a backseat for 22, Keo Lom commune, Dien Bien). another girl who had to drop out to work in the fields: ‘My parents said our The second set of factors that family was poor, so no more school, emerged among respondents as key but working in the fields instead’ household-level factors related to (IDI, F, 19, Keo Lom commune, Dien household socioeconomic status, Bien). This girl attributes the reason ‘In the last school year, 2014- for a variety of reasons summed up for dropping out as financial stress in this quote in a KII FGD: on the family since it ‘Is in a difficult 2015, there was a girl who had situation and lacking in hands’, adding been recognized as very good ‘Poor parents force their children that ‘Many children drop out of school to drop out of school to sell lottery to help at home. Even if girls are able to student for five consecutive tickets, work, cut grass for hire, work attend school, financial constraints of years. When entering grade 6, as masonry assistants against the the family make it difficult for them to children’s will. Secondly, the children access the resources needed to do well’ her parents didn’t agree to let are not allowed to play or relax like (IDI, F, 19, Keo Lom commune, Dien her study in a lower secondary other children, so they can’t develop Bien). school in her residential area, well psychologically, they may have to improvise actions, without foreseeing Even for children in well-to-do they wanted her to go to a consequences of the actions. So the families, perceptions of household high quality school. Two days group of poor children is at high poverty were seen as a risk factor risk. Take for example, An Giang has as one school psychologist pointed after entering the school, 10,000 children in extremely difficult out, ‘Last year for example, due to she killed herself by jumping situations, the social protection the economic downturn, a number officials say that many people in the of children come to us because their off a high building. She left group have mental health issues, but families have problems. They used to a few words in her notebook there is no concrete data’ (KI FGD, live in rich families which then broke, “Parents, I told you many Provincial officers, Long Xuyen city, affecting the children. Or their parent’s An Giang). marriages are in trouble. I have just times that I want to study handled the case of a 6-year-old child with my friends.” That’s all, For children in less well-off whose parents are going to divorce. households, inadequate financial It is a clear trend.’ (KII psychologist very simple. […]I see that resources can limit opportunities Hospital of Paediatrics’ Hanoi). The parents still pay attention for socialising with peers. For link between inadequate financial instance one early adolescent girl resources and scholastic pressures to their children, but their stated that she does not go out with was also made a number of times by consideration makes the her friends because ‘It costs a lot of both girls and boys, especially with money and because my mother is children feeling stressed that, unlike children study for parents, attending a bachelor’s degree course, their peers, they were unable to not for the children. Parents which costs 10 million dongs each attend extra-tuition classes to bring want their children to study in semester. I don’t want my parents to up their grades in school. An older spend more money’ (IDI, F, 12, HCMC). adolescent girl from Hanoi explained quality schools.’ Similarly, an older adolescent girl, the situation as follows: already married, said that while she KII, Child Care and Protection would have liked to travel outside ‘I understand my family’s situation, Division- DOLISA, HCMC her immediate environs, ‘Firstly, it so I just study at school and asked my would cost money to go, and I would parents to allow me to attend extra never earn enough money to do that. classes in literature only in secondary Secondly, when I ask him (husband) school, and then [maths] in high to let me go, he says “a woman should school to prepare for the exams. just stay at home, why wander about?”, Firstly, there are a lot of children in my so I give up’ (IDI, F, 18, Keo Lom family, and I’m the eldest daughter. commune, Dien Bien). Another girl Now if my mother goes out all day (for only finds time to do her homework work), who will stay at home? In the ‘After she comes home from selling past, our family worked as farmers, lottery tickets at 7pm’ (IDI, F, 13, An but now my family has only one sao Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 63

(360 m2) of farm, so we can’t do much. parents who migrated were thought the ones the children wanted for In the past, we could rent one acre to be ‘inattentive’ towards their themselves. This is particularly the (3,600 m2), I mean it was a separate children with ‘grandparents often case for boys more than for girls as one-acre farm we rent from someone indulging the grandchildren too much this FGD in Dien Bien highlights: else, and the one-sao farm was a and spoiling them’ (FGD, Parents, An share of land given to my family by Giang). Children also reported that Q: Do social norms or parents’ my grandparents. But one sao is not they feel that they need their parents’ expectations put pressure on boys and enough for us to make our living, so advice and can only call them via girls differently? now sometimes I have to stay at home phone, but also feel pressure to to help my family out. There are a lot show that they are ‘grown up and A: Yes. Boys suffer more from the of children in the family, and they all becoming independent’. Another boy pressure for their career path. (FGD, F, need money for their studies’ (IDI, F, 18, who lives with his grandparents in 15, Dien Bien Phu city). Hanoi). impoverished conditions worries that they will not be able to afford Another sixteen-year-old boy from Another 12-year-old boy in HCMC medication for his grandmother, and Hanoi summarised the tension stated that his parents do not have has skipped meals in his worry: ‘I was between parents and adolescents enough money to pay for extra worried about my grandma’s health, as follows: ‘In my opinion, parents classes and so he worries about his so I didn’t eat’ (IDI, M, 13, An Giang). always want good things for their household financial situation, and children, but those good things are not in fact, reports that his parents fight Looking longer-term to their futures, necessarily what the children want; over money. These sentiments were some children reported feeling moreover, children are under [parents’] also echoed in FGDs in An Giang high levels of stress because they control regarding their dreams as well with boys whose financial constraints were coming to terms with the as thoughts’ (FGD, M, 16, Hanoi). There were linked with children’s struggles fact that they would be unable was also lot of comparison with to thrive in school: to achieve their dream due to other ‘successful’ family members. As their ‘family's financial situation’ or a girls’ FGD in An Giang emphasised: Q: From your observation, if there are participate in activities due to the some students who often look sad costs involved. One young man ‘Some children are forced to take too and don’t talk to others often, what looking back on his adolescence and many extra classes and don’t have makes them sad? What are their family thwarted educational opportunities time for social activities. I think that situations like? due to poverty still experiences it causes too much pressure, making psychological stress, which suggests students feel disheartened. The A: I think their family situations are a that these mental pressures may pressure comes from an extended bit difficult. persist over the life-course: ‘I family full of good students and intended to continue my studies, but successful members. The child is Q: Is it difficult financially, or because my family situation was too difficult; incompetent, but he is put under their parents don’t have time? A my parents didn’t have money. Only pressure from those people and Financial difficulties. (FGD, M, 12, An if my family had been better off his family who wants him to make Giang) could I have continued studying. We the same achievements. He is didn’t have enough money for me incompetent, so he is under much Several instances in which parental to continue’ (IDI, M, 28, Keo Lom pressure’ (FGD, F, 17, An Giang) migration had a negative effect commune, Dien Bien). Since the on children’s mental health also cycle of poverty did not break for Children also suggest that emerged, with several KIs noting this man, he continues to feel the socioeconomic difficulties could be that children left behind are at risk psychological burden of being poor related to suicide in the future, as for sadness. Parents migrated due to in adulthood: ‘For example, I don’t one adolescent male in An Giang financial constraints on the family. have anything, but sometimes, as I told stated: ‘The majority of those who Children report missing their parents you earlier, my friends ask me out while commit suicide and use substances and wanting to see them again, with I don’t have anything, my family is are from poor families’ (FGD, M, 17, An sadness stemming from wanting poor so I don’t have anything (money) Giang). to spend quality time with parents. to go out with them, so I feel sad. I Those from a ‘difficult family situation’ feel that I don’t have any economic A third key household-level factor (FGD, F, 15, Dien Bien Phu city) were [resources]’ (IDI, M, 28, Keo Lom contributing to children’s psychosocial thought of as most prone to sadness commune, Dien Bien). In many cases ill-being is household tension. The or depression in school. An FGD with children felt that their parents chose overwhelming pattern was that of parents in An Giang indicated that a different career path for them than family pressure on children to excel 64 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam in school (see also school level risk is only three years old, and tell her to Children were also scared when factors and box on the right). Parents tell me “big sister, come on, bring your their parents fight,especially in the had high expectations of children certificate of merit home”’ (IDI, F, 16, case of alcohol-fuelled fights. ‘In my and wanted them to attend university Dien Bien Phu city). The stress from area, usually the children suffer a lot and get high marks in tests, ‘scolding’ studies was causing her to think of family-related stresses, [such as] them when they underperform. One about dropping out: ‘I do feel stressed. violent fathers, or parents divorced, child termed these expectations Sometimes I think maybe I won’t go so they feel there’s no one to protect from parents as those who have the to school anymore; it would be better them; they feel lonely’ (FGD, F, 15, ‘achievement disease’ (IDI, M, 13, Hanoi) to stay home, because here I’m not Dien Bien Phu city). Marital conflict and explains that ‘When parents have close to my parents; and I’m doing between parents sometimes also high expectations and the children can’t poorly in school, so I’m not sure I can spills over directly on children as live up to them, they [children] feel very find a job after graduation’ (IDI, F, 16, well: ‘For example when something sad and depressed’. Another 13-year-old Dien Bien Phu ity). Some children happens in my family that makes my girl in Hanoi states that her parents even reported being beaten by their parents quarrel, I turn out to be the one tell her that they will be ‘ashamed’ if parents when they failed to get good that my parents scold the most’ (IDI, F, she underperforms. In fact, children marks. In extreme cases, children 19, Hanoi). Another child attributed reported feeling scared and worried stated that they had heard of cases stress he feels when his parents fight to share their marks with their parents of suicide when parents scolded the to the fact that if parents fought, if they got low scores. children about poor performance. there was a concern they could get divorced. ‘I am worried that they ‘When I get bad marks, I’m afraid my There was also a general feeling that would go too far with quarrelling and parents will tell me off’ (FGD, M, 12, An parents ‘don't understand’ children divorce. If they do so, I won’t be able Giang) (FGD, M, 16, Keo Lom commune, Dien to live with one of them. I won’t enjoy Bien). This was heightened by the adequate care as I do before that’ ‘If you get low scores, you can be fact that parents and children have (IDI, M, 12, HCMC). Concerns about punished, beaten’ (FGD, M, 13, Hanoi). many problems communicating child abuse within the household with each other. ‘There is difference emerged most strongly in interviews While most children reported that between our thoughts and those in Dien Bien Phu city as this extract parents’ expectations were equally of parents. There is conflict in from a FGD with mid-adolescent girls high for both girls and boys, one conversation. For example, parents highlights: child described that ‘Some families insist that they are absolutely right, don’t expect much from their meanwhile I have different idea which Q: Have you heard about a child daughters. It’s like they still have I think is good for me, but I can’t argue being beaten up and then committing gender prejudice. [In such families,] with them’ (FGD, F, 17, An Giang). suicide? Girls mostly can’t do things that boys Children stated that reasons why do. For example, in conservative parents and children often cannot A: Yes. families, they think that girls should communicate is being ‘afraid’ of only stay at home and do housework, parents’ high expectations of school Q: Did it happen in your commune? while only boys can go to school, and performance, perceiving that the do jobs, such as being a boss’ (IDI, M, parents don’t have enough time A: Yes. 13, Hanoi). to talk to children, and feeling that parents always ‘disagree’ with what Q: How many cases? Parents tended to compare children are saying. Being unable children to other children but FGDs to talk about ‘love affairs’ because A: Many cases. indicated that this ‘Only hurts the of parents’ opposition to them is child’s self-esteem’ and ‘makes the another challenge. Accordingly, Q: Who abused them? Who caused the situation worse’ (FGD, F, 13, Hanoi). ‘Unbearable words by parents’ were violence, their parents, or husbands? For instance, one girl explained that identified as a risk factor for suicide: her parents even involve her much ‘There was a case in which the parents A: Parents and husbands. younger sister to put emotional said a few scolding words, and then pressure on her, and as a result she the child ran to the forest and took Q: Usually the father or the mother, or has ‘headaches when she has to study “heartbreak grass” leaves’ (FGD, M, 15, both? too much’ and when ‘my parents keep Dien Bien Phu city). While most cases calling me, telling me “you should try pertained to girls and stories related A: Both. In some cases, the father is to study better,” and then they give to early marriage pressures, a few addicted and is sent to jail; the mother the phone to my younger sister, who boys also discussed suicidal ideation. stays at home and finds another Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 65 lover so she doesn’t love her children but slaps her face’ once in a while (IDI, anymore. Or in some cases, the mother F, 18, Keo Lom commune, Dien Bien). passed away, and then the father got Another young woman explained a new wife, and the stepmother treats ‘I’m very sad sometimes, because he the children cruelly. In the village, never asks his wife what she thinks, or a lot of children have very difficult if she wants to go somewhere, or what ‘In the past, family members situations; they live with their mother she eats or what she does. I want to and stepfather, but the stepfather have someone to share [feelings] with, had dinner together, and doesn’t love them, and doesn’t let them but he seems not to care, so I feel very spent time with each other; go to school, but forces them to stay sad sometimes’ (IDI, F, 18, Keo Lom home to work. commune, Dien Bien). now the time for it has decreased. People are getting Q: Did someone commit suicide One cross-cutting factor across because of this reason? these family tensions was a lack of busier and the time spent communication between parents with each other is less. The A: Yes. and children – a factor that emerged from interviews with KIs as well. A children are left watching Q: How many cases like that have host of reasons were stated: on the television or playing ipad; happened in recent years? one hand parents were seen to not adults spend less with the have the time to talk to their children A: As for children [cases], must be 2-3 (see quote in text box above). This children to teach them the cases. As for married ones, must be 5-6 was also explained by some KIs as social skills. Some parents cases. being a result of the transition to a market economy, where parents, think that is it fine to let Q: How old were these 5-6 people? being faced with competitive work- the children play alone or related pressures, can lead them A: Around 16-17 years old. to neglect and leave their children entrust someone else with unattended. This ‘being left alone’, the task of raising their Q: What about the 2-3 cases of combined with increasing access to children? social media (see above), can lead children. Sometimes if mental ill-health and psychosocial you love your children too A: From 10-15 years old. (FGD, F, 15, distress, including amongst children much or overprotect them, Dien Bien Phu city). from richer families. Parents are also seen to be ‘impatient’ with children the children will be slow In several KIIs, divorce between while on the other hand children’s to become self- reliant or parents emerged as a risk factor own schedules were often too busy with school administrators reporting leaving them no time to talk to unable to interact with the that children from divorced families their parents. Additionally, children outside world. Parents solve were at higher risk for mental health worry that their parents will feel sad problems: ‘But the most worrisome about the child’s psychological state the children’s problems, so thing is the children live in the families and therefore prefer not to share they can’t learn problem with divorced parents. Some divorced with them. Finally strict parental solving. It is one of the risks parents are not very responsible to monitoring (see discussion above) their children, especially after they was also a cause of family tensions. of psychological and mental remarry, the children are abandoned disorders,’ and feel sad. I observe a number of There was also a sense that the school girls, they rarely smile in a dynamics of families was changing KII, Psychiatry Department, school year. How can they smile when and largely as a result of the their life is such misery?’ (KII, Teacher, transitioning from a traditional Pediatrics Hospital 1, HCMC An Giang). family model (consisting often of different generations) to the nuclear In the case of already married girls, family model in which often children domestic violence with husbands and adolescents felt isolated and also emerged as a key source of stress. which in turn affected their mental For example, one interviewee said health and psychosocial wellbeing. that the husband ‘does not beat her Girls in particular reported difficulty 66 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

in communicating with their parents; like to talk with their parents, never girls in an FGD in Hanoi explained confide in [their parents], because that a ‘generational gap’ is to blame every time they discuss things or for communication problems (FGD, talk to their parents, they (parents) F, 17, Hanoi) One girl emphasised seem to disagree, and do not want to that she cannot communicate with talk with them. And so they are not her mother: ‘It’s very hard to talk to motivated to talk with their parents ‘In practice, the curriculum of my mother. If I’m to make comments about anything anymore. And another about her, my mother is a difficult reason is that they (parents) don’t have our education system is too person, hard to talk to. If she’s not time to care for their children. In many much. For instance, students pleased about something, she will cases, the parents cannot take care shout and swear, very scary, I won’t of their children, so they have to hire have to study the whole day want to talk to her anymore. And now housemaids, and so the children only at school and go to extra my mother works in the market all get to see their parents once a week day, and she brings home with her the or so. The maid could be considered a classes in the evening until affairs at the market, and words that father or mother’ (FGD, M, 16, Hanoi). 10 PM. That makes students are not very nice, and so I don’t want too tired but they still have to talk to her about anything’ (IDI, F, 4.2.2 Household level protective 18, Hanoi). Other children emphasise factors and responses to stay up late to complete the importance of parents spending homework.’ time with their children to avoid Overall, there were was a much communication breakdowns: higher volume of responses related KII, Teacher of USS, HCMC to household risk rather than ‘I think, now, to make the family protective factors. However, two members understand one another sets of protective factors emerged better, I think, firstly [parents] should from our data: relatively better off only work from Monday to Friday, household socioeconomic status those who work as employees, they mitigated some sources of stress just need to work from Monday to experienced by young people and Friday, and spend time for family on was associated with emotionally Saturdays and Sundays. Now if they’re healthy family relationships. In terms too absorbed in their work, they won’t of socioeconomic factors, children know how their children are doing, emphasised that peers in better-off what they need and what they’re households were more likely to thinking’ (IDI, F, 18, Hanoi). complete twelfth grade which is a prerequisite for higher learning and, Similarly, another boy confides: in turn, better future opportunities. However, overall rising levels of ‘What makes me saddest is feeling education has also been contributing lonely. At school I have friends to to more equal opportunities for all hang around, but at home I am alone at a community level according to all the time. My parents don’t live in some children: ‘I think the positive one house, so talking with parents is aspect is that young people can live in a luxury thing. I feel uncomfortable. an educated community. I think that The loneliness makes me feel environment and conditions enable uncomfortable. Not pressure from all people to go to school, without studying. Pressure from studying discrimination between rich and poor, makes me really uncomfortable, but it male and female. Their characters are doesn’t matter’ (IDI, M, 17, HCMC). well trained. They learn knowledge, humanity and solidarity from teachers’ An inability to listen to their children (FGD, M, 13, Hanoi). on the part of some parents also seems to be a key concern: Emotionally healthy family relationships were also a key ‘For example, many of my classmates positive factor in mitigating who sit next to me [in the class] never psychosocial stress and ill-being. Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 67

Across interviews, children felt one boy felt worried about causing students themselves to perform well loved the most by their parents and his mother sadness if he shared his academically was identified as a risk grandparents, and felt happy when sadness with her, he did find that factor for both depression (Nguyen they were able to share their feeling when he shared a situation with his et al., 2013b) and suicide (Nguyen and concerns with them. ‘My parents mother that required advice, he felt et al., 2013a). Another risk factor spend time with me in the evening ‘relieved’ (IDI, M, 12, HCMC). Others identified for depression was having when they tell me their sad and happy also say that they turn to their parents serious quarrels with teachers or stories, and also ask me about my when there is a ‘difficulty’. As one other school staff members, while studying at the school. I think that mid-adolescent boy explained ‘Most anxiety was associated with physical the time with me is enough’ (FGD, F, parents, I feel, if we are serious when and emotional abuse from teachers 12, An Giang). They also reported we talk to them about our issues, our or other staff members at school feeling happy when their parents parents will listen, I think; they will (Nguyen et al., 2013b). Bullying and praised them for getting good marks. understand my problems. My parents peer pressure was also found to be Generally, adolescents feel that they are like that. It depends on the parents; linked to poor health outcomes such can get advice from their parents not all parents are the same’ (FGD, M, as higher levels of suicide (Phuong on most matters in their life, but 16, Hanoi). et al., 2013) and more drinking and are most comfortable talking about smoking behaviours (Jordan et studies with them: Moreover, while many had deep al., 2013; SAVY II). Finally, school concerns about parental control location i.e. being an inner city, ‘Having my dad and mom with me in their lives, some children did urban school was linked to higher has made me happy. My maternal also acknowledge that parental suicidal ideation for both males and grandparents love me, and my monitoring is an important way females (Phuong et al., 2013; SAVY paternal grandparents love me, too. … in which adolescents stay out of I and SAVY II results). For instance, My dad gives me lessons in maths and trouble. For instance, one child is 16.1% of children in urban schools physics at home. My dad was quite not allowed to go to the internet vs. 4.6% in suburban schools had good at maths in the past, so now he cafe alone, and another child's suicidal thoughts (Phuong et al., still remembers. When I have difficult mother noticed the child's unusual 2013). homework, I ask my dad for help and behaviour and took him to a doctor. he will show me. In class, the teacher Family connectedness is also noted In terms of protective factors, one talks so fast that I can’t understand in the way in which boarding school study showed that having an after- very well. At home, I understand better children miss their family and reach school tutor acted as a protective when my dad explains to me’ (IDI, F, 12, out to them via mobile phone when factor against depressive symptoms, HCMC). possible, with some doing so daily: ‘I reducing the likelihood of having talk to them every evening by phone’ depression by 28% (Nguyen et al., Several boys also reported high (IDI, F, 16, Dien Bien Phu city). 2013b). School connectedness, levels of family connectedness. For or feeling a part of or belonging instance, one boy shared that ‘Going to the environment also acted as home and eating with my family’ 4.3 School level risk and protective a protective factor against suicidal makes him happy (IDI, M, 15, Keo factors ideation (Phuong et al., 2013). Finally, Lom commune, Dien Bien). Another school connectedness and peer boy reported that he is ‘happiest In this section we explore risk and support was found to be a strong when his parents don’t quarrel’ (IDI, protective factors that affect the protective factor for children’s mental M, 12, HCMC). Children report feeling mental health and psychosocial health and wellbeing – in a sample of ‘grateful’ to ‘have been born to their wellbeing of children and young over 2,500 university students, friends parents’. In fact, one boy said that at a people. As in the other sections, were the main support for over 40% time when he thought of self-harm, before exploring our primary data of the sample (Huong, 2009). ‘I almost put an end to everything. we briefly present findings from Because I lost the trust in life. It was not other studies carried out in Viet Many of these findings are echoed as good as I thought. At the time I felt Nam that also highlight risk and in the primary research carried out so tired and so sad. But many things protective factors at the school for this study, though arguably our were there to keep me alive. Parents level. Academic pressure stood study goes further and provides are the best things in my present life’ out in many studies as being a key further details and insights. In (IDI, M, 17, HCMC). risk factor to the mental health and addition, our findings are further psychosocial wellbeing of children supported by the results of the SDQ Children feel that they can turn to and young people. Pressure coming and the Self-Efficacy Scale that we their parents in times of need. Though from parents, teachers, and from undertook in four study sites with 68 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam school children from four lower rarely addressed with appropriate having ‘abnormal’ symptoms by secondary schools and four upper education methods. age and residence area. This rate is secondary schools with 402 school considerably higher among children children. The mean age was 15.07 By contrast, the study found that aged 16 or older, girls, children in rural years, and the youngest child was 12 only 7% of the children have areas, and in the North. Noticeably, years, while the oldest was 17 years. ‘abnormal’ symptoms of peer the percentage of children having Girls made up 60.2% of the sample. problems, considerably lower than ‘abnormal’ symptoms is highest in Some 46.3% of the sample were in the figures provided by some other Dien Bien – a Northern mountainous the lower secondary schools and studies. However, the percentage of province and An Giang – a province in rest in the upper secondary schools. children having borderline scores the Mekong Delta. Please see Annex 3 43% were living in rural areas, the for the Peer Problems Scale was for further details on these findings. remainder in urban areas, while 51.2% 2-3 times higher than that for other were in the North, and the remainder domains of problems. A significant 4.3.1 School level risk factors in the South. portion of the children seemed to be rather solitary, had few friends, were Three main areas stand out In terms of overarching findings from not liked by other children their age, amongst respondents both from these two scales, we found that of preferred hanging out with adults, IDIs and FGDs as being potential the four domains of behavioural and and especially, some of them were risk factors for mental health and emotional problems, the number of even victims of or at risk of being psychosocial wellbeing related to children having ‘abnormal’ emotional bullied by their peers. This suggests the school environment: academic symptoms made up as many as that peer relationships are a difficult stress, inadequate support and/ 19.7% of the total sample. The rate of problem for school-aged children. or shortcomings of the school children having conduct/behavioural environment and challenges faced problems in this study also appears The behavioural and emotional by romantic relationships which to be quite high; the most common problems mentioned above differed for many, are likely to start in and symptoms include lack of self-control by the children’s demographic and be associated with the school – getting angry and losing temper social characteristics. The children environment. easily (21.4%). It is noteworthy that of the older age group and higher only 8.2% of the children affirmed education level face more problems Across a majority of the interviews, that they were not incited by other than those of the younger age group children and young people from people into doing things. and lower education level; girls the three age categories (11-14, 15-17, appeared to have more difficulties and 18+) agreed that the academic Only a few of the children reported than boys. The girls face more pressure they face in school is one of to have conduct disorders such as emotional problems than the boys, their main worries. For the younger fighting, bullying, or dishonesty, while in contrast, the boys have group, they were particularly but that many of the children are more peer problems than girls. concerned about certain subjects somewhat prone to these behaviours Hyperactivity seems to be more of a that they reported being not good is a matter of concern to families problem among older children and at – mostly English or Math; for the and schools, because children with in urban areas and big cities. older groups (15-17, 18+), similarly, such conduct disorders will face they felt under pressure when they difficulties not only in building Regarding prosocial behaviours, did not perform well, got low marks social relationships, but also in their the majority of the children in the or when faced with important (e.g. personal development. survey sample had positive social university) exams. All groups also felt relationships, with 80.6% scoring they placed very high expectations The majority of the children in the ‘normal’ and 4.5% ‘abnormal’, on themselves to do well, thus survey sample showed problems or respectively. Overall, no significant further fueling feelings of stress and symptoms of hyperactivity. 8.5% of differences were noticed between the anxiety. This was exacerbated for children had hyperactivity scores in different children’s groups in terms of many students when they compared the ‘abnormal’ band, which calls for prosocial behaviours. Nevertheless, their marks with those of their peers; attention. Very few of the children the mean prosocial score is higher in one FGD with older (15-17) children, were confident that they possessed among children under 15 years of age, respondents noted that ‘jealousy in good attention, judgement and girls, secondary school students, and studies’ was currently one of the most ability to analyse and complete tasks children living in rural areas. stressful parts of their life. effectively. These signs are often ignored by parents and schools and Similarly, the study also discovered For all students, getting into differences in the rates of children advanced classes is highly Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 69 competitive and once in that class, do well. However, the way it is While it was difficult to tease out students feel even more pressure perceived and the responses appear differences among children residing to continue being part of that class. to be gendered. Thus, on the one in rural, semi-urban and urban In one FGD (15-17) it was also noted hand, girls are seen to not have areas, a few tentative differences are that children from ethnic minorities the strength to cope with tougher discussed below. In the rural areas, have to score even higher to get studies: ‘We [some girls] belong to there was a sense that pressure into gifted schools, though this was Group A and Group B, which consist to perform well alongside peer contradicted when other students of Maths, Physics, Chemistry and competition was extremely high, noted that they could perform less Biology. People say only boys have because if children did not do well well and still pass. As mentioned enough strength to deal with these they would very likely return to their in household risk factors above, groups. That’s what I heard. I heard villages with very limited options for many students also spoke about people say that in high school, girls the future. Thus, education can give pressure from family to do well in had better choose lighter groups; they children a way out. Peer pressure school and this came out possibly should not study subjects that are related to issues around poverty also more amongst the older age groups: too tough because it will affect our comes out more in rural settings, ‘Most parents want us to be good minds’ (IDI, F, 18, Hanoi). Girls report with one boy noting how he felt or excellent students, and we want feeling that they need the most inferior to his peers because he went parents to be proud of us, so we spend support in certain subjects (English to school ‘on foot’ and his friends all the time studying, consequently and math). Boys note, however, made fun of him for being ‘too poor’. we alienate from friends and become that ‘girls study harder and are like Also emerging more strongly in autistic or so on’ (FGD, F, 16, Hanoi). programmed machines’, and they rural areas compared to the other Similarly, one girl in Dien Bien Phu ‘tend to cry when they get bad marks’ locations, were the domestic chores city feels pressure from her father: (FGD, M, 15, Dien Bien Phu city). Girls competing with studies, though this ‘When my parents took my score also appear to feel extreme pressure could also partly be explained by report to the People’s Committee for a from parents to perform well, often the fact that children interviewed in stamp, they would see that my scores being compared to other siblings: semi-urban and urban areas were were poor, so I’m reluctant to give it to ‘Parents think that if they compare mostly at boarding schools. my parents. My dad said that I couldn’t their child with other children, the child keep up with others. My dad said a lot. will follow the good examples and the In the semi-urban areas, children My mother said that if I couldn’t study, situation will be improved, but in fact, spoke about wanting to drop out I should drop out. I told my friends it only hurts the child’s self-esteem, because they did not like studying that my mother told me to drop out, causing psychological injuries and and because their performance was and then my cousin advised me that making the situation worse’ (FGD, F, 13, compared to other children and I should drop out, so that my parents Hanoi). other relatives. This did not come wouldn’t have to work hard for me to out in rural areas; one interpretation go to school’ (IDI, F, 16, Dien Bien Phu As mentioned above in the could be that in semi-urban city). household level risk factors, there areas children felt they had more appears to be more pressure on opportunities and thus dropping In the older age categories older girls rather than boys to out was an option compared to the respondents also spoke about the undertake domestic tasks whilst rural areas where there are fewer fact that problems at home also studying. While boys feel pressure options and where education is seen affected their performance in school, from parents, the pressure from as a pathway out of these areas. In and in one case an 18+ year old peers and teachers appeared to be these areas it was also noted that girl, spoke about worrying that her relatively stronger. Boys also note because of the need to pass subjects family could not pay for her extra that rather than hanging out with like math and English they had to classes and also having to carry out friends at home and attending the stop other extra-curricular activities domestic tasks alongside her school Tet festival, for instance, they have according to a girl in Dien Bien Phu work, which was putting pressure on to study. This also points to possible city, for instance: ‘There’s too little time her studies. gender differences / expected to do what we’re passionate about. For gender roles since, arguably, girls, example, this girl may like painting, but In terms of gender differences, whether studying or not, would be because her study timetable is already both girls and boys appear to feel less likely to hang out with friends full, she can’t paint’ (FGD, F, 15, Dien equally the stress and pressure and have free time to attend holiday Bien Phu city). related to being at school, including festivities. peer pressure and the pressure The notion of staying up to all hours from parent/family members to to study came mostly from these 70 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

Like all other students, the urban based students also felt pressure from their parents, but possibly given the middle class status of many families in these urban areas, the expectations of their parents ‘Sometimes, I told parents to cut the internet supply appear to be higher, and according to change the behaviours of children. I kept my eyes to respondents, the highest amongst parents who are doctors on a student of grade 11 when I taught him. He is a and teachers: ‘You want to choose a game addict. He looked dull when he was in class. vocation, but your parents don’t want you to choose that vocation, they may When he entered grade 12, I asked him to agree prevent you, for example’ (FGD, F, 16, with me not to play games so much. In practice, he HCMC). still played games, but he improved. His face looked All of the above has resulted in vital and fresh and he paid attention to lessons children reporting feeling a range of emotions such as anger, sadness, well. It’s different from his previous demeanor when worry, stress, anxiety, jealousy, he didn’t listen to what teachers said because he disappointment, regret, inadequacy, just always thought of games.’ inferiority and shame – with different emotions emerging in varying circumstances. For instance, children KII, Teacher in HCMC feel anger, regret, disappointment and inadequacy upon receiving test scores or report cards. On the other urban areas, and it is notable that hand, they feel inferior and jealous girls mentioned this. According to due to peer competitiveness (see a girl in Hanoi, ‘The teachers say that section on school risk factors below). we should not stay up late too much, Children also experience anxiety, otherwise we won’t be able to go to worry, and shame when they have class the next day. So I stay up until 1 or to share their test scores with their 2 o’clock at most, or half past 12 if I can parents. Physical symptoms have finish earlier’ (IDI, F, 18, USS, Hanoi). A included and ranged from crying, to similar sentiment is expressed by a missing meals – ‘some girls are known girl in HCMC: to even skip lunch when they get bad marks’ (FGD, 15, Dien Bien Phu city) – Q: Why do they feel worried and scared to having nightmares (in relation to and isolate themselves? a boy having to give his mother his report card to sign, and presumably A: I think the first reason is that fearing her reaction to his results), studying in school is too much, putting to getting headaches, to getting much pressure on us, then we spend depression, to fainting because of much time on studying, we even working so hard and late at night. won’t come home from school and This peer pressure, according to classes until 9 PM. We also have to the older age cohorts, also leads to do homework. If we don’t finish the negative coping strategies, including homework, the next morning we will smoking and drinking. Boys in be punished. When you go to school particular also noted that these with unfinished homework, you will feelings of stress can lead to children feel scared and worried, and the feeling feeling like dropping out of school keeps lingering. We constantly live in and some said that academic stress is worries of what will happen if we go a risk factor for suicide. to school without finished homework, my friends will sneer at me’ (FGD, F, 16, The second major risk factor at the HCMC). school level, as expressed by many Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 71 respondents, was shortcomings ‘misunderstood by friends’ and ‘being in an FGD in Dien Bien Phu City within the school environment isolated’, leading to the children to narrating a story of a girl who fainted including inadequate support report feeling sad, stopping talking because she was homesick. for children. Bullying emerged as to their friends, sulking, and not one such major risk factor affecting being able to trust their friends. Another component of the school the mental health and psychosocial In some cases, children, especially environment that children found wellbeing of children and was seen girls, were insulted with derogatory inadequate was the lack of leisure to be pervasive across all interviews, terms, as in the case of a 13-year-old activities, with children feeling that with some slight variations according girl in Hanoi: ‘Children in my class more extra-curricular activities are to age, gender and location. This said “yeah, she’s very mean”, and “she’s necessary to de-stress, while at the is summed up in a quote from a a slut”, and “she often talks behind same time their packed schedule in 13-year-old boy in Hanoi who says people’s backs”, that sort. But actually the day makes it hard to have time for ‘I’m very sensitive, so being made fun I wasn’t like that at all; for example, leisure. of by other people affects my feelings they exaggerated my girliness into the most’. Bullying usually takes sluttiness.’ It was also suggested by a The mental health and psychosocial the form of children being teased 13-year-old girl in a FGD from Hanoi wellbeing of these children and sometimes beaten, often by that being ‘ill-spoken-of’ behind was also affected by how their older children at school, who also one's back or being the subject of teachers behaved with them. Many often demand money from their a rumour was a potential risk factor respondents in all age groups and juniors. More often it is boys who for suicide. Children also reported across all locations felt that teachers are beaten and girls teased. Reasons feeling sadness when friends were were unsupportive – according to for teasing range from being teased short tempered with each other, with them, teachers did ‘not listen to about one's height, about ‘liking a some reports, particularly in one them’, girls talked about teachers boy’ (clearly affecting girls), about school (in Hanoi), of children using discouraging them from following being anti-social, quiet and having foul language and ‘terrible words’ their career aspirations and telling no friends, about having to be in against children from ‘poor families’. them to give up their ideas; they a leadership position in class and ‘Misunderstanding between friends’ also often scolded them for making report on others’ behaviour to the (FGD, F, 15, Dien Bien Phu city) was mistakes or being late. Girls in teacher, and about underperforming one of the most commonly cited particular also spoke about feeling in school. This latter reason was problems among peers across all shaky when teachers interrupted brought out particularly in the urban sites: them and when they had to speak settings where it seems that pressure in public. This resulted in children to perform is even higher than the Q: Apart from that, what else makes reporting feeling sad when teachers other sites. One girl from Hanoi you sad? were unsupportive; additionally, shared that her classmates teased they were also scared when teachers her because of her family's financial A: When friends misunderstand one punished and scolded them, struggles and her inability to pay for another, and when they think things sometimes beating them (mostly health insurance and school field that are not true (IDI, F, 16, Dien Bien the male teachers) with a ruler or trips. In some cases, when it came Phu city). twisting their ears, and in extreme to beatings, teachers intervened. cases using a belt, though this In other cases, children hesitated Being away from family and in occurred most with boys. According to tell teachers for fear of further boarding school, which is relevant to an FGD with 13-year-old girls fuelling the bullying. In one extreme largely for the older age cohorts in in Hanoi: ‘Girls are rarely beaten. case, one boy in HCMC said that in the study and those mostly in semi- They are gentle and weak, so they one class he wrote down name of urban and urban areas, is an added are rarely beaten.’ Students rarely children who had been naughty and stressor. This results, on the one hand reported these beatings, fearing that as a result, that group ‘waited for the in, children missing their parents the teachers would subsequently teacher to leave the classroom, and (‘crying when they talk to them on penalize them through giving then closed the door and beat him up’ the phone’), while on the other them low marks in the future. While (FGD, M, 13, HCMC). hand, in friendships becoming more unsupportive teachers were present important. When these friendships in all areas, the children in the urban In addition to bullying, in all result in conflict or bullying, children sites were more vocal both in terms locations, and across all age groups, take it even harder. While both of the punishments they meted out there were instances of peer conflict boys and girls miss their home and as well as their almost untouchable where children reported being parents, according to boys, girls feel status, as these quotes from two talked about ‘behind their back’, being more homesick, with some boys girls in Hanoi show: ‘When I was 72 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam on the way to school, I saw a male causing much anger to the boy, who 4.3.2 School level protective factors, coping and responses teacher using a ruler to strike heavily reported feeling he had ‘lost the joy’, on a student’s legs. Sometimes male and also fuelling the sentiment of A number of protective factors, teachers drew their belts to strike’ unsupportive teachers (see above). responses or coping strategies were (FGD, F, 13, LSS Hanoi). Similarly, ‘Now Sadness was also triggered amongst identified at the school level, many even if the teacher is wrong, I still have children when relationships broke of which also overlap with individual to say that I’m wrong. We can’t argue; up, all of which also distracted them level protective factors, coping the teachers are gods’ (FGD, M, 16, USS from their studies. strategies and responses. Hanoi). Girls in urban areas in particular One critical response at the school The final risk factor that children spoke about issues of love level are the psychological spoke about was in relation to as being one of the biggest counselling units. These were romantic relationships. The reason misunderstandings between found mainly in the schools in the this is discussed in this section is children and parents as this narrative urban areas and many are associated that often these relationships start from a young girl in Hanoi shows: ‘Q: with / get support from NGOs in in the school environment and are What is the biggest misunderstanding addition to funding from DOLISA often, though not always, associated between children and parents? A: (see Section 5 below). According to with stress. Generally there was In foreign countries, children our study respondents, girls tend to go a sense across all age groups age are not forbidden from falling to the psychological unit more than and all settings, though perhaps in love, it is a very common thing. boys and find it helpful. One boy particularly amongst the younger Children are allowed to love, but who visited the counselling room group since they are considered too not to rely on others, they have to explained that the counsellor ‘Was young to have such relationships perform well in school, and parents just talking with me; he guided me (parents and grandparents will say, equip their children with knowledge through my difficult stage when I was according to 14-year-old girls in Keo about psychology. In our country, love suffering emotional abuse from other Lom commune, Dien Bien ‘You are between boys and girls is seen as worse students’ (IDI, M, 13, Hanoi). Another too young to know, don’t fall in love performance in school, children are respondent, an older girl (18+ in early’ to children under the age of required to study day and night, love Hanoi), accessed the psychological 15), that parents and teachers do is forbidden, so pressure is put on the unit, which helped her deal with not approve of these relationships children’ (IDI, F, 13, LSS, Hanoi). issues of bullying and teasing and that they are forbidden, largely resulting from being unable to pay because they feel (a view that is also Many children, in all settings, also for extra tuition fees, go on school shared by the students) that they spoke about romantic relationships trips, or buy health insurance; she will distract them from their studies. as being risk factors for suicide. also said that no one else she knows Several students note that teachers According to respondents, possible had accessed these units. A KII with ‘think that we can start a relationship, suicide triggers could include a school psychologist revealed that but studying should be guaranteed, unrequited love; parental discovery in cases in which the counsellor is otherwise, intervention will be needed’ and disapproval or forbidding of the available, they work towards creating (IDI, F, 15, HCMC). In her school in relationship; and, for girls in particular, a safe and accessible environment HCMC, the same girl explained that, feeling jealousy. Girls in particular for students to share their feelings: ‘In the beginning of the school year, shared stories about people who had ‘I create an open relationship with there was no prohibition on emotional attempted suicide, with some using students so they feel very relaxed. affairs or showing it at the school, but poisonous leaves in Dien Bien, where Sometimes, it is just a walk together then some couples showed too much they grow in abundance. around the school playground and intimacy and tended to have sexual talk. They can tell me that we do not relationships, so the school was too Upsetting also for many respondents, want any consultation at all, we just worried and imposed a prohibition and particularly girls, was when want to talk to you to ease our sadness’ to stop the trend. Friendship is gossip and scrutiny ensued after (KII school psychologist, Hanoi). advised to be innocent’. Despite people jumped to the conclusion this, relationships continue, which that their friendship with a boy was However, respondents also noted provides fuel for stress if a parent or a romantic involvement. This results a number of shortcomings of these teacher finds out. In the case of one in some children also feeling shy to units. Shortcomings ranged from boy, for instance, a teacher found talk to members of the opposite sex, students often not knowing about out that he had a girlfriend and since it often leads to gossip among these units and therefore rarely told his parents; this resulted in the their peers. accessing them (in one case in An boy breaking up with his girlfriend, Giang the psychological unit was Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 73 turned into a classroom because it was not being used), to girls in Hanoi mentioning that the counsellor was often male, and as such, they felt unable to share their feelings with him, to the psychological counselling unit being housed in a library, which did not afford children the privacy necessary for them to share freely ‘I create an open relationship with students so (Hanoi). It was also noted that even they feel very relaxed. Sometimes, it is just a if students do go to seek support from the counsellor, which appears walk together around the school playground to be more likely in urban than in and talk. They can tell me that we do not want rural and semi-urban areas, they any consultation at all, we just want to talk to only share issues related to school and do not share ‘private issues’. you to ease our sadness’ ‘Most of the students don’t share their family issues there; they only go there (KII school psychologist, Hanoi). if they are under pressure from friends or studying’ (FGD, F, LSS, Hanoi). In urban areas it was also not by children that they would rather seek advice from their peers: ‘who have the same point of view as them’ (FGD, F, 16, HCMC). The following quote from HCMC sums up the shortcomings of these units: ‘I see that many students visit the unit, but most of the students share their thoughts with friends. Many students even don’t know who Mrs. Hoa [the counsellor] is. But the unit is much needed. Meanwhile some students don’t know about its existence at this school’ (FGD, F, 16, HCMC).

A number of respondents spoke about the life-skills training and citizen education that they receive in school which, according to them, helps them deal with stress. According to respondents, the life-skills they are taught, which are usually taught in biology class, includes controlling negative emotions, communication skills, dealing with violence, learning to deal with stresses and sadness, being confident, problem solving, physical health, and protection from ‘social evils’ such as alcohol, drugs and smoking. These clubs are often supported from NGOs such as World Vision, as illustrated in the KII with an officer of World Vision : © UNICEF Viet Nam\2017\Truong Viet Hung 74 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

‘In addition, in some localities, we have through use of drama. According to and helps students get advice on life done it in a more systematic way, that’s a boy from Hanoi, joining this club issues. The internet and Facebook in the commune level community has made him more confident: ‘Since were also seen as being positive child protection system, we establish I joined it, I’ve met many other friends, for study purposes: ‘It (the internet) children’s clubs that are outreaches who have a lot of things that I need is good for studying. If you don’t of the system. When participating to learn from. They are very self- understand some points in the lesson, in the clubs, the children are trained confident. Since I joined it, I also feel you can ask friends or post questions on life skills and social and scientific that I’ve become more self-confident.’ on the teachers’ Facebook pages’ (FGD, knowledge of their interests, besides, F, 16, HCMC). Other respondents they also take part in another kind Amongst HCMC and Hanoi mentioned another website (ASK14) of operation called the locally based respondents, the NGO Plan which could provide support on World Vision’s kid partnership to detect International was also supporting these issues, and a few children, any issues and needs of their friends. these kinds of activities in schools, mostly boys in urban areas, also The World Vision statistics show that and especially in helping children knew about a hotline for counselling, there are over 800 such children’s clubs. to deal with bullying. The downside though no study respondents had of this was that often due to limited ever called it. They [children] are trained on how to time or clashing time-tables, children respond to tension, build relationship were unable to participate in these Teachers, as well as causing or how to say no. It means that we clubs and extra- curricular activities. students’ stress and anxiety (see base on the research on the age group Moreover, in one school in Hanoi, the above) are also an important part of lower secondary school, teenagers activities of Plan are ending, leading of students’ coping repertoires, to know what skills are needed and the headmaster to worry about particularly in relation to studying: divide them by regions.’ being left without any capacity to ‘They really pay attention to my handle psychological problems of schoolwork; if I make a mistake in my Being members of clubs (e.g. the students: ‘I’m worried. For a good notebook, they will show me’ (IDI, F, English, art and Young Leaders’ result, school consultation should be 16, Dien Bien Phu city). According Clubs) and taking part in extra- carried out by staff with expertise in to respondents, in some cases the curricular activities was also social psychology. If schools have no teacher seeks out the child to give mentioned by various respondents consultation activity, conflicts and advice, and in other cases, the child as a way of unwinding and coping violence at school might increase. seeks out the teacher, and in yet with the stresses faced at school; in Second, there will be no one dealing other cases, the teacher reaches out urban areas in particular, children with the psychological problems of to parents, as seen in the box above. also mentioned being part of the students. This will make the number Children spoke about teachers youth and children’s union, which of students having psychological encouraging children not to drop carries out activities that, according problems increase. School consultants out of school. In another example, to this girl from HCMC, ‘help us to are not necessarily full-time staff. A a head teacher spoke to parents of understand each other better’ (FGD, F staff can work on part-time basis for a child who was stressed out, which 16, HCMC). In particular, respondents two-three schools and on shift duty. led to the parents ‘caring’ for the mentioned the Young Leaders’ The school consultants must expertise child more: ‘Last year I met with my Clubs, in which both girls and boys in student psychology’ (KII, Co Loa LSS, class’s head teacher to talk about my participate, though ‘Usually the Dong Anh District, Hanoi). stresses from studying. She explained boys rarely participate in the school to me that my parents were really activities, such as music or other When in school, children also serious about my studies, so when I activities. Very few boys participate. reported using the internet as a got a bad mark, my parents often told Among the students who applied strategy for coping. This tended to me off, which put a lot of pressure on for the school’s Young Leaders’ Club, be more common amongst the older me. Therefore, I was too stressed; as when I applied, I saw that there were children but was equally prevalent a result, my studying didn’t improve, only a few boys, only ¼ were boys, in all locations. Facebook was a but even got worse. Therefore, I talked while the rest were girls. There are only frequently mentioned resource – and to my class’s head teacher, and she nearly 10 boys in the Young [Leaders’] possibly more by girls amongst our helped me talk to my parents (IDI, Club’ (IDI, M, 13, Hanoi). These young respondents – with children using it M, 16, Hanoi). Respondents also leader clubs ‘provide knowledge to as a vehicle through which to voice reported teachers as supportive in future leaders about violence, gender their feelings. For example, children issues beyond studies, thus a girl and gender-related issues’ (IDI, M, 16, spoke about posting to a confession who lives with her grandmother and Hanoi) and also help children learn site that is monitored by a ‘former faces economic difficulties, reported about and deal with bullying, often student who is studying economics’ how the teacher advised her how to Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 75 take care of her grandmother, who Other protective factors, or aspects ‘The natural conditions in this area are was not well and also ‘gave a school of life which children spoke about good for growing this plant. It is also bag, 5 pens and a dozen notebooks’ that make them feel happy included easy to buy this plant from Lao. The (IDI, F, 16, An Giang). Teachers were and ranged from feeling happy drugs are often trafficked from Lao.’ also seen to be supportive when it about being at school/in class came to bullying, telling children to and with friends, to (especially Parents in Dien Bien also spoke about report the bullying and also trying girls in boarding schools) going to the dangers of these poisonous leaves to ensure that children from poor the pagoda with their friends on and suggested a solution: ‘If there’s a families were not discriminated Sundays, to discussing and sharing project that buys poisonous leaves from against: ‘Discrimination used to be their thoughts with friends, to having people and then burns them, after 2-3 there, but the head teacher and head romantic relationships. years, there will be no more [poisonous master talked about the behaviour leaves]. If they mobilize the whole and it has changed. It used to be there village to dig up [these plants], the in the past’ (FGD, F, 17, An Giang). 4.4 Community level risk and plants will be cleared. It will reduce the Some children also felt comfortable protective factors problem of suicide’ (FGD, Parents, Keo enough to discuss their ‘love Lom commune, Dien Bien). relationships’ with their teacher, Relatively few studies have explored suggesting that help- seeking and factors at community level that may There is a consensus across sharing of more personal feelings create risks for children and young interviews that abuse of both alcohol may also be dependent on the people with respect to mental health. and other substances is occurring. quality of teacher. The important The few articles on community Alcohol abuse was mentioned role supportive role of teachers level risk and protective factors particularly among older (15-17) male is summed up in on quote: ‘Most identify stigma against mental youth as shown in the FGD: ‘They of teachers at this school listen to illnesses as the main risk factor that drink wine when they are happy and us. Teachers are also psychological places those already burdened with when they are sad. It is seen as a way doctors’ (FGD, F, 16, HCMC). Students mental illnesses at further risk since to show their personality and internal also spoke about enjoying being they are less likely to seek care (Do strength’ (FGD, M, 17, An Giang). A praised by teachers and teachers et al., 2014). Additionally, lack of KII with DOLISA Dien Bien laid out caring about them. knowledge about mental illnesses the trends among young people’s was found to be one contributing consumption of alcohol: Having supportive teachers in factor to increase stigmatisation leadership positions also promoted a (van der Am et al., 2011; Vuong et al., ‘Children at secondary school age start healthy and positive school climate: 2011). drinking wine. Older children drink ‘Our point of view is that teachers more and it is the same with children should have true affection for the 4.4.1 Community level risk and young people in the mountains students. Criticising the students under factors and river deltas. Students at secondary the flag rarely happens at my school. school ages drink the most. Ethnic Offenders are often invited here or to Three main categories were minority students of secondary school the teacher’s room for a person-to- identified at community level as don’t drink as much as college students. person talk. When we see that the talk posing a risk for mental health and In community, students of secondary works, that’s all. In the examination psychosocial wellbeing of children schools don’t drink wine because they season, I invite doctors to advise the and young people. These included: don’t have wine to drink. They don’t students on how to eat and rest, what easy access to harmful substances, have money [to buy it] and nobody food gives them enough nutrition. lack of access to opportunities, and drinks with them at that age. It is They shouldn’t stay awake too late harmful norms. thought that people in the mountains every night, instead they should have drink a lot but it is just common reasonable sleep. We also look for Easy access to harmful substances amongst those who are employed. ways to reduce stress and pressure on included, particularly in Dien Bien These people have money to buy wine. them. Though this is a quality school, I province (in all locations), access to Local people also make wine at their always remind them that university is drugs and access to poisonous (la homes but only the adults in the family not the only way. A number of people ngon) leaves, which are taken with drink’ (KII, DOLISA, Dien Bien Phu city). like them learn vocational skill and the aim of committing suicide. succeed. We invite successful former For instance, a KI with the Social Reasons for such abuse occurring students to talk with them’ (KII, USS, Protection Division of DOLISA in Dien range from people wanting to use it, An Giang). Bien reported that the high level of to being tempted by their friends, to drug problems can be attributed to, it being available easily and cheaply. 76 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

For instance, one interviewee stated: that]. In my neighbourhood, nearly 40 ‘The substances they use are cheap people, both men and women have and they can buy it easily. The glue is been detained.’ very cheap, costing some thousand dong, so most of the users are from There is a general view held by poor families. The children from rich both those in rural and semi-urban ‘young generations learn families don’t think of it and don’t areas, that opportunities in rural from their grandparents’, use such cheap things. So it happens areas are limited and are therefore more often to the children from poor causing potential stress for children often by observing. Similarly, families" (FGD, M, 17, An Giang). and young people. In urban areas stereotypes around ethnic Another reason for drug abuse is the narratives were more around that ‘many fathers pass it on to their higher level career aspirations of groups are a reason stated children’, as was noted particularly children and young people, which for high numbers of suicides in Dien Bien. Easy access once again were misaligned with what their underlies this problem since Laos, parents wanted for them (see above – one respondent was asked which is where opium is most easily in household risk factors). There whether his area is mostly available is only ‘an hour from Dien was also a limited knowledge of Bien by motorbike’. A KII further vocational options, especially for occupied by Hmong people, corroborates this and shares that, those who did not feel that their and he replied, ‘Yes, they lack ‘To buy heroin, they drive motorbike scores were enough to get them knowledge. Those with better for two hours, then walk in the forest into highly competitive universities for a day. It takes them a day to go to in the future: ‘My classmates have awareness [in other areas] are Laos and a day to return. They start determined their career direction; I less likely to commit suicide’ in the morning and reach Laos in the haven’t determined my own. In grade evening, they spend a night there 10, my performance in all subjects (FGD, M, 15, Dien Bien Phu city). and buy heroin, return home the next was similar, nothing stands out, so I morning. Border guards and police don’t know what group of subjects I have caught several people [going like should follow. I worry because I don’t know how I will perform in grades 11 and 12. I review my scores and search on the internet to see if there is any vocational training compatible with my score level. I have searched websites for a long time, I read newspapers to look for career guides. There are several newspapers that often give career guides’ (IDI, F, 15, HCMC).

Thus in rural areas, it was largely boys who spoke about limited opportunities in terms of employment and infrastructure, whilst for girls (and parents) the limited availability of services – ranging from contraception, to having someone to teach about these services and from whom they could seek advice (it seems the Women’s Union was not active in these areas, otherwise they could have been an option), to support for drug users’ detoxification and rehabilitation) – seemed to pose more of a threat to their wellbeing. © UNICEF Viet Nam\2017\Colorista\Hoang Hiep For instance, one young man shares that that it is costly to find a job: ‘We Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 77 want stable, long-term employment A: Being humiliated on the internet, respondent was asked whether his that can give us income. Working for or your photo is edited for wrong area is mostly occupied by Hmong the state is preferable, light-duty work purposes. people, and he replied, ‘Yes, they is better than farming’ (FGD, M, 16, Keo lack knowledge. Those with better Lom commune, Dien Bien). Concerns A: Your video clip is posted. awareness [in other areas] are less around employment are validated by likely to commit suicide’ (FGD, M, 15, KIIs: ‘Many children cannot get a job A: Your photo is edited to prove the Dien Bien Phu city). after school; some children even say wrong doing that you didn’t do. (FGD, frankly that they don’t need to go to F, 13, Hanoi) Perhaps even more striking are the school, because it would be pointless, norms around gender, which largely because they won’t get a job anyway. Harmful norms appear to be affect girls in a negative way and are It’s a stress in their lives. Vocational perceived differently according to particularly prevalent in rural areas training and employment are difficult whether respondents were based in and in the north (Dien Bien), though in Dien Bien at the present. Jobs are rural and more urban/semi-urban there is evidence of such in An very limited in this small province, areas. Some of these views were Giang as well. These include norms especially in mountainous areas’ (KII, also echoed in the discussions with around early marriage – usually also DOH, Dien Bien Phu city). Another key informants. Thus in rural areas resulting in a girl leaving school at an young boy discusses the challenges and largely in the north norms and early age – what a girl should do with in reaching the school due to failing stereotypes around ethnicity are her life, how she should behave and roads: ‘What concerns us is the road. often perceived by respondents to look/dress, and the domestic roles The school is far from our houses, the be a major causes of mental health that she needs to take on. It should road is bad and difficult. If you don’t challenges. Thus, for instance, be noted, as already mentioned know the road, you can fall’ (FGD, M, according to one respondent from above, that despite the legal age of 16, Keo Lom commune, Dien Bien). Dien Bien, excessive alcohol drinking marriage being 18 for girl and 20 for Similarly one young man shares that can be a result of ethnic rituals and boy in Viet Nam, the reality is that in employment is difficult because customs, including receiving guests: places such as Dien Bien girls are still of lack of transportation: ‘We do ‘We ethnic people often have ritual getting married at very young ages. a lot of work, but earn little. It’s not ceremonies. Hmong people often do it All of these can affect the mental efficient. And we don’t have means of when someone is sick. We drink alcohol health and psychosocial wellbeing transportation either, so it’s difficult and we also kill animals, for example of girls. Thus one respondent spoke for us to travel’ (IDI, M, 28, Keo Lom chickens or pigs, and then invite our about girls getting married as young commune, Dien Bien). relatives to come’ (IDI, M, 28, Keo Lom as six years old. She continued, commune, Dien Bien). Ethnic norms ‘There’s one girl who didn’t get married There was also a sense that there were also given as an explanation as until age 17, but are considered “on the were limited leisure opportunities in to why people ‘smoke black opium’. shelf” when they are 20’ (IDI, F, 19, Keo all areas, and even when they were Thus parents in an FGD in Dien Bien Lom commune, Dien Bien). Another available, infrastructure to support explained that when someone is not respondent also spoke about how the activities was lacking, as noted in well, a shaman is called upon who she had chosen to marry early and the interview of a 15-year-old girl in makes the ‘sick person smoke first’ the neighbours had disapproved, HCMC, who stated that even though before healing them. They further asking: ‘Why are you getting married boys and a small number of girls play explained this ritual, also distancing so early? You’re still young, why don’t sports, ‘The playground here is not themselves somewhat by saying you wait? If you do that, you’ll have sufficient enough to play’. This lack that: ‘There are two types of Hmong; to drop out.” That was what they said, of leisure opportunities was shown we’re white Hmong; we also smoke but I had already married him, so I to result in children and young [drugs], but less. The red Hmong smoke couldn’t do anything’ (IDI, F, 18, Keo people spending a lot of time on the the most. There are 25 villages in the Lom commune, Dien Bien). This internet (see individual risk factors commune, but the majority of drug same girl went on to say that despite section above), which was also smokers are red Hmong’ (FGD, Parents, being in an unhappy marriage, she seen particularly by girls as being Keo Lom commune, Dien Bien). They had very few options now because dangerous and a risk factor also for also noted that this phenomenon of the norms around custody of her suicide, as this narrative from girls in is likely to continue since the children. If she asked for a divorce Hanoi shows: ‘young generations learn from their she would lose the rights to her grandparents’, often by observing. children, and her own family would Q: What is the risk factor for Similarly, stereotypes around not allow her to return to live with committing suicide among young ethnic groups are a reason stated them permanently out of fear of the people? for high numbers of suicides – one 78 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam societal backlash that would result wife go together. But to Hmong people, should walk ahead of them or behind from a divorced woman: the wife stays at home to look after the them to be able to protect them’ house for the husband to go’ (IDI, F 18, (FGD, M, 16, Hanoi). Similarly, boys ‘The children would be in my husband’s Keo Lom commune, Dien Bien). believe that they want to show girls custody; it’s his right. Some people split ‘strength, power, being manly, being [the children]; they may say the son In An Giang, an FGD with KIs a lady-killer, worker, fame’ and they belongs to their family line, so they let describes norms that constrain girls’ expect girls to be ‘beautiful and have the father take him away. Meanwhile, participation in leisure activities – a nice body’ (FGD, M, 16, Hanoi). One as for the daughter, some people may something that is already limited to introspective boy stated that ‘(he) say she’s a girl; she is staying here now begin with: ‘Girls are under pressure if likes girls who have “Cong – Dung – La but she will grow up and then get they do what they want. For example ngon – Hanh’ (industriousness, good married, and she then won’t belong they are not allowed to play football or appearance, being well-spoken, to the family anymore. Therefore, the something requiring strength. Parents virtue – four qualities of an ideal mother can take her away because say that’s men’s business, “if you play woman according to Confucian later on she will get married anyway. football, you will be sneered at”’ (FGD, concepts). ‘They don’t have to be Some people choose that solution. Provincial officers, Long Xuyen city, pretty; an average and good-looking Meanwhile, some people say that the An Giang). appearance is enough’ (FGD, M, 16, first person to mention divorce doesn’t Hanoi). get the right to raise their children… Respondents in semi-urban areas According to our ethnic tradition, also perceived people in rural Generally there is a sense (which once I’m married, it’s like I will not be areas, and in particular girls, to was voiced predominantly by included in their (my family’s) worship be more at risk of harmful norms. 15-17-year-olds) that urbanisation rituals anymore. If I walk away [from Thus, for instance, in a focus group is viewed as ‘the society is getting my marriage] alone, I can stay with discussion with girls in Dien Bien Phu worse’ since people care about them (my parents) for 1-2 years, [but city, they note that norms around ‘economic issues (money) and social not] longer. And then they will build a gender, including those around son status’ without paying attention to small house for me to live in separately; preferences, in rural areas may put ‘human emotions’ (FGD, F, 15, Dien I won’t be allowed to live with my girls at a higher risk for suicide: ‘In the Bien Phu city). This is highlighted, parents anymore. And when I’m too commune, girls face more difficulties, according to respondents, by the seriously sick, they will not perform because in ethnic [minority] groups, fact that the increasing social my funeral in their house; that’s not people often value men over women. status often associated with urban allowed. It’s said that my family’s The society is progressing, but some residence drives parents to have ancestors don’t recognize me anymore, parents are not knowledgeable, so different career expectations from so they will build a separate house for they often prefer having sons. They children than the ones children me’ (IDI, F, 18, Keo Lom commune, may treat daughters a bit differently’ have for themselves, leading also to Dien Bien). (FGD, F, 15, Dien Bien Phu city). clashing values, which, with lack of communication between parents Other girls also in Dien Bien spoke Boys also perceive girls to be and children, merely worsens things. about how their teachers had more discriminated against than Similarly, and different from other dissuaded them from having certain themselves, as this following quote studies, people in town are believed career aspirations, suggesting shows: ‘Girls are forced to drop out to to be more knowledgeable than that they focus on what was more work, marry men they don't love, [are those in villages and as such it is acceptable for a girl. Other girls subject to] wife kidnapping, though believed that they are less likely to also mentioned the need to take on that is not as commonly practiced commit suicide (as mentioned in domestic tasks: ‘When I was little, my anymore’ (FGD, M, 15, Dien Bien section 3). Moreover, urbanisation older brothers cooked. When I grew Phu city). Norms around males as is driving parents to be away from up, in 7th-8th grade, I had to cook protectors are also prevalent in boys’ their children due to changing because here boys don’t usually cook’ minds as noted in the following employment structures, as noted in (IDI, F, 22, Keo Lom commune, Dien quote: ‘Boys are scared too, for the KII with a teacher in Hanoi: ‘Co Bien). Finally, comparisons were example, when I come home late Loa [a commune of a suburb in Hanoi] made between the Kinh and the from class, that road section is very is mainly based on agriculture, but Hmong women, with respondents dark, and in that case, if I’m robbed, I farmland is being narrowed because of noting that Hmong wives were more won’t know how to cope; or when I go population growth and urbanization restricted: ‘We Hmong people are not home with two girls, I’ll hold the heavy speed. Parents are hired workers in like Kinh people. When Kinh people go responsibility of protecting them. Da Hoi. They go to work early in the somewhere, both the husband and the In that case, I don’t know whether I morning and leave their children Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 79 almost to grandparents’ care. Some baby gets free health checks, despite parents allow a girl to keep a child might go to work at 2-3 AM. They buy not having a health insurance card. out of wedlock). This was framed, vegetables in Van Noi, Van Tri which There are also ‘delegations from however, as a comparison to other is about 10 km away from Co Loa and Phu My Health Station who give ethnic groups: ‘We ethnic people, sell in Hanoi. Several parents have day information about health’ (FGD, M, when we like each other, we don’t do labourer jobs (iron foundry) in Da Hoi. 17, An Giang). All these reasons may like Kinh people. If we [want to] get A number of people work for industrial be why ‘Traditional medicine is not married, we just do it ourselves, just zones which are 7-8 km away from popular anymore. People rarely use go to the husband’s home, and the Co Loa (footwear factories) and Bac it. It’s not available here. I heard it’s parents won’t know until then .. In my Thang Long industrial zone. Workers of available in Muong Cha, which is 100 ethnic group, we get married when we industrial zones finish work very late so km away; some people go there to get want; if one is 30 or 40 years old, she they have little time for their children.’ it’ (FGD, Parents, Keo Lom commune, will get married if she likes; otherwise Dien Bien) (see also section 4). she just stays that way’ (IDI, F, 22, Keo 4.4.2 Community level protective Finally, in terms of infrastructure Lom commune, Dien Bien). factors, coping, responses development, a FGD with parents indicated that children now have As well as being taught about the In terms of factors at community better access to school due to harmful practice of early marriage, it level which can be seen as ‘big roads’, and ‘for those in remote was noted by boys the importance of protective, many of them are the villages, there is a boarding school, being taught broader, everyday skills: mirror images of what is discussed and [children from] poor families are ‘Just some everyday life skills, I think. above. Thus, where and when there supported with [free] meals in the Soft skills that are very important to are opportunities or services, these boarding school’ (FGD, Parents, Keo us, which are necessary both in school can be seen as being protective for Lom commune, Dien Bien). time and later on when we become children and young people’s mental adults. For example, how to dine health and psychosocial wellbeing. Children and young people also properly, what to observe and what to In terms of services, children and note that the importance of holding do during a meal. Or how to choose young people, particularly in urban positive attitudes and beliefs, all food, which food is good and which areas knew about the existence of which has a positive effect on mental is not. Or how to treat other people, the MOLISA psychological hotline health and psychosocial wellbeing, what behaviours and actions are right that ‘provides us with psychological a perception coming largely from and appropriate, in terms of society counselling’ (FGD, M, 13, Hanoi). They children and young people in the and social ethics, and human dignity’ are also aware of a ‘sharing radio urban areas, as seen in the FGD with (FGD, M, 16, Hanoi). These same channel’ that comes on from ‘8 to 17-year-old girls in Hanoi: ‘The positive boys also pointed out how they 11 PM’ and ‘shares about everything, thing for young people is that we are wanted to learn about the world: ‘The psychological [issues], sexual health, open and objective, so we can find culture of communication, to improve anything’ (FGD, M, 16, Hanoi). many people with the same ideology general understanding. Viet Nam is Despite the shortcomings of the like ours. We are also supported by increasingly integrating itself in the rural health centres, children and parents, so we have positive looks at world, such as WTO, and OPEC, and young people also mentioned that the life.’ According to an FGD with joining some large economic markets, they were important sources of boys in Hanoi, avoiding harmful so we should learn from [the world’s] information about ‘sanitation during practices is taught in schools: 'Boys experiences’ (FGD, M, 16, Hanoi). menstruation, contraception, child are taught about harmful effects of marriage, reproductive health, and early marriage in school: They say that student psychology, which helps girls if marrying early, your body has not know more life skills and understand fully developed, and you will give birth better about gender’ (FGD, F, 17, An to a baby with deformity’ (FGD, M, 16, Giang). Keo Lom commune, Dien Bien).

The commune health station also In conversation with girls, however, saved the life of a young man who despite the relatively high frequency had taken poisonous leaves in Keo of early marriage for girls in Dien Lom. Similarly, a married mother in Bien, their perceptions appear to be Dien Bien discussed how she was more flexible and subject to their able to get a health check at the own choice. Thus, older girls say commune health station when she that they largely can choose their ‘had pains in her belly’ and that her marriage partner (and even that 80 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam © UNICEF Viet Nam\2017\Colorista\Hoang Hiep Nam\2017\Colorista\Hoang Viet © UNICEF Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 81

CHAPTER 5 Mental health and Psychosocial Care service delivery systems 82 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

The provision of mental health are checked and included in the through the different ministries services falls within the remit of list … The labour affairs sector (MOH, MOLISA, MoET). a number of ministries, including reviews all the cases and manages the Ministry of Health (MOH), the the cases. The serious cases will Before exploring services through Ministry of Labour, Invalids and Social be requested to get an allowance. these largely public institutions, it is Affairs (MOLISA), and the Ministry of The less serious cases will be cared important to note that in Viet Nam, Education and Training (MOET). Each for by the health sector. For these both the private and NGO sector ministry has a different paradigm of cases, we pay for home visits and pays inadequate attention to the administration, with different areas regards, give gifts and provide provision of services, particularly of responsibility, roles and functions, checks-up or help’ (KII, DOLISA social services to people with and has their own programmes, staff, Dien Bien Phu city). mental illnesses in some special proposals and models for dealing difficult provinces. In addition to the with mental health and psychosocial The ways these different ministries government’s mental health-related issues. For example, MOH is in approach and provide services of service provision programmes and charge of health-related matters, mental illness and psychosocial schemes which the MOLISA has hospitals and health centres. Health distress vary depending on the implemented, there is a limited centres and hospitals diagnose functions and responsibilities of the number of NGOs providing mental and provide treatment primarily ministry. The ministries develop and health related services to children for serious and persistent mental implement complementary policies and young people in Vietnam as illness stemming from neurological for people with mental illness and follows: i) RTCCD which has set conditions and developmental people in difficult circumstances. The up a clinic, TUNA, in Hanoi, which disabilities. While MOLISA, through health stations, psychiatric hospitals focuses primarily on mental health its system of community and and paediatric hospitals largely problems, starting from pregnancy social protection centres, deals provide medication and use a set of of the mother; ii) BasicNeeds with social support policies for internationally recognised tools to (funded by BasicNeeds UK) also social protection beneficiaries and diagnose problems of serious and based in Hanoi, which opened in provides services for cases in need of chronic mental illness, neurological 2009, has three fulltime employees urgent protection (according to the disorders and developmental or and works with Women’s unions. Government’s Decree No. 136/2013/ cognitive delays. Some of the cadres Their activities include: designing ND-CP of October 21, 2013, providing of MOLISA have proper qualifications tools to screen for common mental for social support policies for social in health and social work. Annually, health problems, building capacity protection beneficiaries; Decree No. MOLISA holds senior and master’s of community level health staff to 103/2017/ND-CP of September 12, degree courses on social work. screen for and treat mental health 2017 stipulating the establishment, problems, organising activities organization, operation, dissolution MOLISA staff will also refer people for patients (peer support groups, and management of social protection to their social protection and social support to find employment), and facilities; Decree No. 28/2012/ND-CP work centres, where they exit. training other NGOs and government of April 10, 2012, detailing and guiding According to study respondents departments in mental health related a number of articles of the Law on from DOLISA in An Giang, they see issues (KII, BasicNeeds, Hanoi); and iii) Persons with Disabilities; the Prime themselves as playing a ‘connector PHAD (under the Viet Nam Union of Minister’s Decision No. 1215/2011/ role’: ‘We mainly serve as connector, Scientific and Technical Associations QD-TTg of July 22, 2011, approving the because we are a state management (VUSTA)), which is implementing Progrgamme for community – based agency, not a service provider… a three-year project, ‘Taking care social protection and rehabilitation For example, the provincial child of mental health for adults and for people with mental illnesses and protection fund belongs to DOLISA, children–a cost saving initiative’, mental disorders in the period of 2011 we connect sponsors for health care a model for depression control in – 2020; Decision No. 32/QD-TTg on services, such as screening, treatment community which has been carried March 25, 2010 of the Prime Minister, and surgery’ (KII, DOLISA, Phu Tan out in 8 provinces/cities in Vietnam, approving the Programme on the District, An Giang). Finally, in schools, sponsored by the Grand Challenges development of the social work aside from diagnosis of illness, Canada-GCC and MOLISA. The profession. approaches used are geared to project consists of two components: psychosocial distress and are largely one for adults with depression and ‘Health centres check and provide those of counselling of students. In one for children with behavioural treatment. Labour affairs sector this section we explore mental health difficulties. Hanoi and Danang have is the second agency which will and psychosocial service provision been selected as the pilot sites (KII, provide allowance afterthe cases PHAD (Institute of Population, Health Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 83 and Development), Hanoi); and iv) WeLink which, established in 2013 Box 4: Mental health services through the in HCMC, provides both training government hospitals in Hanoi particularly to teachers working as counsellors in schools in HCMC The National Hospital of Paediatrics has a department of mental health and counselling for mental health where around 80 out-patients are examined, tested (through the use of a number of psychology tests), and diagnosed every day. These patients are challenges. often referred from other departments (e.g. neurology or rehabilitation) within the hospital. Once the diagnosis is made, treatment programmes According to key informants, there are developed, which can include behavioural therapy or family therapy, were no NGOs focusing specifically usually requiring the patients to visit at regular intervals. According to on mental health in Dien Bien, study respondents, around 25% of the cases are diagnosed as autism, 20 though some (e.g. World Vision) to 30% as hyperactivity, and the rest are a range of disorders. In terms of were integrating it into their ages of patients, around 20-30% are adolescents (KII, health worker and existing programmes. Additionally, psychologist, National Hospital of Paediatrics, Hanoi). There are a total of it was noted that when the social five doctors specialized in mental health, seven nurses, and two teachers protection centre in Dien Bien could specialized in providing therapeutic treatment for autistic children and not house any more children they those with special needs. It seems all staff come together as a group every day to discuss cases; when there are emergency or difficult cases, they can would refer them to the SOS village: call the more specialised staff. ‘But in addition to this Centre, there is also an NGO-funded SOS village The National Institute of Mental Health is an affiliated institute of Bach which has better infrastructure; it Mai Hospital. It has a total of 187 beds, and receives annually about 3,000 has different houses, each of which patients for inpatient treatment for mental disorders, and carries out has its own “mothers” (caregivers), so maintenance tracking for more than 50,000 outpatientsi. they can take in a larger number of children’ (KII, Social Protection Centre, Additionally, Hanoi has been implementing the national program on Dien Bien Phu city). In An Giang it mental health care for community and children in the whole city. All the was noted that UNICEF and JICA district medical centers have psychiatric clinics, and each district mental supported the Social Work Centre for health clinic has from two to eight clinic nurses and doctors. Currently, 100% of communes, wards and towns have consolidated the network of Child Protection in the past, but their mental health care. Each ward/commune has a specialized staff for the support has ceased (KII, Social Work management of mental patient records, and is dispensing medicines for Centre for Child Protection, Long patients monthlyii. Xuyen city, An Giang). ihttp://bachmai.gov.vn

ii 5.1 Service provision through http://www.soyte.hanoi.gov.vn Ministry of Health infrastructure

The health system in Viet Nam food safety; health insurance; and and supervising mother and child is decentralized into four levels: family planning (UNICEF & MOLISA, health care activities throughout central, province, district and 2015, p. 22). While the various the country. The National Hospital commune/ward. The Ministry departments and agencies within of Paediatrics is given charge of of Health (MOH) is in charge of the Ministry of Health all have the northern provinces, while the technical aspects, including both some functions and tasks related HCMC Children’s Hospital No. 1 is in prevention and treatment activities. to child healthcare, the key unit in charge of the southern provinces. The MOH currently plays the most charge of healthcare for children Implementers of nutrition and prominent role in delivery mental is the Department of Maternal and prevention activities for children health services and, as stipulated Child Health. The national hospitals, also include the National Institute in Decree No. 36/2012 / ND-CP, including the National Hospital of of Nutrition, National Institute of is dedicated to the management Paediatrics, National Hospital of Hygiene and Epidemiology, the and operation of: preventive Obstetrics and Gynaecology, HCMC Hospital of Tuberculosis and Lung medicine; medical examination and Children’s Hospital No. 1 and Tu Diseases, and National Institute of treatment, rehabilitation; medical Du Hospital (HCMC) are assigned Malariology (MOH, 2006). examiners, forensics, forensic the responsibilities of providing psychiatric; traditional medicine; guidance to the lower levels, Drawing on findings from our study, reproductive health; medical supporting the development and the next sections explore mental equipment; pharmacy; cosmetics; dissemination of plans, monitoring health services at the city level; this 84 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

is then followed by a description Box 5: Mental health services through the of mental health related services at government hospitals in HCMC provincial, district and commune level. Mental health services are provided in the Paediatric Hospital through the psychiatry ward. The staff in the psychiatry ward is comprised of three doctors, including two trained in psychology, two psychologists, two 5.1.1 City level mental health teachers specialized in teaching children with mental diseases, one social service provision worker, a reception nurse, a nurse’s aide and volunteers. The volunteers support patients and relatives by, for instance, carrying out administrative In Hanoi, mental health services tasks and acting as a go-between with the hospital staff: ‘When patients are provided through a number of are admitted to the hospital, the volunteers help them with administrative hospitals, including the National procedures. Or the patient’s relatives have some complaints, but can’t get Institute of Mental Health, the National feedback to the staff, so the volunteers serve as a bridge. Or they help the Psychiatric Hospital No. 1, Hanoi school-age patients continue studying. Or if the children feel sad, the volunteers Psychiatric Hospital and the Mai help entertain them or organize annual events such as the full moon festival Huong Daytime Psychiatric Hospital. or the Children’s Day on June first for the children to participate in, with the Box 4 provides some details of two of aim to make the hospital friendly and children feel almost at home. In addition these hospitals. to that, the volunteers guide those who need psychological consultation to see the psychological specialist’ (KII, Paediatrics Hospital No 1, HCMC). The In HCMC, mental health services services provided at this hospital primarily include examining, evaluating and classifying children, referring them onwards for the correct service. are provided primarily through a They also provide education to the patients, and hold training courses in number of hospitals including the clinical psychology for doctors, nurses and social workers. A KII with the Paediatrics Hospital No 1 and the psychologist reveals that in addition to providing counselling for cognitive Psychiatric Hospital. Box 5 provides problems, behavioural problems, and somatic complaints mentioned in some details of these hospitals in section 3, the psychiatry department also provides mental health support HCMC. for families with children who exhibit homosexual tendencies, children who have faced child abuse, and counselling for parents whose children have 5.1.2 Provincial Level mental had to undergo serious surgery. health service provision In terms of awareness-raising about the psychiatry ward’s services, the hospital uses a range of approaches: ‘First, we rely on mass media – for In Dien Bien Province mental health example, television, newspapers and radio. I rely heavily on them to let people services are essentially provided know about us and they come. Then we also communicate to schools. Several through the government and schools organize the sessions of health education where specialists are invited through two hospitals in Dien Bien to talk with parents and teachers. At some schools, teachers recommend Phu city: the provincial (general parents to take the children with problems for examination’ (KII, Paediatrics hospital), which has a mental ward Hospital No 1, HCMC). Other approaches include distributing brochures and the Psychiatric Hospital, which in the districts on a regular basis that is organised and coordinated by a ‘Department of Healthcare Network’ in the mental health hospital. was established in June 2012. While there are a large number of private The Psychiatric Hospital of HCMC is the leading hospital specialized in clinics and health care providers mental health in the south of Viet Nam, providing services to both adults in Dien Bien Phu city, according to and children. There are nearly 400 employees to undertake the prevention, study respondents, none provide detection, and treatment of all mental disorders and mental illnesses. The mental health services. hospital has three agencies. The main agency, with 100 beds for acute patients, is located in Cho Quan, and the second agency, with 250 beds for subacute, chronic and rehabilitation patients, is in Le Minh Xuan. The last The Psychiatric Hospital is housed, one, specialized in children, is located in Phan Dang Luu. and has been since it opened, in the TB hospital. Currently there are ‘Every day, we [at Cho Quan] receive 500-600 outpatients; […]there is another two floors and about 20 offices and location in Le Minh Xuan, also about 500 outpatients. The one in Phan Dang Luu receives 120-150 patients per day’ (KII, Psychiatric Hospital of HCMC). treatment rooms. There are a total of 30 staff, up from an initial 17; out Additionally, HCMC has a network of district psychiatric clinics in all 24 of these staff, there are five doctors districts (usually located in the medical centre of the district), which and seven nurses, but currently no are responsible for the treatment and case management of outpatient counsellors or psychologists. All the psychiatric patients and coordinating activities of the network of health medical staff have received some stations at ward level. Currently, HCMC has implemented the national program on mental health care and protection for community and children form of mental health training – in 49 wards/communes.i for nurses it is three months, for physicians and doctors it is six-seven i http://www.bvtt-tphcm.org.vn Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 85 months continuously at the National disorders due to substance abuse, this hospital, so they bring the patients Mental Hospital; they also get including alcohol. Additionally, a here; they don’t have to go to the refresher training every three-four disorder reportedly on the rise was national hospital anymore. Secondly, years. Currently, there are 20 beds, computer game addiction. In terms the quality of the treatment has been up from four when it opened, and of treatment of common mental improved; and another thing is that they are in the process of trying disorders (vs the severe ones that the scope of treatment has been to ‘borrow’ more rooms from the were mentioned) or where patients broadened. Before, headaches and TB hospital to be able to increase could go to receive just counselling sleep loss used to be treated by internal their beds to 50, though they still in Dien Bien, the response was that medicine only, but now they’ve face challenges in infrastructure, there was nowhere else to go (KII, been considered mental [problems]. equipment and human resources. Psychiatric Hospital of Dien Bien, Affective disorders and anxiety According to study respondents, Dien Bien). disorders too; they weren’t considered the number of inpatients has illnesses before, but now people have been growing over the last few According to the DOLISA key realized that they are, so they come years, largely as a result of better informant from Dien Bien, he noted here’ (KII, Psychiatric Hospital of Dien communication and education on that staff at this hospital work with Bien, Dien Bien). mental health. Thus, in 2014 there health centres all over the province were 270 inpatients, in 2015 there to identify people facing disabilities Although there is no psychiatric were 398, and estimates for 2016 /mental health problems. He also hospital in An Giang, according to were around 500 (in the first quarter said that the hospital provides key informants, the DOLISA staff there were 130 people). In 2015, there counselling services, and staff from support the hospital wards and were a total of 2,800 outpatients and, this centre/hospital hold training health centres by providing them according to key informants, they are courses for health workers in the with financial support to accept currently managing 760 patients in districts and communes every year. referrals of serious mental health the community, covering the whole patients; they also have formed a district. In terms of awareness-raising about social work centre: ‘Although we their services, they use a range of [DOLISA] haven’t got a centre, we still According to study respondents, approaches: ‘First of all, people have have the responsibility to support inpatients present the following learnt about this hospital because hospital wards and health centres, disorders/complaints: schizophrenia, many newspapers have mentioned providing them financial support to affective disorders, dissociative us. Before this hospital was opened, send serious patients off for treatment. disorders, depression, anxiety people had to suffer a lot; they had to Secondly, we formed the Centre for disorders, headaches, sleep loss, go all the way to the National [Mental] Social Work and Child Protection old age dementia, and mental Hospital No. 1. Now they know about and Care - which mainly provides

The exterior of the TB hospital which houses the Dien Bien Psychiatric Hospital. © Fiona Samuels, 2016 86 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam counselling to children who haven’t port of call for people living in rural mental health issues out of the got mental disorders (at risk), I mean areas when mental health related framework of my communication providing counselling to children who challenges arise. In addition, in some and education. I told them to take suffer from shocks or stresses.’ areas a community mental health more rest and don’t think too programme was in operation. much. (KII, hamlet health worker, An Giang also has been Keo Lom commune, Dien Bien). implementing the national Keo Lom in Dien Bien District, Dien programme on mental health care Bien Province The community mental health for community and children within programme (see also Section 7) the whole province. While the DOH The commune health centre in Keo appears to have been running has been in charge of medicine Lom has a total of six staff members, for around ten years in Dien Bien distribution for mental patients including one head of the centre, province, whereby the psychiatric with schizophrenia, epilepsy and three physicians, one midwife, and hospital distributed medicines to the depression, DOLISA has been one nurse. The commune health districts and the responsible officers responsible for providing support centre sees around 450-500 people (generally the head or deputy head in the form of cash to beneficiaries per month. Additionally, there are of the health centre) at district from the national program of mental 21 hamlet health workers (HHWs) level, who then distributed them health care, and supporting health in Keo Lom (there are 25 hamlets, to patients in their coverage areas. centres for mental health care. four without a health worker) who Thus, through this decentralised are selected at commune level, with programme, health workers There is also a Women’s Union that a minimum requirement of lower based in the community treat and provides support to those with secondary school and completion of follow mental health patients, also mental health needs. For instance, a nine-month training course. These providing them with appropriate the Women’s Union facilitates the HHWs focus largely on providing medications. According to a Keo process of getting admitted into a check-ups, reporting the number of Lom commune health worker, the hospital, though it seems that this births and deaths every month and service has expanded over time: ‘It only takes place for someone who is undertaking some communication has been carried out for 7 or 8 years. severely mentally ill: ‘If any woman and education activities. They meet I was promoted to be deputy head member has a child having mental with the health workers at the of the centre for several months. problems, I will recommend her to the commune station once a month, The medicine has been supplied receiving council in the township or though if there is an urgent case this way for 5 or 6 years only. Before write a recommendation to a hospital they will meet straightaway. During that, they [patients] had to go to the for examination and treatment. If it these monthly meetings, they provincial capital to get it, as the is a seriously ill mental patient, he/ report on numbers of births, deaths, district authorities didn’t supply it”, (KII, she will get social protection from challenges and successes, and in Commune Health Centre, Keo Lom the local authority. Generally, there general share their experiences. It commune, Dien Bien). are fewer mentally ill children than appears that a sub-group (10) of the adults. In my neighbourhood, there Keo Lom HHWs attended a training As part of this community mental are several mentally ill adults. They class in which they were taught how health programme, there is also a wander the streets and make a fuss’ to identify mental health problems system at commune level whereby (KII, Chairwomen of the Women’s and access drugs for the patients at people with disabilities are identified Union of Phu My town, An Giang). the psychiatric hospital in Dien Bien. by the commune officers in terms This KI notes that awareness raising It was also noted by other HHWs in of their eligibility for an allowance about the presence of the Women’s Keo Lom who have not dealt directly through DOLISA. Since mental Union is lacking. with mental health issues that they illness is also considered a disability, do informally raise issues of mental DOLISA can also identify people 5.1.3 Commune level mental health: with mental health issues. However, health service provision according to study respondents, Q: Have you talked about identifying people with mental As mentioned above, the commune mental health issues in your health problems is more difficult: is the lowest level through which communication and education ‘If a person has an epileptic seizure health services are provided. In activities? or threatens other people, it is easier addition to having commune to know, but it is difficult for our health centres, remote areas also A: Not yet. I just focus on the issues communal staff to identify the cases have hamlet health workers. These guided by the health station. of ordinary depression. In this case, centres and individuals are the first Besides, sometimes I talk about we will recommend that these people Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 87 get appraised by the provincial do. I also encouraged them to share development of children, and the medical panel. Based on the result, their feelings with me.. I integrated Department of Social Protection the commune will decide whether it with the knowledge on gender which is responsible for addressing to provide disability allowance’ (KII, equality, child legislation and others. the needs of social beneficiaries DOLISA, Dien Bien Phu city). They were interested in it very much. with mental disorders. Among its They told me that it’s difficult to speak tasks, collaborating with the Ministry According to study respondents, about child psychological issues. of Health in implementing health only ’serious’ and ‘very serious cases’ They didn’t know how to explain it care and nutrition activities for are eligible to receive an allowance, (KII, hamlet leader, Phu My town, An children is included (MOH, 2006). of which there are several levels. Giang). Annually, MOLISA coordinates with ‘The standard level is 180,000 dong. the Ministry of Finance to allocate For the poor, it is 270,000 dong. In Officers of the Women’s Union and budgets to provinces and cities to the future, the level of support will Youth Union feel that awareness provide cash assistance to social be the same for everyone at 270,000 raising is an important step, one policy beneficiaries, including dong. Those with mental health that is currently missing from their the families of individuals with problems receive support worth about services: ‘here is no material on mental severe, serious and mild mental 540,000 dong. The rate for elderly and health. My organisation, like the disorders. Institutions under MOLISA children is higher. Amongst people Women’s Union needs communication through which mental health and with disabilities, there are rates for materials to disseminate in our psychosocial wellbeing-related the serious disability and less serious activities so that both parents and social work services are provided disability; the poor and non-poor. The children can learn. The prevention include the social protection centres, mental patients are the people with of mental problems is rooted in the social work centres and the disabilities’ (KII, DOLISA, Dien Bien the family, so we should do our hotlines. Annually, cadres, staff and Phu city) communication activities for families collaborators have been trained in on the prevention and treatment mental health related issues. Thus, It also appears that at commune of mental problems. […]Through according to the DOLISA staff in Dien level, community meetings are held communication activities, people will Bien, for the past few years, in liaison in which communication on mental be aware of mental problems so that with the psychiatric hospital in Dien health is integrated: ‘Yes. There are they can discover the patients to send Bien, they have been organising general community meetings, in to hospital’ (FGD, officers of Phu My mental health related training, which communication on mental town, An Giang). including refresher training, for their health is integrated. Besides, there officers at district and commune are communication posters in public level, teaching them about mental spaces. This is organized by the mental 5.2 Service provision through health problems as well as ways to program because it has a fund for it. As MOLISA identify them. Additionally, between for slogan banners, they are available 2013 and 2015 they also trained family in some places, not everywhere, According to Decree No.36/2012/ members (approximately 120) so usually only in the communes’ (KII, ND-CP issued by the Government that ‘they can help the mental health DOH, Dien Bien Phu city, Dien Bien). of Viet Nam, MOLISA is ‘responsible patients in the family’. for managing the following sectors: Phu My town in An Giang province employment, vocational training, In 2011, the Vietnamese Government wages and salary, social insurance, has approved a programme for social In terms of awareness-raising on occupational safety, veterans and support and community-based mental health and existence of their families, social protection, rehabilitation for people with mental services, one hamlet leader received child care and protection, gender illnesses and disorders, for the period a seven-day training course on child equality, control and prevention of 2011-2020 (Decision 1215 for short). development a couple of years ago “social vices”, i.e., illicit drug use and Through social mobilisation, the that included child psychology the sex trade’ (UNICEF & MOLISA, programme aims to both prevent the issues. Upon returning to the village 2015, p. 26). The departments triggers of mental ill-health and also he shared what he learnt, which working on mental health related support families and communities by included information on mental issues under MOLISA include the providing spiritual, material support health and wellbeing: ‘[I shared] not Department of Labour, Invalids and rehabilitation for people with only with the adults in the hamlet, and Social Affairs (DOLISA), the mental illnesses and support them but also with the children. I gathered Department of Child Protection and to integrate into the community, children in a group and explained to Care (DCPC), which is responsible contributing to improved general them what they should and shouldn’t for ensuring the comprehensive social security. 88 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

The network of social protection services; (vii) Organize rehabilitation work services, thus meeting the need institutions has been established and occupational activities; assist for social support of 30% of people in and developed throughout the beneficiaries in self-management, difficult situation. country, with 418 social protection cultural, sport activities and other units throughout the country, activities suitable for the age and While there have been a number including 195 public units and 223 health conditions of each group of of telephone hotlines operating non-public units, (including 33 social beneficiaries; (viii) Take the lead and in Viet Nam, the most prominent, protection institutions taking care coordinate with relevant institutions longest-operating one (since 2004) of the elderly people; 144 social and organizations to provide that deals with young people and protection institutions taking care of academic and vocational training mental health issues is ‘the Magic children in special circumstances; 74 and career guidance to promote Buttons –18001567”. Housed in social protection institutions taking comprehensive development of MOLISA headquarters in Ha Noi care of people with disabilities; beneficiaries, physically, intellectually under the Department of Child Care 31 social protection institutions as well as in terms of personality. and Protection, it operates 24 hours providing care and rehabilitation (ix) Provide social education and a day, 7 days a week and has 20 staff for people with mental illnesses capacity building services (Provide and 10 collaborators /adjunct staff and disorders; 102 general social social education services to help with backgrounds in psychology protection institutions taking care beneficiaries develop problem- and special education. There is an of beneficiaries of social protection solving capacity, including parenting advisory council of doctors and or those in need of social protection; skills for those in need; teach life academics specializing in psychology 34 social work centres providing skills to children and adolescents; and law to provide support in counselling services, urgent care or Collaborate with training institutions difficult cases. Between 2014-2015, other necessary support for those in to organize education and social the hotline received more than 2 need of social protection) (MOLISA, work training for staff, collaborators million calls from children and adults 2016). Social protection institutions or those working for social work throughout the country. have the following responsibilities: service providers; Organize (i) Provide urgent services (receive training and workshops to provide 5.2.1 Social protection centres those in need of urgent protection; knowledge and skills to beneficiaries assess beneficiaries’ needs, screen who have demand. (x) Manage As described above, the social and categorize beneficiaries. When beneficiaries who receive social work protection institutions are needed, refer beneficiaries to health, services… to all beneficiaries of established in 63 provinces and cities educational, police, judicial or other social protection and those in need to receive, assess, provide care and relevant institutions or organizations; of urgent protection. support and other necessary services ensure safety and address urgent to various groups of social protection needs of beneficiaries such as: This network of social protection beneficiaries, vulnerable groups, temporary accommodation, food, centres currently care for specially disadvantaged children, clothes and transport); (ii) Consult approximately 42,000 social people with mental illnesses, and and treat mental disorders, psycho protection beneficiaries, provide women suffering postpartum crisis, and physical rehalibitation social protection services to tens depression. The social protection for beneficiaries; (iii) Advise and of thousands of people in difficult institutions also organize activities assist beneficiaries to access situations and social protection such as rehabilitation, education, social support policies; coordinate beneficiaries, of which children, vocational training and career with other relevant units and people with disabilities and guidance and provide social work organizations to protect and assist mental illnesses make up a large services, thus meeting the need for beneficiaries; search and arrange proportion, 46.5%. On average, 01 social support of 30% of people in types of care services; (iv) Develop social protection institution cares difficult situation. Up to date, there intervention and assistance plans for for about 100 beneficiaries. The are 45 Centres for social protection beneficiaries; monitor and review total number of workers and staff and rehabilitation for people with intervention and assistance activities, in the social protection network mental illnesses providing care, and adjust plans if needed; (v) is around 15,000 individuals. The rehabilitation, basic education, Receive, manage, and care for social social protection institutions receive, vocational training, livelihood protection beneficiaries who are in manage, care and feed social support (such as mushroom growing, seriously difficult situation, unable to protection beneficiaries, organize pond garden farming, votive paper take care of themselves and cannot activities such as rehabilitation, making). live in a family and community; (vi) education, vocational training and Provide primary medical treatment career guidance and provide social Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 89

While original function of some the age of the children ranges from 4 (KII, Social Protection Centre, Dien centres was to look after orphans, to 22 years. Bien Phu city). elderly people, people with disabilities, and homeless people, There are a total of 24 staff and 5.2.2 Social work centres according to study respondents, three departments in the centre: the they are now also dealing with Nutrition and Health Division takes The category of social work centres people with mental health problems, care of the children’s health and daily (SWCs) was also mentioned by though the beneficiaries appear to be diet and is staffed by two physicians various respondents. According to disproportionately adult males.Thus — if there are difficult cases, they UNICEF & MOLISA (2015, p.31), “the in An Giang province, according to a can be referred to the ward health SWCs are envisioned to provide KII at DOLISA there are now two social station, city health station, or services and supports to people in protection centres, one of which provincial or national hospital. The disadvantaged circumstances and takes care of mental health patients: Beneficiary Management Division individuals with mental disorders ‘In the past, the Social Protection provides extra-curricular activities and to assist with other social Centre only took care of social welfare to children, including teaching service needs that are identified beneficiaries, such as lonely and elderly cultural knowledge and life skills, in communities and at the SWCs people, people with disabilities, and music, sports, vegetable gardening throughout the country”. In 2016, orphans. But now they also have to and pig and chicken rearing. Staff there were 30 social work centres take care of mental patients, including on this division were mostly former and plans for 33 more (Kidd et al., both children and adults … But it only teachers and while some have been 2016). According to a key informant admits a very limited number, because given additional (one-week) training in An Giang, the social work centre the infrastructure is not sufficient. Now on social work, none have received there focuses on child protection we have two centres in the province; training on psychological counselling and care: ‘There’s a Centre for Social the one in Long Xuyen is taking care of for children. Despite this ‘All the staff Work and Child Protection and Care, about 40 mental patients, and many here has a lot of compassion and love directly under the administration other beneficiaries. The second centre is for them. Because it comes from our of the provincial DOLISA. Currently, the Chau Doc Social Protection Centre own hearts, we always try to provide this centre has the functions of of Chau Doc city, which mainly takes the best conditions for them. Although providing counselling and guidance care of homeless people’ (KII, DOLISA, the salary is low, we always stay close, to abused children, and psychological An Giang). pay attention and take care of the counselling to children. The staff children’ (KII, Social Protection Centre, here received training on mental The social protection centre in Long Dien Bien Phu city). health in Hanoi’ (KII, DOLISA, An Xuyen city, An Giang, is staffed by Giang). This is validated by the six nurses, caring for a total of 40 The social protection centres findings from UNICEF and MOLISA’s people, of which 27 are children. receive an allowance per child (2015) report that states that There are a total of 33 staff at the from MOLISA, though they stress the social work services that are second social protection centre, this was not sufficient and had to being provided in these centres including 10 people in charge of seek support from other sources, include counselling, psychological administrative work, caring for a though this was not consistent: ‘The treatment, case management, total of 150 people. Out of these 150 meal allowance, according to state community re-integration, referral, people, 38 are mentally ill, of which 5 policy, is 80% of the minimum wage, resource mobilization, prevention, are under 14 years of age. which means 920,000 VND/month. communication, training, and The living allowance, which includes capacity building. In Dien Bien, according to study electricity, shampoo, toothpaste and respondents there was one social such, is 30% of the minimum wage, According to Decision No. 32, every protection centre in operation that which means 345,000 VND/month. For year, MOLISA is responsible for targets orphans (single and double) those who are attending universities/ supporting Social Work Centres to and vulnerable children in the colleges, their meal allowance is 80% develop their networks of social province. In operation since 1990, of the minimum wage, which means work collaborators, provide social there are currently 77 beneficiaries 920,000 VND/month, and their living work services to disadvantaged and (they have a maximum capacity allowance is 50% of the minimum vulnerable groups in the community, of 80), 65 of whom receive direct wage, which means 575,000 VND/ provide capacity building for social care (on site) and 12 of whom are month […] Our centre has to call for work cadres, staff and collaborators attending universities, secondary support from other organizations through technical training courses technical schools and vocational and donors to increase the amount of on operating social work centre schools. There 32 girls and 45 boys; money for dinner for these 25 children’ models, case management 90 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam procedures, community-based children and trafficking (KII, Social 5.2.3 Hotlines rehabilitation procedures for people Work Centre for Child Protection, with mental illnesses and disorders, Long Xuyen city, An Giang). While there have been a number case management for people with of hotlines operating in Viet Nam disabilities, caring and foster care However, even though the social dealing with a range of topics, for children in difficult situations; work centre is supposed to provide the most prominent, longest- sharing experience of operating counselling to children, it is unclear operating one that deals with social work centre models; organize the extent to which people know children and young people and also training on case management for about this; an FGD with provincial includes mental health issues and people with disabilities for Labour, officers in An Giang thought that psychosocial support is the one set Invalids And Social Affairs cadres and there was no counselling service nor up by MOLISA, also referred to as ‘the staff throughout the country. specialised ward for dealing with Magic Buttons – 18001567’ which has mental health in the province. This been changed to number 111 since Similarly, according to a member of was echoed by a KI in An Giang: December 2017. This nationwide staff at the Centre for Social Work in hotline is housed in the MOLISA An Giang, they support on average Q: Is there any examination and headquarters in Hanoi under the about 40 children a year who were treatment service for the children with Department of Child Care and abused and suffering from violence, mental health issues or psychological Protection. Since 2004, it has been including sexual violence. Staff difficulties? supported by Plan International. at the centre have been trained It operates 24 hours a day, 7 days to provide psychological support A: There is no such kind of service. a week. There are 20 staff and 10 and counselling to these children: If you are ill, just go to the hospital. collaborators /adjunct staff with ‘My team has received training on There is no psychological consultation backgrounds in psychology and identifying children with depression or mental health clinic. There is no special education; additionally, there and providing psychological mental hospital in the province. People is an advisory council, consisting of support for children suffering from with mental diseases often go to Dong doctors and associate professors with psychological disorders’ (KII, Social Thap and Tien Giang for examination psychological and law specializations Work Centre for Child Protection, and treatment. (KII, DOLISA, Phu Tan to support in difficult cases. The Long Xuyen city). They have also district, An Giang) telephone counselling staff have improved their resources as noted specialisations in psychology, social in a KI with the head of the Child To raise awareness of a Social Work work, social studies, and law; upon Protection Division of DOLISA Centre for Child Protection, one being recruited they all receive an in An Giang: ‘Previously only one respondent described the following additional two- month training social worker was in charge of child approaches: course focused on dealing with protection at commune level, now children. the child protection program has A: First, we inform local authorities established a network of collaborators at communal level; we send to 164 Children from all 63 provinces can in hamlets and also set up the social communes information about the make free phone calls to share work centre for child protection, functions and responsibilities of information, look for psychological making the address better known to our centre. The second way is to and spiritual assistance, receive many people to come or call there.’ communicate through newspapers and recommendations and get More generally, the social work television; they will do propaganda for connected to the appropriate centre focuses on three main areas: us. The third way is to display in each organizations or emergency service ‘educational communication; referral of 11 groups of districts a billboard to if needed. Adults can also call to look service (e.g. if a child is HIV-positive, propagandize about our centre. for information related to child care they will connect to the relevant and protection. The hotline gives service) and case management; and Q: Where are these billboards located? priority to counselling, answering community development. Educational questions and providing intervention communication is divided into A: At district or communal people’s and support in five areas: (1) child two sub-areas, one is educational committees, or areas with a high protection against mental violence, communication and propaganda, density of population, such as train or physical violence, sexual abuse, depending on each annual topic, the bus stations. (KII, Social Work Centre neglect, abandonment, exploitative second one is treatment, receiving for Child Protection, Long Xuyen labour, and smuggling; (2) providing cases and providing consulting city, province). information and services related to treatment’. In 2014, the centre also child protection; (3) Psychological set up a 24-hour hotline focusing on assistance; (4) Counselling on Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 91 treatment, policies, laws on children children.’ The respondent went on provide children with psychological protection; and (5) linking services to note that there are usually more protection and consultancy. for the children in need. Since 2011, mothers than fathers who bring the hotline has strengthened its their children since ‘their perception operation of evaluating and directly is that taking care of children is the 5.3 Mental health and psychosocial applying psychotherapy for children. responsibility of women and that service provision through schools It also provides skill training for women are better at passing on the children and parents in life skills; skills they learn to their children. It’s On 18 December 2017, the Ministry motor and sensory development for easier for mothers to show their love of Education and Training issued a kindergarten children; open classes (to their children) than it is for fathers, circular guiding the implementation for creative mind development so usually more mothers than fathers of psychological counseling for for preschool and primary-school (come here)’ (KII, Hotline, MOLISA). students in general schools with children; and parenting skills. the purposes to: (i) Prevent, support Recently, according to study and intervene (when necessary) Between 2014-2015, the hotline respondents, more calls are for students who are experiencing received over two million calls from being received from rural areas, a psychological difficulties in their children and adults throughout the phenomenon that can be explained studies and life so that they can country, 20% of which asked for by the fact that the hotline has been find approriate resolution and advice. More than 3,000 children operating recently on the VOV (radio mitigate negative impacts which who had been abused, suffered from channel). People in urban areas, may possibly occur, contributing to violence, been smuggled, been lost however, are less likely to listen to the establishment of a safe, healthy, or abandoned, or in been in need radio: ‘Because urban people are used friendly and violence-free school of financial assistance benefited to using the internet, they rarely watch environment; (ii) Support students from the hotline intervention and TV or listen to radio. But rural people to practice life skills, strengthen their assistance. MOLISA keeps track of listen to radio very often; recently, will, trust, courage and appropriate all calls, noting the locality, sex, we thought that radio broadcasting behaviors in social relations; age, and problem type of the caller. wouldn’t work, but in fact, it has come exercise physical and mental health, Counsellors, upon receiving a call, back to life again recently. Farmers contributing to the forming and give an initial diagnosis and/or bring radios with them to the fields. improvement of their personality. provide callers with information That’s why the calls have to do with about a particular mental disorder people in rural areas. We received calls There are two main ways in which (e.g. ADHD, autism, depressions) and related to mental disorders related to mental health and psychosocial then refer them to relevant services parent-child attachment. Most of the wellbeing of children and young for further treatment, if necessary. calls were made by adults, not children. people are potentially addressed ‘In the North, we can refer them to When we described the symptoms of through schools. On the one hand, our therapy centre (an “in-person children with mental disorders, a lot, and as also mentioned by children, Psychological and Therapy Centre’ 80-90% of the calls were made from life skills training, which includes that has existed for three years”). To grandparents, or caretakers, telling ‘teaching the kids about social children who are abused and suffer us that their grandchildren had the skills, life values, self-management from psychological traumas or crises, same symptoms as described on the and working ability; about all the we provide them with direct treatment radio. Nearly 100% of these cases are different fields, understanding for free. We also collaborate with due to the parents leaving rural areas about themselves, about society, different projects to raise funds to for urban areas to make a living over about relationships, about their support them during their travelling a long period of time, not returning to working capacity, and [guiding the and stay’ (KII, Hotline, MOLISA). take care of their children. Children at children to] practice all these skills’ an early stage, if separated from their (KII, Psychologist, Olympia School, Both adults and children use parents, they will be troubled, leading Hanoi), can have an impact on their the hotline, and so both receive to behavioural disorders’ (KII, Hotline, broader psychosocial wellbeing. This treatment. ‘When they (parents) bring MOLISA). training is carried out by teachers them (children) here, we have to work who themselves have usually been with the parents as well. In some cases, On 6 December 2017, upgraded trained specifically on this. The when the child was abused, the parents from the children consultancy and number of hours spent on this were in an even greater crisis than the support hotline, the National Child subject varies by school, with private child. Therefore, we have to work with Protection Switchboard with schools generally paying more them; only when their psychological the telephone number of 111 was attention to it than government state is stable can they support their lauched with the responsibility to schools: ‘This school pays a lot of 92 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

attention to life skills. I proposed that (which often go together, i.e. many all the school teachers spend one hour/ USS are located in urban areas). day on teaching life skills to primary Similarly, the large cities of Hanoi pupils, and two-three hours/week to and HCMC appear to have a more secondary and high school students, widespread programme offering not like other schools which only psychological services, particularly ‘The boys are in 6th and 7th allow one period per week for life skills private schools: grades. Almost no boys in 8th education’ (KII, Psychologist, Olympia school, Hanoi). Q: Do the private schools in Hanoi and 9th grades come because have psychological counselling rooms? they have their own passions. The second main way of providing support to mental health and A: Some schools do; and we also For example, they like playing psychosocial wellbeing in schools is launched a school mental health care shuttlecock kicking on the through school-based counselling program at Doan Thi Diem School services (see Annex 2 for further and some other schools. The schools playground, which is more details on the background of school implement it themselves and pay interesting’ counselling in Viet Nam). Thus in the salaries with their own money, An Giang, for instance, six schools because they’re not limited in terms of (KII, school psychologist, LSS District are currently providing counselling. number of official staff. (KII, National 3, HCMC). However, this service tends to be University, Hanoi) provided mostly in upper secondary schools (USS) and in urban areas

Box 6: Systemic counselling in schools (a case of Olympia School in Hanoi) ‘In general, [the children’s situations] are varied, but of course the majority of them don’t have good connections, at least to their family. Because when I ask them who they often talk to, the children often answer that they usually don’t talk to anyone. Not because there’s something wrong with their parents, but in general they don’t feel connected. In this school, my counselling approach is a systematic one.’

‘For example, people often think of counselling as directly influencing (working on) a child when he or she is under distress or bullied, or worried or miserable about something. But here I will not only do that, but also influence the amount of homework assigned to him/her. Homework can be reduced for him/her for a while. I will intervene in things such as [making sure] at least one teacher will talk to him/her once a day, or make a certain number of calls to him/her outside class hours, or talk to him/ her before or after class. Or there must be some kind of activity in his/her class to create a more favourable environment for his/her presence in that community. And I’ll influence the education system around him/her, or his/her family, for example, the family culture must be changed. For example, in the afternoon, he/she should not have to wait for too long for her parents to pick him/her up. Their parents need to pick him/her up on time. Because I work in a school, my advantage is [my ability of] influencing the system. And I find this approach very effective for children, because we can’t demand that a child is an agent of change; instead, the entire system has to support him or her.’

‘We support each family throughout an entire process of change, from very little things; it’s a long process; changing habits of not only one individual. In all the cases that I provided counselling for a year or 3 months or so, the change has been quite steady. I mean they change from the smallest things. Some people, when they got home and saw their children throwing things around, they shouted at the kids right away, and so suddenly everyone in the family became tense. And my counselling is very simple; I ask them for example, “When you go home, you just say hi to your child and then go take a shower; after the shower, you’ll already have a different feeling when you see your child; you won’t feel annoyed and tired anymore.” I aim for such changes to change the state of the whole family, from the smallest habits of that system. If meals are the only time when the family meet, I’ll follow up with them, to see what percentage of time is spent by parents and children on talking to one another, I’ll take notes about the parents and the children; every change needs to be followed up with for quite a while before it becomes the new norm. In principle, once I’ve talked to them, they may stop shouting at their children for the next three- four days, but because it’s a habit, of course they tend to revert to their old habit very quickly. In some cases, if they’re highly motivated to change, they will stay with the counselling process for a long time; they will come once a week and say, “Oh dear, I hit my child again yesterday,” and I’ll listen and give them advice. Or, “Everyone in my family has been very happy the last few weeks!” and then I’ll acknowledge their [efforts]. Such a procedure brings more sustainable changes.’ KII, psychologist, Olympia School, Hanoi Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 93

The quality of the counselling service of and can access the counselling as well as the level of training and units. The counselling service can be commitment of the counsellors advertised during school activities; provided in schools appears to vary in one school, a Facebook page considerably, with those outside of was created for students. Teachers Hanoi and HCMC being of generally can also identify students who they lower quality and, consequently, think may be facing difficulties, and ‘Patients living in rarely accessed. In the large cities, the in other cases, the psychologists mountainous and ethnic quality is quite high. For example, themselves may identify students by the psychologist in the lower walking around the school area. minority areas use it secondary school (LSS) in HCMC has (traditional/ herbal medicine), a degree in educational psychology ‘For example, when I walk around, I from the HCMC University of see some students who do not play but people in the nearby Pedagogy. She holds sessions in or talk with anyone. They just sit and areas don’t’ the school five times a week, and look at nowhere. That is the first case. in some cases her job requires her The second case is someone who is too (KII, Health Worker, National to go to students’ homes (often on naughty, or someone whom teachers Hospital of Paediatrics, Hanoi) Saturdays and Sundays), providing complain about too much, so then I consultation through emails and invite them to my office to talk to. It also through Facebook (KII, school is because there are some students psychologist, LSS District 3, HCMC). with special family conditions. Their The psychologist at Olympia School parents are divorced or separated. The in Hanoi holds a degree from common thing about most of the cases France and prior to starting at the I invite here is that there are some school was a lecturer in psychology problems in their families’ (KII, school at the national university. While psychologist, LSS, District 3, HCMC). recognising that teachers can do counselling and some have been The number of students that the sent for training, she feels that there psychologists see varies. One says is need for professional psychologists she sees, on average, 10-15 students in schools.6 Similarly, while she a month (KII, school psychologist, recognises that different approaches LSS District 3, HCMC) while another are necessary according to different says she sees only 4-6 cases each cases and can take varying lengths quarter (KII, school psychologist, LLS of time, she generally works within Dong Anh District, Hanoi). While one a systemic approach that deals with psychologist says there are equal sometimes trains others (KII, school the child in context over a relatively numbers of girls and boys in her psychologist, LSS District 3, HCMC). long period of time. As a result, she patient base, another said that for also talks to parents, and teachers every 10-15 students there are only and takes into account the general 3-4 boys and those who come tend 5.4 Service provision through environment around the child (see to be younger: ‘The boys are in 6th informal providers Box 6). School psychologists also and 7th grades. Almost no boys in 8th refer the children to the national and 9th grades come because they Traditional medicines and hotline and to a new website (ask14. have their own passions. For example, shamanism vn), where it is relatively easy for they like playing shuttlecock kicking children to share their problems on the playground, which is more The use of herbal medicines anonymously and receive answers interesting’ (KII, school psychologist, and shamanism persists in some (KII, school psychologist, LSS, Dong LSS District 3, HCMC). areas. According to some study Anh district, Hanoi). respondents, due to a range of Some teachers in An Giang were sent interrelated factors, including According to the school for training to HCMC. One school remoteness, allegiance to ethnically psychologists, there are many ways psychologist in HCMC mentioned rooted practices, and lack of in which students are made aware getting refresher training from awareness, people will take herbal Welink (the courses cost around VND remedies and perform certain rituals 200,000 to 300,000), and she in turn before taking people to formal health providers – this is as much 6. 94 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

Box 7: Shamanism and the Hmong according to Hmong Shaman ‘In general, yes [there are shamans in my community]. Also in Hmong communities. I am a shaman myself. They ask me to help them; I don’t like to do it, but it’s our people’s traditional custom. Rituals only [help] in part; they have to go to hospital to get over illnesses. Going to hospital and performing rituals, the former makes up two parts, while the latter makes up only one part (of treatment). If a person doesn’t get better after going to hospital, or even gets worse, when they get home and perform the rituals, they will get better. […]

We say we go to see the ghost; it’s the ghost that causes the headaches, so we’ll perform the rituals. It does help to perform the rituals. Yes, the ghost causes belly aches or headaches, or harms and gradually weakens people. There, so I’ll see that it’s due to this ghost, and ask it whether it wants to eat something, a chicken. And then I kill a chicken and call for the ghost to eat it, then [the patient] will get better. But it won’t make diseases (more serious than belly aches or headaches) better; they can only be treated by hospitals.’ (KII, Village Patriarch, Keo Lom commune, Dien Bien)

He goes on to say that while he thinks most people believe in this, in general he thinks children do not. He also thinks that people now compared to the past are healthier since ‘In the past, old people kept believing that belly aches, appendix pain… they kept saying that it was caused by a ghost, so they just performed rituals, and after 1-2 days, the patient died. They didn’t know it was the appendix. Now people don’t believe in it anymore; people have studied medicine, and they examine, if it’s the appendix, [the patient] will have to go [to hospital] quickly, within 24 hours, to have the appendix removed. Now it’s much better.’

KII, Village Patriarch, Keo Lom Commune, Dien Bien

the case (or more) for mental health ‘They [people in the community] problems as other medical issues buy traditional medicines and use (see Box 7). it together with Western medicine. I know that many families go to hospital ‘Patients living in mountainous and they use traditional medicines as and ethnic minority areas use it the supplement’ (FGD, officers of Phu (traditional/ herbal medicine), but My town, Phu Tan district, An Giang). just able to train their caregivers’ (KII, people in the nearby areas don’t’ (KII, DOLISA, Dien Bien Phu city). Health Worker, National Hospital of The family … parents as Paediatrics, Hanoi) supporters In the cities there is a move to both train and involve family members ‘The traditional customs of There is a sense that the family in issues relating to both better mountainous people are still very already plays an important role in parenting and how to deal with backward. Usually they must perform the provision of care for mental children facing mental health rituals before going to hospital. In health patients and could provide challenges. Thus, one school in Hanoi some cases, after hospitalisation, more if they were trained. ‘Serious provides sessions for parents on they still asked to go home to perform cases should be sent to treatment parenting skills, though uptake could rituals in the middle [of the hospital centres and for those who are living be better: ‘Each parent has the chance treatment]’ (KII, Psychiatric Hospital of in the family, family members should to attend at least one half-day training Dien Bien, Dien Bien). be trained to provide proper care. It’s course on parenting skills each year. impossible to train the patients, we are But among the primary pupils’ parents, the attendance rate is about 60% of Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 95

the parents, while that of secondary family just hires a maid or private tutor classes for the group of parents of and high school students’ parents for children, then how can there be autistic and hyperactive children. The is perhaps 50%’ (KII, Psychologist, sharing between parents and children? highest number of participants is 20 Olympia School, Hanoi). In general, if parents are close to their parents in a time. It is held once a week children, children will have stable for the parents who bring the children Similarly, a psychologist working psychological development’ (KII, for consultation in the mental health in a school in HCMC stresses the school psychologist, LSS, District 3, department on Thursday afternoons importance of both working with HCMC). and for the parents whose children families as well as the critical role of come for intervention in the hospital parents in supporting the general Parents are also a focus in some every Tuesday. […] It costs [the wellbeing of their children: ‘There of the hospitals in the cities. Thus parents] 200,000 VND a session’ (KII, should also be programs for parents a health worker in the National Health Worker, National Hospital of to learn that it is essential to care for Hospital of Paediatrics in Hanoi talks Paediatrics, Hanoi). their children. In the city, there is a about the training classes held for large number of students not receiving parents with autistic and hyperactive enough spiritual care. Having money, a children: ‘We are holding training 96 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

CHAPTER 6 Challenges in service provision 98 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

6.1 Supply side challenges and policy implementation, Administration (Medical Technical improved coordination between Division), MOH, Hanoi). In this section we explore challenges government departments is critical: in the delivery of mental health ‘I think the most important is the inter- The limited number of qualified services including the failure to agency coordination between MOLISA, staffwas a challenge mentioned differentiate between treatment MOET, and MOH. Department of Child by all respondents, and particularly of serious and persistent mental Care and Protection is implementing at district and provincial level. illness, neurological difficulties and community-based consultation on an The limited number of staff from severe learning disabilities with the experimental basis. Because it’s a state a social work background who psychosocial distress associated with project, it is located in communities are able to deal with less severe the risk factors listed in the earlier to make it widely effective. In these mental disorders and psychosocial part of this report. consultation spots, there will be social distress, was particularly challenging. workers. It’s like a social work centre for Additionally, there was considerably Generally, and drawing also on the children, but staff of the consultation less capacity to deal with children previous chapter, the realities in spots have their own duty. For instance, and adolescents presenting with Vietnam show that service delivery the psychologists will give a test to mental health and psychosocial is mainly concerned with a group of assess the personality or disorder level distress issues: ‘In terms of doctors, the people with serious or severe mental of children. Social workers will manage human resources specialized in child disorders and pays relatively little cases and work with community’ psychiatry are very limited in Viet Nam. attention to the provision of services (KII, Hanoi National University of This aspect is largely not being focused for children and young people facing Education, Hanoi). on; therefore, in-depth diagnosis and common mental health disorders and treatment for children with mental psychosocial distress. 6.1.2 Lack of qualified, sufficient disorders are currently very limited’ and gender appropriate human (KII, Officer, Agency of Medical 6.1.1 Limitations in coordination resources needed for the Services Administration (Medical between government care and treatment of severe Technical Division) MOH, Hanoi). departments psychosocial distress … Thus, for instance, in An Giang while they have the space/land to build/ Our findings suggested that there ‘Another group that we’re totally upgrade the social protection centre is a mixed level of coordination lacking is psychotherapists. In Viet (to start to take care of mental health between government departments, Nam, there are only about 50 clinical patients), the main challenge is to and although there are some good psychotherapists. There are many find permanent qualified staff, i.e. practices, there is still further room [people specialized] in general those with a social work background. for improvement. Similarly, while psychology, but that’s different. Similarly, they stressed the need for the role of the DOH was seen to Psychotherapy requires specialized more qualified staff particularly at be critical in terms of coordination training. For children, psychological community level as currently in An between different ministries and therapy has a more emphasized role; Giang they are almost ‘non-existent’. departments, it was also seen to if only medication is used, it will be be lacking and in need of revision: difficult to cure [the problems]; it can Even in a city like HCMC, the KIs ‘Even the roles of the DOH need to even worsen the condition. But in Viet reported being ‘stretched too thin’ in be revised, to include provision of Nam, people don’t pay much attention terms of staff, with one KI making a guidance and advice to the provincial to psychotherapy. For example, the stark comparison between HCMC People’s Committee, and especially problem of depression is very common and Paris to explain his point: ‘Paris is concerned departments. There among children or adolescents, but a city with nearly the same population should be guidance from the DOH most of the cases of children having as HCMC, but it has more than 3,000 to the commune health stations and at-risk and suicidal behaviours are not psychiatrists, whereas this city has only related departments, such as DOLISA detected until too late. Or when the 90 psychiatrists in total, from here and and DOET to develop activities to facilities provide treatment to patients the 24 districts. The entire population of implement. The DOH has the roles of of depression, they mostly focus more France is 60 million people, while ours leadership and orientation; and then on medication, while medication is 90 million. There, that’s the difference we can review our target groups for can’t cure these cases. In such cases, between the human resources [of the management and treatment’ (KII, they should start with psychotherapy; two countries]’ (KI, Director, mental DOH, Dien Bien Phu city). only when psychotherapy fails health hospital, Hanoi). should medication be used. On the According to study respondents, in contrary, they use medication first’ (KII, In HCMC in particular, doctors and order to have effective programme Officer, Agency of Medical Services psychologists feel unprepared Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 99 for dealing with issues around Protection Centre, Long Xuyen city, culturally- sensitive issues, including An Giang). homosexuality, as mentioned by a KI in the Paediatrics Hospital in Even where there were qualified staff, HCMC: ‘And another thing which is as in the case for the major cities, quite common at the present, which many are away on further training we are also being confused about and and short courses. Furthermore, sometimes fail to help – it’s the issue once they are qualified and trained, of homosexuality. Children nowadays many of them leave (KII, psychologist, show these tendencies too early. Many Hospital of Paediatrics, Hanoi). It ‘There should be training children came here just to tell us “I’m was also noted that currently in Viet here to prove to my parents that that’s Nam there are limited numbers of courses on caring for people what I am.” I mean they’re expressing students in the specialisations that with mental disorders. We themselves more strongly. They’re also are needed – according to the hotline adolescents. More girls’ (KI, Paediatrics manager, they need experts in clinical are not professionally trained Hospital, HCMC). psychology and special education to care for them. We teach and ‘There are not many students in Self-learning and on-the-job these two specialisations yet, and it’s ourselves. Mixing medicine learning in relation to mental health another story whether they can [find] with tea is our own idea. It is appears to be a coping mechanism work after graduating. When we take given the lack of training provided. them in, we do provide training, but not what we are trained. I am Thus a nurse in Hanoi says: ‘I haven’t funding and training experts are still not sure if it is the right way taken any systematic training in the our limitations’ (KII, Hotline, MOLISA). or not’ mental health speciality. We are nurses who were trained in general nursing Lack of sufficient (and qualified) (KII, Vice Director Social Protection care of children... Regarding paediatric staffalso came out in relation mental health, we have to teach to the provisions of counselling/ Centre, Long Xuyen city, An Giang). ourselves, read books and learn from psychological support in schools. In more experienced colleagues. Self- particular, when comparing public teaching poses certain challenges. The schools with private schools, it was workload is heavy and the number of noted that teachers were less willing patients is high, we have little time left to take on and provide counselling for self- teaching’ (KII, Health Worker, service to their students (where National Hospital of Paediatrics, there was not a dedicated school Hanoi). Similarly, a health worker counsellor or psychologist, which in the social protection centre in is often the case, as mentioned An Giang says: ‘We have to learn by in several KIIs) because of their ourselves and provide care accordingly. workloads and the fact that class I know the characteristics of each sizes in public schools were so child, hence, I don’t find it difficult’ large (50-55 pupils vs. 25-30 in (KII, health worker, Social Protection private schools). This reluctance Centre, Long Xuyen city, An Giang). existed despite the fact that the In another social protection centre school principal (of a public school) in An Giang, a KI indicates that when was keen to start a counselling mentally ill patients are unwilling to programme in her school and was take medicines, the [workers at the willing to provide some incentives for centre] mix it with tea to trick them, the teachers (KII, National University, a technique they learnt on their Hanoi). Additionally, it was felt that own: ‘There should be training courses there should be a dedicated and on caring for people with mental appropriately qualified psychologist disorders. We are not professionally or counsellor in schools, as opposed trained to care for them. We teach to teachers taking on additional ourselves. Mixing medicine with tea workloads and being unqualified is our own idea. It is not what we are for it. Because of salary-related trained. I am not sure if it is the right constraints in public schools where way or not’ (KII, Vice Director Social there are psychologists, it was 100 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

noted that they are often unable to of patients; we have to care for them carry out the necessary number of day and night, even when they have sessions with the students or have a fit. When they have a fit, we have to the continuity critical for dealing work extremely hard, because they with issues related to mental health have disordered behaviours, and we and wellbeing. Finally, it was noted can even be beaten. Caring for and that byworking in the private sector, serving them are very strenuous and someone can earn three times the difficult; and for difficult cases, they salary as in the government sector will run away immediately if we fail to (KII, school psychologist, LSS District watch them. If we lock them up in a 3, HCMC). room, they’ll defecate all over the place. ‘Only some schools do Regarding our compensation policy, we Even where there are school are included in the group of hazardous it (school counselling) psychologists, often their gender is and dangerous occupations and get substantively. In some cases, not appropriate, i.e. girls are reluctant our occupational allowance which is to speak to male counsellors and 70% of our salary. And plus 0.4% for the the sign of “school counselling vice versa (see also sections 4 and hazardous nature of the job. Nothing corner” was hung on the door, 5). Thus possibly because of gender else. It’s similar to those working in TB, but no one comes in. It means issues, but also because of sufficient/ forensics, and HIV. In some provinces qualified staff and lack of awareness, with better conditions, they get an that they haven’t won the some schools may have a counselling additional 30% of their salary” (KII, trust of the students’ service only in name: ‘Only some Psychiatric Hospital of Dien Bien, schools do it (school counselling) Dien Bien). (KII, Principal Teacher, USS Phu My substantively. In some cases, the sign of “school counselling corner” was hung In terms of remuneration, when town, Phu Tan district, An Giang). on the door, but no one comes in. It asking about the salary of means that they haven’t won the trust psychologists, in the one hand the of the students’ (KII, Principal Teacher, response that the salary was fine, but USS Phu My town, Phu Tan district, on the other hand it was felt that it An Giang). was not sufficient when compared with other staff since psychologists 6.1.3 Stress on existing mental have to devote much more time to health providers… a single patient: ‘We think that it (the salary) is reasonable. It is not high, Arguably mental health providers it is not low, and it depends on what face a double stress burden. First, people think. It is low in comparison to they are stressed because the scarcity staff members of other departments, of mental health providers increases because we spend nearly one hour to the workloads for existing ones. For handle a case, while other specialists instance, in HCMC, the head of the have done a lot of things in the one psychiatry department explains that hour’ (KII, psychologist, Hospital of as a result of limited staff, they are paediatrics, Hanoi). unable to meet demand for services. Second, providers speak about Similarly, in HCMC, a psychologist in the high levels of stress because the hospital of paediatrics reports of the subject matter: ‘Most of us that, ‘Frankly, we work for the State, so are under pressure, we have to be we must accept its pay policy. But often self-confident to endure the pressure. times I feel it’s not worth our efforts. Usually the pressure is very high’ (KII, Because it doesn’t match what we have Health Worker, National Hospital to do and invest in. For example, in of Paediatrics, Hanoi). Similarly, the the hospital, we charge 70,000 VND or director of the psychiatric hospital in 150,000 VND per case (30-60 minutes), Dien Bien says: ‘A psychiatrist is always while our colleges in the private sector at a disadvantage, because taking can charge 500,000 VND-700,000 care of normal people is already hard VND for a similar therapy session. The work, let alone taking care of this type difference is quite big for that same Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 101 work position’ (KI, Psychologist in departments where the seriousness mental health are at a disadvantage’ Department of Psychiatry, HCMC). is visible. It takes much more time (KII, Psychiatric Hospital of Dien Bien, for patients in this department to Dien Bien). Similarly, a respondent 6.1.4 Undervaluing /stigmatizing improve and the improvement is from the paediatrics hospital in of mental health services not as visible as for the patients with HCMC says that for some, being a physical injuries. For example, patients mental health doctor is a last resort: Not only do people refrain from with high fever are treated with fever ‘.. very few people choose to follow this accessing mental health services reducer, patients with pneumonia career. Those who choose it can be because of the stigma associated are treated with injections for several divided into two groups. Some follow with mental illness, but there is also days, and then they recover. It is their family tradition. And others are a sense coming from providers that unlike treating the patients with high employed by no one else, so they are mental health is not seen on a par or fever who recover after several days driven to this position. In general, in is undervalued when compared to of intervention. It is so difficult’ (KII, the doctor’s circle, the mental health other health areas. Thus, for instance, Health Worker, National Hospital of doctors receive less respect than others. as a KII from the national hospital of Paediatrics, Hanoi). But the situation is different if I am a paediatrics in Hanoi reports, given podiatrist associated with psychology, that mental health challenges are There is also the perception amongst the approach is different, the word not as visible as physical injuries, the mental health doctors themselves ‘psychology’ is preferable. People prefer people do not treat them as seriously. that delivering mental health services visiting a psychological ward to a Similarly, mental health issues cannot does not have as much status as mental ward. Because mental disease be treated quickly in comparison with doctors working in the General means something terrible to them (KII, physical injuries, which usually have Hospital, as the quote from a mental Paediatrics Hospital No 1, HCMC). visible treatments and improvement health doctor in Dien Bien shows: Another KI discloses that ‘psychiatrists quickly manifests itself. ‘Even among us, we say that working suffer from inferiority complexes’ and in the mental hospital or TB hospital being a psychiatrist himself, he does ‘Many people think that patients in this doesn’t sound as impressive as those not specify that he works for a mental department (mental health) are not doctors who work in the General health hospital in social gatherings, in as serious conditions as those in the Hospital over there. It’s even the same choosing instead only to mention the intensive care department, or other at the central level; those working in name of the area he works in.

6.1.5 Infrastructure 6.2 Demand side challenges take medication regularly or not. Their families get disheartened. They Infrastructure-related challenges In this section we explore challenges (people) are poor, and once broke, appear to be more frequently relating to access and uptake they don’t have any more money for mentioned in the locations outside of services. According to study treatment’ (KII, Psychiatric Hospital of of Hanoi and HCMC. The challenges respondents (see also Section 3), Dien Bien, Dien Bien). in locations beyond Hanoi and HCMC either people: i) do not recognise range from having no provincial mental health challenges; ii) even The lack of importance placed mental hospital, as is the case for An if they do see that their child might on mental health issues was also Giang, to having poor infrastructure be facing difficulties, they do not brought out by a mental health and equipment. In An Giang, there think it is important enough when doctor in the psychiatric hospital is only a small psychiatric ward in compared to physical health in Dien Bien when comparing the general hospital, so patients to warrant attention, including differences between Viet Nam and have to be sent to Tien Giang, Dong sending them to an appropriate ‘developed countries’: ‘In developed Thap and HCMC for treatment. Since service provider; iii) do not know countries, they really pay a lot of the number of people, particularly where to go for an examination; attention to mental problems, such young people, facing mental health and iv) will only access a service as headaches, sleep loss, anxiety and challenges is increasing, this lack provider, rather than caring for stress; when they have these problems, of a specialised centre raises severe them at home, if someone is seen they will see a doctor for counselling, challenges (KII, Social Protection to have a ‘serious mental health treatment and care. We’re only a Division, DOLISA, Long Xuyen city, An problem’. This is particularly the developing country, so for now we Giang). case in areas where there are limited only pay attention to physical health. service options and availability. Secondly, people underestimate Even where there is a mental health But even in areas where there are [mental problems]; they only seek hospital, as in the case of Dien Bien appropriate services, people are treatment once it’s already become Phu City, it continues to be housed reluctant to access them – often serious” (KII, Psychiatric Hospital of in the TB hospital, and the focus on because of the associated stigma Dien Bien, Dien Bien). providing treatment to children is – and even if they do access these largely absent. This hospital also services, either they do not see their In remote areas, people will resort lacks space and equipment, yet importance or get disheartened first to herbal medicines and people travel up to 300 km to go when the individual does not appear perform rituals, for both mental there because there are no services to be improving: health and other related problems, whatsoever in outlying areas. resulting often in coming too late for Likewise, Social Protection Centres, ‘Several patients don’t understand why treatment: ‘The majority of people are despite increasing caseloads, they come here. They say that they not well aware, so people in remote often lack the space to expand to come here at the doctor’s request, so hamlets usually hold worshipping accommodate more beneficiaries they don’t cooperate. They only listen rituals before going to health centres (Dien Bien) and/or accommodate the and do what they are told to do, they … Three years ago a baby was brought addition of mental health patients don’t understand this stuff. In their to the centre; I told them that the baby (An Giang). mind, medicine should be used to cure had a very serious case of pneumonia diseases … According to psychology, and gave them permission to transfer In terms of challenges in the most common response to to a higher hospital, because I didn’t infrastructure relating to school diagnosis of such diseases is that at have enough medicine or the oxygen counselling services, as also first they reject the diagnosis. They concentrator… They brought the mentioned by students, often the can’t accept that the diagnosis is right. baby (home) to perform worshipping office or room is inadequate; thus, They will argue or look for another rituals and intended to bring the baby students will refrain from seeking doctor to have the diagnosis which to hospital the following morning, but out the service: ‘..many schools do not they like. It is a normal response. Before he died. After performing the ritual, have good facility, students will not the diagnosis, they don’t tell anyone. they picked leaves to hang around the come if the room is not relaxing, or for After the diagnosis, they hide it (KII, house (KII, Commune Health Center, example, if the consulting office is near Paediatrics Hospital No 1, HCMC). Keo Lom commune, Dien Bien). the principal’s office, students won’t dare to come” (KII, Social Work Centre ‘Mental illnesses are extremely The general lack of knowledge about for Child Protection, Long Xuyen city, difficult to cure; they can only be mental health issues among medical An Giang). stabilised. Whether it takes a short or professionals is also an obstacle; long time depends on whether they patients often have to go from one Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 103 doctor to another before being People think that mental illnesses are finally referred to see a psychiatrist/ abnormal illnesses that these illnesses psychologist: ‘When patients come, twist a person’s personality, and are we often ask them if they’ve been incurable. Whenever they talk about somewhere else for examination before “mental”, people tend to be sarcastic, coming to us. Many people said that contemptuous, or want to deny. Any when they had such symptoms, they family that has a mental patient feel went to the local health station at first. haunted by it. If they have another type For example, when a patient felt he of illness, they can talk about it with had a problem, he went to the health people outside the family, such as “I “Some boys come for station, but they (health staff) said have a stomach ache”, but if someone there was no problem and just gave in the family has depression, anxiety or consultation, but don’t feel him some supplements. And then they psychosis, they will hide it. Sometimes comfortable so they do not (patients) would go to the district, and they go for health examinations, but then provincial hospital. Most of them they mostly will hide it from other share all the details about went to the General Hospital. Some people.’ There were even discussions their problems. And their even came here with a pile of medical about changing the name of the files; I mean they’ve done all these tests mental hospital in Dien Bien to friends tease them so I cannot without finding out anything. And I encourage more people to access the complete my consultation don’t know how much money they’ve services. had to spend all those years. They only with them. Girls even send came to our ward in the end. When Others also share that they refrain messages to me whenever asked why they didn’t come from the from using the term mental health they are sad beginning, they said that they didn’t when they work with families and know, that other doctors didn’t tell instead use child health: ‘First and (KII, school psychologist, LSS, District them’ (KII, psychologist in Paediatrics foremost, it’s necessary to control the Hospital, HCMC). so-called stigma which influences 3, HCMC). families. Families are afraid that their The gender of providers also creates children have mental problems, they challenges for uptake of services. will hide it. You think, “if a girl of grade As also outlined in sections 4 and 7 or 8 is a mental patent, her future 5, according to children and young will be influenced”. It also relates to her people, the gender of the school prospect of marriage. But if you say counsellor will influence whether it’s the health of the mind, it’s fine. We their services are used. Thus, for did research to find out what people instance, girls are reluctant to talk think about mental health, the health to a male counsellor. Similarly, a of minds, mental disorders. If you say female school psychologist mentions it’s mental disorder, [people will think] that boys do not share freely with it relates to the situation that children her compared to girls: “Some boys learn too much and the situation can come for consultation, but don’t feel be worked out by letting them rest, comfortable so they do not share all the changing their schedule and reducing details about their problems. And their shouting at children. But if it’s mental friends tease them so I cannot complete problem, you have to take medicines my consultation with them. Girls even and hospitalise. The symptoms are send messages to me whenever they known as looking half-witted and are sad (KII, school psychologist, LSS, wandering aimlessly. No one wants District 3, HCMC). their children to be considered having mental problems’ (KII, Officer, RTTCD Stigma also remains a barrier to NGO, Hanoi). accessing services as noted in several key informant interviews, for instance with the director of a mental health hospital in HCMC: ‘People’s attitude is a big problem. It’s called “stigma” (using the English word). 104 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

CHAPTER 7 Political economy of mental health and psychosocial support in Viet Nam 106 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

Viet Nam’s rapid economic growth and commitment to ensuring every National Program of Action for over the past two decades has child enjoys the best healthcare Children, the Extended Program brought many financial resources possible, as clearly stated in the UN on Immunization, the National for increasing state expenditure Convention on the Rights of the Strategy on Nutrition, the National on healthcare and contributed to Child, of which Viet Nam was the first Strategy on Protection, Care, and improving the health of children. country in Asia and second in the Improvement of the People's Health, The Vietnamese Government has world to ratify. Moreover, Viet Nam the National Action Plan on Safe also introduced various strategies has also developed and put into Motherhood, and other policies on and solutions to reform the policy effect multiple policies and programs financing healthcare, strengthening of health financing, including related to healthcare for children. and developing the grassroots rapidly increasing the proportion of The Law on Child Protection, Care healthcare system, regulating Social public finance resources; reducing and Education, first passed in Protection Centres, and improving step-by-step the out-of-pocket 1991, was revised and renamed the quality of healthcare services. payment method; and upgrading the “Law on Children” in 2016. The health facilities, with priority given law, which provides for children’s Specifically, some policies are more to strengthening the grassroots right to comprehensive childcare, aligned with addressing the needs of healthcare system, the preventive will go into effect on 1 June 2017. mental health issues than others. For medicine system, the provincial and It. Healthcare for children is also instance, Decree No. 136/2013/ND-CP district-level general hospitals, and mentioned in several other laws, states that individuals must have the regional health centres. such as the 1989 Law on Protection severe disabilities in order to accesses of People’s Health, the 2008 Law on social assistance benefits (UNICEF The policies related to socialisation Health Insurance, the 2006 Law on & MOLISA, 2015). Decree 68/2008/ of the healthcare system - which Gender Equality, and the 2007 Law NĐ-CP delineates policies that include policies related to public on Domestic Violence Prevention regulate Social Protection Centres finance resource allocation, and Control (see Annex 4 for further such as ensuring the admission universal healthcare coverage, details). In addition, there are a of individuals who are living with health insurance for the poor, number of other laws that do not exceptionally serious (mental) and healthcare services for deal with the topic directly, but have disabilities, pending the absence of disadvantaged groups such as regulations related to protection family support or ability for self-care. ethnic minority children and poor of children’s right to healthcare This decree also grants beneficiaries children - which the Vietnamese in the event of legal conflicts or at Social Protection Centres the Government has been implementing violations, namely the 1999 Penal rights to: health care, education, over the past years have produced Code (amended in 2003 and 2016), information, vocational training, favourable results, contributing to the 2000 amended Law on Marriage leisure activities, opportunities better healthcare for children in Viet and Family, and the 2006 Law on for production, autonomy and Nam, despite continued inequality HIV/AIDS Prevention and Control. community interaction (ibid.). The of access across social class and Moreover, the Law of People with Government Decree No. 103/2017/ geographical area (Dang, 2015 a, b). Disability (Law No. 51/2010/QH12 ND-CP dated 12 September 2017 addresses people with disabilities regulates the establishment, more generally. Individuals living organization, operation, dissolution 7.1 National level legislation and with mental, psychiatric and and management of social assistance policy on mental healthcare and intellectual disabilities are identified facilities. The Decree No. 28/2012/ psychosocial support for children as a subgroup under Article 3 ND-CP dated 10 April 2012 details whereas Article 4 of the disability law and guides the implementation of prescribes the rights of people with a number of articles of the Law on Currently Viet Nam does not have disabilities. Persons with Disabilities. Similarly, an explicit mental health law, or in 2011, the Vietnamese Government any specific legislation on mental In parallel with revising and approved the decision No. 1215/ healthcare for children in particular. improving the laws, the Vietnamese QD-TTg approving the scheme of No policy dealing with children’s Government has promulgated and social support and community- mental healthcare explicitly has led the implementation of various based rehabilitation for people with been in place. Nevertheless, general policies, strategies and programs mental health illnesses and people healthcare for children has been that directly or indirectly address with mental disorders for the period well noted in the Vietnamese healthcare for children in general of 2011-2020. The scheme aims to legal system, which shows the and mental healthcare for children mobilise families and communities Vietnamese Government’s efforts in particular. Examples include the to provide spiritual and material Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 107 support to the rehabilitation of medical treatment to prevent and field of mental health. As a result, six people with mental illnesses to help treat mental disorders. Moreover, 34 training modules on mental health them stabilise their life, integrate provinces and cities have built social care have been developed, including into the community and prevent work centers some of which have general knowledge on mental people from acquiring mental been evaluated by MOLISA to be health care, case management, disorders, thus ensuring social effective (e.g., the Provincial Social clinical psychology, counselling, security (MOLISA, 2014). A number Work Centers in Quang Ninh, Da social work in mental health care, of agencies and departments are Nang, Ben Tre, Long an, Thanh Hoa and procedures for caring and responsible for implementing the and Ho Chi Minh city). rehabilitation for people with mental scheme. Among them, MOLISA illnesses (MOLISA, 2014). Additionally, plays a key role as the hosting In 2010, the Prime Minister of MOLISA has collaborated with organisation, followed by the MOH Viet Nam approved the National UNICEF and the University of Social and MOET. These ministries also Project on Social Work Profession Labour to develop curricula and coordinate with organisations and Development (2010-2020) to be technical instructions on social work agencies at various levels to carry out implemented by MOLISA with professional skills in supporting the scheme’s activities at these local the aim of training 60,000 social people with mental illnesses and levels. To date, four projects have work staff, including both social to organise training courses for been rolled out: (1) Constructing workers and managers, by 2020. social welfare cardes and staff of infrastructure and equipment for Based on that, on 24 October 2013, employees who work at social the social protection facilities which the MOLISA issued the Circular No. protection centres for people with provide care and rehabilitation 07/2013/TT-BLDTBXH regulating mental illnesses in the provinces services for people with mental professional standards of social which implement a pilot project illnesses; (2) developing human work collaborators at commune/ (ibid.). resources for community-based ward/town level. It tasks the social social support and rehabilitation work collaborators with helping In 2006, the Ministry of Health issued for people with mental illnesses; people with mental illnesses and the ‘National comprehensive plan for (3) developing facilities for mental people with mental disorders protecting, caring for and enhancing disorder prevention and treatment; including: collecting and receiving Vietnamese teenagers’ and young and (4) communicating and raising information or requests for help people’s health for the period 2006- awareness on the responsibilities from beneficiaries; monitoring and 2010 with vision to 2020’. Among of families, communities and the assessing their health situation, other things, ‘mental trauma and wider society in caring for and family and social relationships other issues related to mental health’ rehabilitating people with mental and what kind of support they are seen as one of main dangers to illnesses. need ranging from counselling, Vietnamese teenagers’ and young consultancy, therapy, education, people’s health. As a result of the Programme 1215, prevention to separation; by 2014, there have been 45 social participating in the implementation Presently, the government of Viet protection units (which include social of policies and programs supporting Nam is creating a National Mental protection centres) which provide the beneficiaries; and participating Health Strategy on prevention and care and rehabilitation for people in communication efforts to control of mental disorders for the with mental illnesses, of which 26 raise awareness for families and period 2015 – 2020, with a vision to units provide specialised care and communities on mental health. So 2030 (UNICEF & MOLISA, 2015). 19 units provide combined care far, 50 provinces and cities have (MOLISA, 2014). Some provinces and approved the plan for establishing Additionally, the first ever National cities have built successful models of the network of about 10,000 social Programme on Child Protection occupational therapy and rotating work collaborators. Some provinces in Viet Nam (2011-2015) promoted rehabilitation for people with or cities like Quang Ninh, Long An, the establishment and functioning serious mental illnesses, for example Ben Tre, Da Nang, Thua Thien Hue, of the community-based child the Provincial Centers for Social An Giang, Khanh Hoa and Phu Yen protection system (CBCPS). Specific Protection in Son La or Thua Thien have taken initial steps in forming aims for this programme were that Hue and the Center for nursing and the network of collaborators and community-based social assistance rehabilitation for people with mental social workers. MOLISA has also would be provided to 80% of illnesses in Viet Tri. The centres have collaborated with universities children in special circumstances taken initial steps in combining those provide training on social to rehabilitate and reintegrate counselling, psychological therapy work in development of training themselves into the community and social work services with programmes and curricula in the and 70% of children at risk of falling 108 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam into special circumstances would 7.2 Existing programmes and plans the report does not disaggregate be identified for early intervention on mental health and psychosocial the data related to children and so as to mitigate and eliminate teenagers. that risk. There were five priority wellbeing projects under this programme: However, there are many challenges a) communication, education and The National Target Program on to the effectiveness of the project, social mobilisation, b) building the mental health started in 1998 including financial and human capacity of child care and protection when the Prime Minister signed resource issues, as well the staffs, collaborators and volunteers, the inclusion of the Project community’s attitude toward mental c) building and developing child for Community Mental Health illnesses. Funds allocated to the protection service systems, d) Protection into the National target project in its first year, 2011, were building and expanding models program on prevention and control only 47% of the planned amount, of community-based support for of some social illnesses, dangerous and the discrepancy between the children in special circumstances, epidemics and HIV and AIDS (now it budgeted and allocated amounts and e) improving the effectiveness is a part of the National program on grew over time. In 2012, the project of state management of child healthcare). In 2001, the Government only received 42% of the budgeted protection and care. Although the approved the Project for Community amount, in 2013, 37%, and in 2014, a improvement of the mental health Mental Health Protection, which was paltry 11%. The report also indicates of children is not explicitly stated implemented in three phases, each factors that constrain effectiveness of in the objectives, the nature of the with a distinct focus: (1) 2001-2005 the project (they are also difficulties projects and target beneficiaries with a focus on mental healthcare facing the project), including: (e.g., vulnerable groups, such and protection in communities’; specialised doctors and medical as children, who are victims of (2) 2006-2010 with a focus on personnel serving the psychiatry trafficking, kidnapping, abuse, and the integration of epilepsy and sector are lacking; the education violence; children with injuries; and depression into the first phase of work on mass media is limited, children from poor families) suggests the project as part of the initiative especially in remote, mountainous that they will reach children who are ‘Prevention and Control of Some and island areas; the system of in need of mental health services. Non-communicable Diseases’; mental healthcare services is See also Annex 4 for further details and (3) 2011- 2015 with a focus inadequate; some localities do not of these policies, strategies and on mental health protection for have inpatient care facilities; people’s programmes. communities and children. awareness about mental illnesses is still limited; many mental illness In summary, from reviewing the According to the report on patients are not in treatment; and system of laws and policies related implementation of the component transportation for implementation to healthcare for children, it can project of ‘Mental health protection and checking are not available. be argued that this system has for communities and children’ created a basic legislative and policy (Ministry of Health, 2015) during the The Joint Annual Health Review framework for the improvement period 2011-2015, treating mental of 2014 (ibid) evaluates difficulties of children’s healthcare. However, illness patients in communities helps in implementing the projects and within this framework, there is still them stabilize their illness quickly, indicates that the implementation of a need for specific regulations that integrate more easily with their policies on mental health care in Viet explicitly address the issue of mental families and society and reduce the Nam is not comprehensive and lacks health care for children. According cost of treatment. The network of a long-term vision. Not only has the to the Ministry of Health (2009), mental healthcare has developed law on mental health has not been limitations of the strategies and evenly and widely from central to formulated, but existing policies are policies on healthcare for children lie local levels; mental health expertise not based on a comprehensive, long- in the lack of science- and evidence- has also been improved among term strategy with vision, target and based content and targets. Policy- district and commune level officers. concrete solutions on mental health. making is too slow to keep up with The project is implemented in all The project that only focuses on the country’s speed of economic and 63 provinces and between 2011 and schizophrenia, epilepsy, depression, social development. Collaboration 2015 it treated an estimated 72% of all has not dealt with other common between different sectors has not patients nationwide diagnosed with mental disorders, has not focused been vigorous enough, and the schizophrenia, 65% of all patients on special target beneficiaries, such monitoring and supervision of policy nationwide diagnosed with epilepsy as children, teenagers, pregnant implementation are still limited. and it also treated a total of 19,900 women, mothers, people in detention suffering depression. Unfortunately, centres, and people with mental Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 109 disorders after natural disasters. Management of depression patients Box 8: Limitations in policies is only implemented in some pilot On mental health care and children models and hasn’t been included in a regular management program. There ‘The healthcare sector only takes care of children’s general health and nutrition. is no intervention to reduce the risk There is no program for mental healthcare for the children … school healthcare of mental illnesses in communities, deals only with dentistry and ophthalmology. With regard to mental health, the school medical workers are unable to detect any issue. It is not their specialty. schools, families and workplaces Most of the workers are accountants and take charge of the school medical (MOH and Health Partnership Group, units; they were not trained in medicine’ (FGD, provincial officers, Long Xuyen 2015). city, An Giang).

‘Regarding the policy on mental health, I think that the public healthcare 7.3 Limitations in policies network should pay more attention than it does today, because most patients look for help at the national paediatric hospital. There is no public mental When people were asked their healthcare service, according to my own point of view, there is no such thing’ views on policies around mental (KII, Health Worker, National Hospital of Paediatrics, Hanoi). healthcare, particularly for children and young people, it was generally ‘This field (children and young people’s mental health) hasn’t received much thought that these were lacking interest in the community. Currently, within the mental healthcare system in particular, and for children in Dien Bien in general, it’s largely still absent. and more attention needed to Guidance from the Ministry and province for this field has been very limited. be paid to them, both within the The issue of mental healthcare for children really needs more attention from health sector more broadly and the Government and Ministry. Only after that can we have orientation for its also with school related health programmes; the province also needs to provide training on this type of work… care. This lack of services results We need to strengthen the network of mental healthcare, at least at the district in, amongst other things, people level first, and then the commune level. At the commune level, healthcare for the not being able to access services elderly and people with disabilities is receiving more attention’ (KII, DOH, Dien or going to inappropriate places. Bien Phu city). There was also a sense that while there is policy on mental health, ‘There has been no policy for mental health support, especially in terms of though not necessarily for children, prevention. For example, when children suffering from mental disorders go to hospital, they enjoy [benefits under] the Ministry of Health’s policies, but these little or nothing exists concerning are general policies; there’s no special support policy for children… in Viet psychological counselling, and if Nam, there has been almost no policy for mental health support in schools. there is some psychological service Neither the MOH nor the MOET has produced any policy. Currently, the MOET being provided, often through the has issued a circular on school healthcare and paid attention to the issue of private sector, it is not regulated in physical health, for example physical education in schools, and there was a any way (see Box 8). circular in 2006 which requires psychological counselling to be provided in schools. They are all there, but there have been no guidelines for implementing Even where there are policies, as these circulars… Therefore, at present, parents and teachers just do what they already seen in section 4, there is a like’ ( KII, National University, Hanoi). lack of staff and other resources to On the psychological dimension implement them. ‘Private services are booming. From what I see, in big cities, many types of ‘In terms of effectiveness, the policies counselling centres have sprung up; you see psychological counselling centres everywhere you go. But whether such centres are licensed, who manages introduced by the state, no matter them and how [good] their quality is are still unclear. Because psychological what is said, always bring a certain counselling is an area that has a lot to do with the practitioner’s ethics and impact on the beneficiaries, helping license. Take depression for example. We often say jokingly that if you don’t them to be more stable, and solving do a good job, maybe the child will even kill himself, not that he will feel part of their family difficulties. But better. And there has been no policy (regulation) either for these psychological the most challenging thing at the counselling centres, for example in terms of requirements of practicing license present is that, although the policies or professional certificates. Of course those centres must have worked with are there, the current human resources Science and Technology Department or so, so they’re legal, but there is no to support these target groups at regulation on professional quality and expertise requirements’ (KII, National the grassroots level are insufficient, University, Hanoi). even mostly non-existent. I mean in addition to the money, we need a team to provide psychological counselling 110 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

and support to them; even within the ‘There are policies on mental healthcare. But no policy on psychology is labour (DOLISA) or education or health in effect. No professional license is issued or managed. There is no official sectors, I find it’s lacking. As long as administrator, making it difficult for both practitioners as well as patients, this gap persists, the effectiveness of because people don’t know the practitioner’s qualification as well as their supervisors. There should be clear regulations about such things. Besides, the these programs is not high’ (KII, Social developmental and behavioural speciality is very new, I don’t know who to ask Protection Division, DOLISA, Long for help’ (KII, Paediatrics Hospital No 1, HCMC). Xuyen city, An Giang).

‘There has been no [compensation] policy for psychologists. At the present, the Generally, it should be noted that hospitals pay their psychologists independently. The hospitals sign separate current mental health-related contracts with them… There has been no policy either (for).. training or further policies are scattered in various training’ (KII, National University, Hanoi) legal documents in which mental health is mentioned to varying ‘Vocational allowance is needed (for psychologists). For example, the mental degrees. Additionally, mental health health staff working six or seven hours a day can enjoy it. The psychological is generally not considered a major staff deal with the same cases, but they are not eligible for it. Secondly, they issue in the provisions of these have to work administrative office hours, there is no regulation allowing them to work fewer hours’ (KII, Paediatrics Hospital No 1, HCMC). documents. Even in the People’s Health Care Law, a very important ‘The current National Program only focuses on three groups, which are legal document in the field of schizophrenia, epilepsy and depression. The rate of children with epilepsy is health, mental health issues are only 0.05%. But in fact, the rate of children with epilepsy currently being managed mentioned in a cursory manner. at commune and ward health stations is lower than 0.05%. That means most of the children [patients] have not been included in treatment management. But that’s not everything, because in some cases, the family can afford to send 7.4 Future plans regarding policy their child to higher-level facilities for treatment, without going through the development and implementation commune health station. The children’s epilepsy treatment gap is about 70- 80%; I mean only 20-30% of the children patients are being managed. Although The Government of Viet Nam is the policy is there – which states that patients of epilepsy or schizophrenia or developing the National Strategy depression are entitled to treatment management and free medication – in fact, they can’t access these services, perhaps partly because they get treatment on Mental Health, 2016-2015, with a from other facilities. Besides, maybe during the treatment process, some drugs View to 2030. The draft document in the National Program are from the old generation, which have many side expresses the view of providing effects and can cause other disorders, such as mental disorders, if used for a healthcare coverage to all people, prolonged period. Only when a child has serious fits of convulsions will he/ giving priority to poor regions, those she be taken to a mental health hospital and given new-generation drugs. At in difficult situations, and ethnic that point they won’t want to go back to the commune anymore, because if minorities and other vulnerable they do, they will get the same old generation drugs which have a lot of side groups. The attention to children’s effects. There are such policy barriers’ (KII, Officer, Agency of Medical Services mental health is also expressed Administration, Medical Technical Division of MOH, Hanoi). using a lifecycle approach, in which policies, plans and mental healthcare services should be adapted to the healthcare and social needs in all life phases (new-born, childhood, teenage, adulthood and elderly period). Notably, the Draft Strategy has a target for the prevention or early dection of up to 50% of mental disorders in children and teenagers by 2025 (Draft Decision on the National Strategy on mental health in the period 2016-2025)7.

According to study respondents, several policy recommendations

7. Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 111 have been put forth to improve the ‘Two (social protection) centres have national mental health program, but got approval in Chau Doc, I mean it’s are currently in draft phase: ‘Firstly, about upgrading the Social Protection with such a budget, you should only Centres, and add the task of caring focus on issues such as training of for mental patients into their existing human resources and communication responsibilities. The Provincial People’s activities; that money shouldn’t be Committee (PPC) has agreed and used to buy medicines. Because those approved everything, but now we’re drugs, if not provided by the National just waiting for investments… Now Target Program, can still be obtained the hardest part is the permanent staff under the health insurance policy if quota’ (KII, Social Protection Division, the child has a health insurance card. DOLISA, Long Xuyen city, An Giang). They will be given drugs included in the ‘In terms of effectiveness, MOH list of essential medicines, which In An Giang provincial officers also the policies introduced by are covered by the health insurance. spoke about wanting to establish the state, no matter what is And so instead of buying medicines counselling points in the community – and that budget is not enough to and to link child protection workers said, always bring a certain do it anyway, they’d better focus on with Women’s Union members who impact on the beneficiaries, training of human resources to make could provide additional support: ‘ sure everything is done properly. In the period 2016-2020, we intend to helping them to be more Currently, children under 6 years of publicise the hotline (see above) and stable, and solving part of age can enjoy the free medical services upgrade the centres. Secondly, in the policy; as for other groups, from 6 to child protection program 2016-2020, their family difficulties. But 15 years old, the rate of having health we plan to connect and establish the most challenging thing at insurance is very high. For children counselling points in the community to the present is that, although with mental disorders, usually the help the children protect their mental local authorities have other policies, health and avoid serious illnesses. the policies are there, the for example, if they’re from near-poor We advise the provincial people’s current human resources to households, they are all entitled to free committee to link child protection health insurance. According to surveys workers with trustworthy addresses support these target groups of other mental hospitals, they also of the Women’s Unions, which have at the grassroots level are said that nearly 70-80% of the patients been established in 156 communes with mental disorders have health and wards. As we can see, the insufficient, even mostly non- insurance. Therefore, instead of buying addresses have been established but existent. I mean in addition drugs for them, you should use the very few children and parents come, health insurance policy, and there are because they don’t understand that to the money, we need a more drugs in the list of medicines that child abuse can affect their mental team to provide psychological are covered by health insurance’ (KII, health’ (FGD, Provincial officers, counselling and support Officer, Agency of Medical Services Long Xuyen city, An Giang). In An Administration (Medical Technical Giang as well, though also aware to them; even within the Division), MOH, Hanoi). of the human resource constraints, labour (DOLISA) or education they spoke about expanding the At the local level, our findings school counselling model (currently or health sectors, I find it’s suggested that there are also provided in six schools) as well as lacking. As long as this gap some specific plans for future establishing further social work implementation of programming offices in 11 districts and towns ‘under persists, the effectiveness of and service provision around mental the government’s scheme No 32’ (FGD, these programs is not high’ health, including more places to Provincial officers, Long Xuyen city, care for people facing mental health An Giang). (KII, Social Protection Division, challenges. In other places, it appears DOLISA, Long Xuyen city, An Giang). that the polices and programme have been agreed and they are just waiting for the investments, including staff: 112 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

CHAPTER 8 Recommendations 114 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

Our findings highlight that while of mental health care for children SPECIFIC RECOMMENDATIONS Viet Nam has made huge strides and young people. There is a economically and in tackling poverty, need for additional and improved the social sectors have often been policies that strengthen the roles 1. Better and more coordinated left lagging, and now with rapid and responsibilities of key agencies, policies on mental health globalisation and exposure, there is including providing clear guidance psychological counselling, for an urgent need to tackle the resulting and mandates to all relevant cultural and inter-generational agencies (MoET, MoH, Commission children and young people conflicts. Without a firm foundation on Ethnic Minority Affairs and of support and care for mental and Women’s Union) on mental health Although various policies related psychosocial ill-being, it will be care for children and young people, to mental health are in place, they difficult for Viet Nam to ensure that its as well as specific mechanisms are scattered across many different young people have the coping skills to ensure effective coordination legislation documents; and generally, and set of services to overcome these between these agencies. in such documents, mental health challenges going forward. Viet Nam is not a main focus. Even within needs to find a uniquely Vietnamese Based on the study’s findings, this the Law on Protection of People’s path through these challenges, report also recommends increasing Health, a critical document in the which would involve, at a minimum, the quantity and quality of field of health, the issue of mental drawing on traditional cultural values human resources, including the health is modestly addressed. The (e.g. collective solidarity, tight family development of a training plan for Government of Vietnam needs to bonds etc.) whilst also recognising the more and better social workers, pay attention to improving the need in the current age for flexibility counsellors, psychiatrists, and policy system related to mental and adaptation facilitated through psychologists to deal with less severe health care and psychosocial support improved communication skills across / common mental disorders, tailoring for children and young people, generations. their training to the needs of children especially in the National Programme and young people. on mental health care and healthcare Based on the study findings, programmes for children. The the report proposes following Raise and improve awareness National Programme on mental recommendations: around young people’s health care needs to cover less psychosocial and mental health serious/common mental disorders care needs, as well as existing as well, not only focusing on serious GENERAL RECOMMENDATIONS support services, including illnesses such as schizophrenia, providing supports to parents, epilepsy and depression. In terms of policy framework, there largely through or linked to school is a need to complete the national environments, in parenting, caring Consider improving the laws level legislation and policy on and communication skills training and policies related to mental mental healthcare and psychosocial and support, including regular health care in the social assistance support for children. Although the follow- ups to promote positive and social security system in Viet system of laws and policies related behavioral changes in mental health Nam, because they serve as the to healthcare for children has care for children and young people. legal basis for increasing human created a basic legislative and policy resources and enhancing networks framework for the improvement of Increase the number and quality of mental health care services children’s healthcare, there are still of specific support services for for children and young people, many gaps in the mental health children and young people’s including policies on social work care and psychosocial support for mental health care throughout the practices. This would allow for: 1) the children. In the future, Vietnam country. Develop clinical diagnostics strengthening of human resources needs to develop more specific standards and activities for children and 2) improving the quality of regulations that explicitly address and young people thus allowing for mental health care services in social the issue of mental health care and the early detection and treatment of assistance establishments and in the psychosocial support for children mental health challenges as well as community, and 3) development of and young people. psychosocial distress among children specific policies explicitly targeting and young people. children and young people. This Develop more and better policies process would need to be led by on enhancing responsibilities and MOLISA and MOH in collaboration coordination between relevant with other key ministries. agencies and sectors in the field Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 115

School healthcare programmes MOLISA will have a critical role to training programmes in each of also need to address more specific play in ensuring integrated policy these fields related to the needs issues related to mental health care and programme implementation. of children and young people is and psychosocial support for school essential. Embedding such training children; this includes setting specific Policy implementation will also within an integrated model would objectives for the prevention and necessitate providing clear be especially helpful, including for treatment of mental health problems guidance and mandates to all the purposes of early detection, for school children. Currently, the relevant agencies – Ministries of prevention, and early intervention. existing school healthcare policies Health, Education and Labour and still focus mainly on physical health, Social Affairs – to ensure that these The role of the education sector such as prevention and treatment goals are reflected in their respective and schools in particular is critical of children’s spinal problems, eye policies and programmes. Additional here as well. Thus more training diseases, infectious diseases, dental linkages to ensure a holistic is needed to establish a cadre care etc., while mental health care approach to supporting children of dedicated and professional for children, including psychosocial and young people’s mental health schools psychologists and counseling and support, is still being and psychosocial wellbeing would counsellors, who are not teachers neglected. include the MOET’s Department of working as part-time counsellors Student Affairs), the Commission without professional and formal Going forward, it will be important on Ethnic Minority Affairs, and the training, which is now often the case. for the Government of Viet Nam Women’s Union. It is also necessary to develop school to approve the National Strategy psychology graduate programmes, on Mental Health in the period Given the high level of unmet especially given the present context 2018-2025, with its emphasis on demand for support services and of Viet Nam where huge needs for providing healthcare coverage to treatment among children and psychological counselling among all people, giving priority to poor young people, capitalising on children and young people are being regions, those in difficult situations, existing NGO and private service met with a very limited system of and ethnic minorities and other providers by providing referrals as psychological counselling services vulnerable groups. Adequate budget well as clear guidance on practice are still very limited. Therefore, it allocations from the Ministries standards will be an important will be critical to provide adequate of Health, Education and Labour short-term step. Of course, any such resources for dedicated counsellors and Social Affairs will require not approach should be embedded in school settings, along with only increasing the number of within an integrated model that the appropriate infrastructure social workers, specialised medical includes attention to addressing (counselling units /centres). professionals, and community- and broader determinants of mental Different models of providing school- based counsellors, but also ill-health and psychological stress, such kind of support in a school setting standards and guidance including poverty and inequity. environment (e.g. using different for tailored training and periodic kinds of counselors / psychologists) retraining to ensure professionals could also be piloting, drawing on in the field at all levels (national, 2. Increase quantity and quality of existing models currently being used provincial, district and commune) human resources in schools in Viet Nam but also from are adequately equipped to deal other countries. with the evolving psychosocial There is an urgent need to enhance and mental health vulnerabilities training to develop a cadre of It is also essential to develop a cadre that young people face in a fast- health workers, from nurses to of professional of social workers. paced developing country like doctors, as well as specialist training. While policy documents refer to Viet Nam. Additionally, synergies Because the current system is highly a cadre of professional social should be promoted through the medicalised and there is a lack of workers, our findings highlighted development of an Action Plan and attention to broader psychosocial that they are not yet in place, at implementation of the Master Plan wellbeing dimensions, there is a least in our four research sites. This for Social Assistance Reform and strong need to pay attention to presents an urgent need for more Development for 2017-2025 with developing training for more and and better training and capacity vision towards 2030 (MPSARD), better counsellors, social workers, building to establish a cadre of which includes attention to social psychiatrists, and psychologists social workers in the field of mental assistance for particularly vulnerable who could deal with less severe health care, clinical psychology and groups, including those with mental types of mental health problems psychotherapy. In particular, there health problems. In this regard, and disorders. Moreover, tailored appear to be insufficient incentives 116 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam to motivate relocation to rural areas. and in particular that they are This awareness-raising could With the implementation of the incentivized to work in areas beyond be done at various levels, but in scheme to develop social work, there large cities. This is particular the case particular starting at the commune is a possibility of improving caseload for those dealing with the less severe level, providing communities with burden. However, the scheme only mental health disorders (the social more information about symptoms, puts forth administrative policies workers, counselors etc.) who are still manifestations and available support to develop the field of social work few in number. On the other hand, it services, including the role of the and does not lay out ways in which is also critical that all these cadres are social workers (where they exist) as quality of social workers will be provided with sufficient and good well as hotlines. At commune level, maintained. In addition, there is quality supervision and guidance. the role of the village health worker an urgent need to strengthen the could include awareness-raising knowledge and capacities of the about mental health, the need to staff at Social Protection Centres. 3. More and improved awareness train them to be able to identify Finally, because existing social around young people’s psychosocial symptoms of mental illness, in workers have such high case loads, and mental health care needs, as counselling and referrals. In this there could be important dividends regard, the Women’s Union as well as in developing a cadre of para-social well as existing support services other grassroots political and social workers (commune collaborators) organizations at ward or commune who could play an important role in Currently, MOLISA provides support level, could also potentially play a case collaboration. for social protection beneficiaries, role in raising awareness among its including people with severe, serious members and the community more The community health level model and mild mental illnesses living broadly, as well as detecting and appears to have been very successful in social protection institutions referring early symptoms of mental in general, although not yet at scale, and in the community. Every year, ill-health. indicating that there is a need to MOLISA organizes training to raise revisit and support retraining for awareness among social work Related to this, it would be beneficial a cadre of community level health staff, collaborators and families to support parents with parenting, workers. These health workers could about mental health care. There is, caring and communication skills in turn be trained in psychosocial however, need to increase these training and support, including and mental health support, and awareness raising activities in order regular follow-ups in order to provided with clear guidance and to raise public awareness around promote behavioural norm changes. resourcing from district, provincial less severe mental health and Some of this is happening through and central levels. psychosocial needs of children and private schools but could usefully young people. In particular, it would be expanded to public schools, The content of the training be important to raise awareness and/or be organised beyond the programmes need to be developed about the linkages between school environment, e.g. through jointly with mental health and discriminatory social norms – e.g. community health workers following psychosocial experts, drawing on pressures for child marriage, limited appropriate training. international best practice, but also options for girls in rural areas given ensuring that the particular realities traditional gender roles – and mental It is also vital to ensure that the of the Viet Nam context are taken ill-health and the social isolation approach is inter-sectoral, and so into consideration. Modules should that many girls often feel in such at the commune level for example, include an exploration of different situations. must include working with teachers, drivers or risk factors of mental and training them – given their health and psychosocial wellbeing This awareness-raising can be proximity to children and general amongst children and young people done through a range of activities awareness about community and would include discussion around including: developing training dynamics – to detect early warning norms as well as issues around curricula for different carders of signs and to refer students to school violence and changing contexts all workers and relevant to their sector counsellors and relevant healthcare of which can precipitate mental ill (e.g. health, education); developing professionals, commune office staff, health and psychosocial distress communications activities and social workers. amongst this age cohort. targeting communities; and through providing information (leaflets, etc.) It is also important that the prevention For all cadres of staff, it is important at service points (e.g. health centres/ of potential risks to children’s mental that on the one hand they are commune clinics, schools, etc.) health and psychosocial wellbeing incentivized to work in this sector, is included in the communication Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 117 programmes on mental health in dedicated infrastructure is in (v) Facilitate support groups for the community which are being place for provision of specialized parents who are caring for children carried out by MOLISA under the support related to mental health and with specific and diagnosed mental Scheme 1215, Scheme 32, Scheme psychosocial wellbeing. health disorders – e.g. autism or 647 and Scheme 529. Given that epilepsy. These parent support group MOLISA has an existing cadre of (ii) In the near future, develop clinical models exist in multiple international child protection workers at various diagnostics standards and activities contexts, so it would be advisable to levels, more training and knowledge for children and young people thus learn from this good practice and, should be provided to them about allowing for the early detection drawing lessons also from where the prevention of potential risks to and treatment of mental health such groups already exist in Viet the children’s mental health, enabling challenges as well as psychosocial Nam, adapt these models to local them to carry out this communication distress. This requires active support needs. work. At the community level, and budget from MoH, MoET, and especially in rural areas, there needs MOLISA. In addition, given the inter-linked to be improved coordination between nature of many psychosocial and child protection workers and medical (iii) At the same time, set up mental health problems, there workers, women’s unions and youth collaborations and partnerships is a need to invest in systemic unions in disseminating knowledge between line ministries for the counselling, i.e. working closely both about potential risks to children provision of services to ensure with families to help them provide and young people’s mental health as complementarity and best use adequate attention and care to their well as possible ways to prevent this of resources. A cross-ministerial children. This is already happening in mental ill-health. Communication working group and collaboration some schools but the model needs efforts around children’s mental health mechanism could be set upin order to be expanded to other schools and could also be integrated into existing to facilitate this at national level, beyond the education sector. programmes, such as women’s union’s which could also be mirrored at programmes, in order to be cost provincial and commune level. In order for these changes to effective. At present, MoET has joined the happen, a prerequisite is clearly collaboration in organizing regular raising the profile of the specificity Moreover, it is also essential to health check-ups for school children of children’s mental health needs at organize activities to raise public at the beginning of each school year. national level and across sectors, led awareness and provide knowledge However, these regular check-ups by a clear governmental champion of caring for children with mental have been focusing only on height, who can move this agenda forward and psychosocial problems at the weight, eye diseases and spinal – in both its mental and psychosocial community level. At the same time, problems, while neglecting the dimensions. effective mechanisms should be screening and early detection of developed to link families of children students’ mental health problems. with mental health and psychosocial Therefore, MoET needs to consider 5. Ministry of Education should take challenges to social protection including screening and early on role for championing children’s services in a professional manner, detection services of mental health needs for better mental health and to support these families in taking problems and psychosocial distress care of their children’s mental and for school children, based on psychosocial wellbeing psychosocial wellbeing. national standardized criteria and tools for diagnosis. Our research shows that a significant set of risks to children’s mental 4. More and better coordinated (iv) Besides physical infrastructure, health and psychosocial wellbeing services throughout the country capitalise more on the connectivity are related to study pressures, and of many young people, and ensure to relationships with teachers and Through the health and social that there are strong online sources friends; meanwhile, risk prevention protection facility systems, MOH and of information and support that and control services are still limited, MOLISA should: can be accessed by mobile phones and there is a lack of mental health or computers. At the same time, it care and psychological counselling (i) Increase the number and quality is obviously critical that there are services in schools. As such, MOET of mental health and psychosocial- adequate safeguards in place to has a key role to play and should be related services throughout the protect children from the negative encouraged to further champion country, while at the same time dimensions of social media and the mental health and psychosocial ensuring that appropriate and addictive behaviours. well-being of children and young 118 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam people. Amongst other things school health workers in the field • National data collection on MOET, through both primary and of mental health and psychosocial manifestations and prevalence secondary schools, could: i) support wellbeing. of different mental ill-health and a focus on prevention by teaching psychosocial problems children the skills needed to respond Moreover, MoET also needs to to emotional and psychological strengthen the coordination • Improved monitoring and difficulties faced in relationships between families and schools evaluation reporting at all levels, with parents, teachers, friends and related to mental health care from commune through to people around them - this could and psychosocial support. This central levels vis-à-vis service be done by increasing the number could be done through regular provision for children and young of class hours devoted to life-skills communication between families people education in the official curriculum and schools to foster sharing about in both primary and secondary the psychosocial problems and • Improved data collection and schools; ii) relieve study pressure by difficulties that children face at databases on referrals and evaluating the volume of knowledge school or at home, and prompt follow-ups children are expected to learn; iii) coordination between teachers and invest in developing psychological parents in supporting children to • Support further analysis of the counselling in all schools, especially improve their psychosocial issues. strong linkages with underlying for children of ethnic minorities; On the other hand, MoET should also gendered social norms that and iv) equip parents with skills develop appropriate communication impinge on adolescents’ mental that can help ease the problems approaches to support both teachers wellbeing that children face at school and and parents to understand the at home, by teaching them better importance of having a balanced • In the future, carry out studies on communication skills and providing development of children, of which larger scales on issues related to knowledge about emotional academic achievement is just one mental health and psychosocial and psychological difficulties dimension. wellbeing of children and corresponding to the biological adolescents in Viet Nam. At the and psychological characteristics of same time, conduct research on children and young people. But also 6. Further research and better data mental health and psychosocial to support parents to understand wellbeing among particular the importance of having a balanced Given that the focus of this study groups, such as children development of children, of which was on limited number of areas, and young people in special academic achievement is just one broadening the geographical situations, or ethnic minority dimension. scope in subsequent studies to groups. cover a wider range of regions and MoET could consider developing ethnicities would be important. More and piloting a number of models specifically, we would recommend of mental ill-health prevention and that a number of steps be taken to psychosocial support in schools address the data gaps on children’s for children with mental problems. mental ill-health and psychosocial ill- Currently, a dedicated full-time being in Viet Nam. These knowledge staff or a part-time staff who is also gaps include the following: the school health worker has been available in most of the schools in • Local level service mapping Viet Nam. This serves as a convenient in order to inform local basis for the provision of checking, communities about what screening, managing, counselling services are available. Prior services to students and parents to local service mapping, it is in a timely manner in the process necessary to carry out research of supporting school children with and survey to assess the mental problems, at the same time quantity, quality, variety and enabling them to access social density of service providers, such activities suitable for their health as basic social services or social conditions. However, this also work services. requires the Government to invest in training and capacity building for Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 119

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Table 1: Dien Bien Province, 2015

(Source: Dien Bien DOH)

Cases resulting in death (from Female among total cases Total Attempted suicide total attempted suicide cases) Attempted Cases resulting in death Total 333 73 159 35 Age 0-4 1 Age 5-14 63 3 36 Age 15-19 76 13 41 11 Age 20-60 191 57 82 24 Over 60 2

Table 2: Dien Bien Dong District Suicide data by “la ngon”, January-June 20158

(Source: DOLISA Dien Bien Dong)

Cases resulting in Female among total cases Total Attempted suicide death Attempted Cases resulting in death Total 62 12 43 7 0-9 - - - - 10-14 16 - 15 - 15-19 25 7 17 5 20-24 7 3 4 2 Over 24 14 2 7 -

Table 3: Dien Bien Dong District Suicide data by “la ngon”, January-June 2016

(Source: DOLISA Dien Bien Dong)

Cases resulting in Female among total cases Total Attempted suicide death Attempted Cases resulting in death Total 53 25 39 15 0-9 3 2 3 2 10-14 10 3 9 2 15-19 12 5 9 4 20-24 11 5 8 3 Over 24 17 10 12 4

8. There was no data on suicide cases from July-December 2015. Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 125

Table 4: Keo Lom Commune suicide cases, 2007-2015

(Source: commune health station)

Suicide cases by gender Male Female Total 40 16 24 0-9 3 - 3 10-14 4 1 3 15-19 14 5 9 20-24 6 3 2 Over 24 13 7 7

Table 5: Keo Lom Commune suicide cases by year9

(Source: commune health station)

Years 2007 2008 2009 2010 2011 2012 2013 2014 2015 Cases 4 3 3 3 6 5 7 6 3

Note: There were 35 Hmong, 3 Thai and 1 Kho Mu from the total of 40 cases. 36/40 cases took poisonous “heartbreak grass” leaves.

9. There was no data on gender and age by year. 126 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam Annex 2: Background on School Psychological Consulting/ Counselling in Viet Nam

Terminology daily life and in need of assistance discussions with the psychologists to solve his problems, and any and teachers-counsellors in schools other concerned individuals, in an that provide counselling services The English term “School educational setting. However, the suggest that this model seems to be Psychological Counselling” is author herself also noticed the quite common in HCMC only. Most translated differently in the differences between “counselling” secondary and high schools in HCMC Vietnamese language, most and “consulting” in other studies. The have their own “School consulting commonly as “tham van tam ly author cited Tran Tuan Lo (2006): offices”. Meanwhile, this model hoc duong” (school psychological “consulting is a process of seeking has not gained such popularity counselling) or “tu van tam ly hoc and providing advice, between in Hanoi. In An Giang, there are 4 duong” (school psychological party A – either an individual or an schools that have psychological consulting). These two terms organisation that is seeking an answer counselling offices, but still in the bear different notions, but both for a question or a solution for a form of pilots. No presence of the denote the English term “School problem, and party B – an individual or school counselling model was Psychological Counselling” or organisation that has the appropriate observed in Dien Bien. In Hanoi, the “Psychological Counselling in Schools”. expertise and experience to help party psychological counselling model MOET’s Directive No. 9971/BGD&ĐT- A answer its question or deal with is applied by several schools, in HSSV on 28 October 2005 on its problem.” Nguyen Thi Tram Anh which counselling services are implementing student counselling (2014), argued that “counselling” did directly provided by psychology services clearly states: “Career and not stop at helping the subject find specialists; however, the majority socio-psychological consulting a way out; it also aimed towards of these schools are private or services” (“counselling” in some improving the subject’s capacity international ones.10 Recently, places), generally referred to as “tu to understand and solve his own PLAN International in Viet Nam van hoc duong” (school consulting), problems. has been funding and supporting are focused mainly on secondary and pilots of the “Safe, Friendly and Fair high school students. According to Tran Thi Minh Duc School” model in 20 secondary and (2003), counselling is an interactive high schools in Hanoi. Within this In this field study at secondary and process between a counsellor – a project, each school established a high schools where a counselling/ person with counselling expertise “School counselling office” to provide consulting office was available found and skills and professional ethics, assistance to students to deal with that the use of these terms seemed who is recognised by the law – and difficulties related to school violence, to differ between HCMC and Hanoi. a client, a person in need of help for socio-psychological and studying Schools in HCMC tend to use the psychological issues. With skills in issues (The project is ending on 30 term “School consulting office”, while effective communication, rapport November 2016). those in Hanoi (within PLAN project) building and sharing of inner prefer the term “School psychological feelings, a counsellor helps the client HCMC appears to be the only locality counselling office”. However, the understand and accept his situation, where the “School counselling office” goals and implementation methods and find strength within himself to model is being applied on a large of these offices are similar, and lean solve his own problem (as cited by scale. According to HCMC DOET’s closer towards the “psychological Nguyen Thi Tram Anh). data, (as cited by Nguyen Thi Tram counselling” meaning. Anh, 2014), school counselling Number of secondary and high services have been implemented In her research into school schools that have a counselling throughout the vast majority of the counselling services in HCMC office secondary and high schools of the schools, Nguyen (2014) developed city: 89% of public secondary schools a working definition of “school Currently, no official data on the and 86% of public high schools; 57% counselling” as follows: School total number of schools in the consulting is an interactive process country with a psychological between a consultant and a student consulting/counselling office is 10. Different numbers are obtained from who is facing difficulties in school and available. However, within this study, different sources (varying from 5-10 schools) Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 127 of non-public secondary schools and in social sciences such as Political total syllabus). In 2000, a Clinical 22% of non-public high schools. Education, Technical Education, Psychology team was set up, and a Literature, History, Geography, Counselling Psychology team was Human resources for school Economics, even Aesthetics and formed in 2008 (Cao Xuan Lieu, 2014). counselling activities Physical Education. The Study also found that these part-time Discussion on effectiveness of Currently, in charge of counselling counsellors faced difficulties in the model offices are mainly school teachers, providing counselling services to who are already burdened with their students, such as lack of counselling Building on existing studies on own responsibilities in the schools. and support knowledge and students’ socio-psychological They are mostly Civics teachers or skills (which were rated as the top problems, Nguyen Thi Tram Anh teachers in charge of the school’s difficulties), and other issues such (2014) concluded that most students Young Pioneers’ Organization or as low compensation and pay, lack were faced with psychological Youth Union, and lack professional of a private counselling office, lack difficulties and had high demands and in-depth training (they only of time due to large demand were for counselling services. However, attended short-term courses). This also reported, though rated less the nature of current counselling has been noted by many psychology significant(Nguyen Thi Thuy Dung, offices has led to a bias that specialists as a challenge and 2014). counselling offices are where limitation to the present school “problematic” people are treated, counselling services in Viet Nam (Cao A critical cause of this current which makes students reluctant Xuan Loc, 2014; Ngo Thi Thu Dung & situation of school teachers/staff to approach for fear of their peers’ Nguyen Thi Van Anh, 2014; Nguyen being assigned with the role of inquisitive eyes. Meanwhile, the rest Thi Tram Anh, 2014). counsellors in Vietnamese schools as are largely unaware of the existence proposed by Cao Xuan Loc (2014) was of counsellors and psychological For instance, in HCMC, data from the the fact that up to that point, MOET support activities in schools. The city DOET (2013) pointed out that had not promulgated a regulation to quality of the human resources for of the total 480 school counsellors allow School Psychology graduate school psychological counselling (305 from secondary schools and 175 programs to be included in the is still inadequate. At the present, from high schools); only 21% were formal education system; as a result, school counsellors are usually part- full-time, while 79% were part-time.11 most of the existing staff who work in time; they are only present at the The number of counsellors with field of school psychology lack formal counselling office when a student is appropriate qualifications (degrees and professional training required for taken there. There is a lack of detailed in Psychology, Education or Social the job. planning and programming towards Sciences) made up only a modest comprehensive development for proportion (18%) (as cited by Although no graduate program students and school relationships13. Nguyen, 2014). on School Psychology has been available, a number of universities A number of studies also stressed the A study conducted in 2013 with 16 have started teaching subjects lack of professionalism of existing schools (comprising of 10 secondary or course credits that are related school psychological counselling and 6 high schools) across the 13 to school psychology. Within the offices, and problems related to urban and rural districts of HCMC Educational Psychology faculty at qualifications as well as working revealed that the majority of the Hanoi University of Education12, conditions of the counsellors school counsellors in the study a School Psychology program (Nguyen Thi My Loc, 2014; Nguyen sample (26 in total) were part-time. has been incorporated into the Thi Thuy Dung, 2014). In addition, Most of them were already working university’s syllabuses as a major Dinh Thi Hong Van and Nguyen Cat as school teachers (54%), supervisors specialisation since 2008 (Tran Thi Tuong (2014) believed that current (19%), teachers in charge of school Le Thu, 2011, cited by Cao Xuan Lieu, counselling centres in schools still Young Pioneers’ Organisations (15%), 2014). The Psychology specialization failed to come up with proactive members of school boards (8%), under the Psychology faculty of measures and plans to effectively even school health workers (4%). the University of Social Sciences support students who were at risk of These counsellors had qualifications and Humanities has been offering mental health issues or disorders. course credits related to school psychology (making up 12.5% of the

11. The data are consistent with the researchers’ observations and information collected 13. This is fairly consistent with qualitative data from interviews with teachers in Hanoi and 12. See KII with a Lecturer from the Social Work collected from interviews with teachers and HCMC. Faculty, Hanoi University of Education. students in Hanoi and HCMC. 128 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

Students’ demands for needed areas were career orientation Dinh Thi Hong Van & Nguyen Phuoc counselling services and learning; next came relationships Cat Tuong. 2014. The Relationship Recently, psychologists have with teachers, peers, parents and between the Psychological Counseling been paying a lot of attention to other family members, and then love Needs of High School and some students’ demands for psychological and relationships with the opposite Psychosocial Factors. Papers Kit of the counselling, which originate from sex (Dinh Thi Hong Van & Nguyen IV Conference on School Psychology. adolescents’ psycho-physiological Phuoc Cat Tuong, 2014). Hanoi 14-15/8/2014. Page 337-346. characteristics; during this period, teenagers experience various A study on the state of and demand Le Quang Son & Ho Thanh Thuy. internal changes as well as influences for the Competency-Based Training 2014. The Characteristic of the Needs from society. Some authors have model in the education sector was in Psychological Couseling of High published research providing conducted in 2011-2013, sampling 466 School Students (The case of Da Nang proof of the tremendous demand teachers and school management City). Papers Kit of the IV Conference of students for psychological staff, Youth Union/Young Pioneer on School Psychology. Hanoi 14- counselling services, which have not Organization officials and student 15/8/2014. Page 453-460. been fulfilled. affairs officers from 466 educational and training institutions throughout Ngo Thi Thu Dung. 2014. Forecasts A study in Danang city of 349 high 63 provinces and cities. The study of human resource needs for school school students and 9 teachers- provided useful information on counselling in educational and counsellors in 2004 discovered that current problems with regard training institutions, period 2011- 2020. a huge proportion of the students in to students’ socio-psychological Papers Kit of the IV Conference the sample wanted to be counselled issues. Although this project did on School Psychology. Hanoi 14- on the problems they were facing not include students in their study 15/8/2014. Page 213-224. in studying, social relationships and sample, gathering opinions and personal troubles. The degree to ideas from management and Ngo Thi Thu Dung & Nguyen Thi Van which they needed advice varied by teaching staff is crucial to draw the Anh. 2014. The organization of school area as follows: studying: 71%; peer attention of policy makers and state counselling and student support relationships: 64.8%; relationships administrators in the education networks in educational institutions. with teachers: 60.2%; relationships sector towards the urgent needs Papers Kit of the IV Conference on with parents 52.7%; and inner to train and establish a qualified School Psychology. Hanoi 14- troubles about themselves: 51.3%. team of counsellors to help students 15/8/2014. Page 59-66. The study also pointed out that control and overcome socio- students were seeking counselling psychological difficulties and prevent Nguyen Thi Thuy Dung. 2014. The and advice mostly from friends; mental health risks. According to Situation of School Counseling at they found it very hard to talk the study’s statistical results, 75.75% Secondary School and High School in with teachers and parents about of the respondents believed that Hochiminh city. Papers Kit of the IV their issues. The authors believed psychological counselling services Conference on School Psychology. a discrepancy existed between were needed for students. The Hanoi 14-15/8/2014. Page 67-78. the high demand of students for study also pointed out that at the psychological counselling and the present, the support for students in Nguyen Thi Tram Anh. 2014. low performance of schools and managing their problems was very Disscusion about Program Assistance educational institutions in fulfilling limited within existing educational School Psychology in the Context of such needs, which posed threats to and training institutions (See Ngo Thi Viet Nam Education Today. Papers students’ mental wellbeing (See Le Kim Dung, 2014). Kit of the IV Conference on School Quang Son & Ho Thanh Thuy, 2014). Psychology. Hanoi 14-15/8/2014. Page 35-44. Another study in 2012 of 622 students from 3 high schools in Hue City also References Nguyen Thi My Loc. 2014. showed similar results for the high Competence Standards for School demand for psychological counselling Cao Xuan Lieu. 2014. Desining the Psychologists/Counselors in the among the sampled students. 57.8% School Psychology Training Bachelor World and some Suggestions for of the students expressed hopes to Curriculum Following Credit Training Establishing Training Program School be helped by psychology specialists Model in Viet Nam. Papers Kit of the Psychologists/Counselors in Viet in coping with their difficulties. IV Conference on School Psychology. Nam. Papers Kit of the IV Conference Areas for which the students needed Hanoi 14-15/8/2014. Page 243-255. on School Psychology. Hanoi 14- counselling were varied; the most 15/8/2014. Page 15-32. Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 129 Annex 3: Findings of Statistical Analysis of SDQ and Self-Efficacy Scale Scores

(From a survey in 4 provinces and 2013; Vu Cong Nguyen et al.14 etc.) 10 reflect strengths, 14 reflect cities in Viet Nam) and widely applied in child mental weaknesses, and one item may health research in Viet Nam, such be considered neutral. Each item as in the 2005 study by Mai Huong can be answered as: 0 – Not True; Introduction of the SDQ Psychiatric Hospital, a 2010 study 1 – Somewhat True; and 2 – Certainly by Hoang Cam Tu and Dang Hoang True. The Questionnaire is divided To identify mental health problems Minh of children in 02 high schools into 5 scales of 5 items each: 1) among the target groups, the in Hanoi and former Hatay province, Emotional problems; 2) Conduct research team used the Strengths a study by Amstadter, Richarsdson et problems; 3) Hyperactivity/ and Difficulties Questionnaire (SDQ). al. (2011) of children in 02 provinces Inattention; 4) Peer problems; and This is a screening tool for common in Central Viet Nam, and the 2013 5) Prosocial Behaviour. The Prosocial mental disorders among children study by Dang Hoang Minh et al. scale (the 5th scale) gives a positive and adolescents (3 – 16 years score, while the other four scales old) (Goodman, Ford, Simmons & The SDQ version used by the (emotional problems, conduct Gatward, 2000 – as cited by Dang research team for the school children problems, hyperactivity/inattention Hoang Minh et al., 2013). The SDQ samples in this Project was translated and peer problems) give negative is a brief behavioural screening into Vietnamese by the team itself, scores, which are summed to questionnaire appropriate for and later with reference to other generate a Total Difficulties Score. young children and adolescents and translated versions by the Young children. It is a commonly used tool Lives Project, CSAGA and Dang The SDQ has some of the limitations for the detection of mental issues Hoang Minh et al., 2013; Vu Cong such as: Issues around accuracy, in the community. The Strengths Nguyen et al.. The team’s version is specificity, sensitivity and its use as a and Difficulties Questionnaire is similar to the previous translations specific diagnostic tool. Also, cultural designed to be used as a screening in terms of content; however, resilience may play a role in the tool in clinical assessment, to assess the specific wording has been resulting scores and it is not suitable interventions outcomes, and as slightly adjusted to better suit the persons aged 18 years or older. a research tool. SDQ is one of the Vietnamese context. reliable and effective evidence-based Based on the instructions on tools, used to collect information Compared to other mental health Interpreting Symptom Scores from multiple sources such as research tools, SDQ has the and Defining “Caseness” from children, parents and teachers. advantage of being concise – it Symptom Score15, the cut-off point There are three versions of the asks only 25 questions (focusing of the SDQ Total Difficulties Score SDQ for different informants; one on assessment of behavioural and (ranging from 0 to 40) in this Study self-report version for children, emotional problems), as opposed is set at 15, with scores of 0-15 being one parent-report version and one to other tools such as the Child considered “Normal”; scores of 16-19 teacher-report version. In this Study, Behaviour Checklist (CBCL) which being “Borderline”; and 20-40 being only the self-report version of the asks 118 questions, or the Youth Self- “Abnormal”. Questionnaire for children was used. Report (YSR). However, SDQ also has The tool has been proved to have its disadvantages – it cannot assess Similar cut-off points have been good psychometric attributes and serious mental disorders (such as used in several studies. For has been used to screen mental obsession, paranoia etc.), and it does example, Shojaei., et al., (2009) health problems among children not distinguish between physical used the strengths and difficulties in many countries in Europe as well disorders and emotional symptoms questionnaire to research the as in Asia, such as Bangladesh, Iran, etc. (Dang Hoang Minh et al., 2013). validation study in French school- Malaysia etc. (Dang Hoang Minh aged children and cross-cultural et al., 2013). The SDQ has been The SDQ version for children ages comparisons. The authors examine translated into Vietnamese (Tran 12-16 includes 25 items, of which the psychometric properties of the Tuan, 2016; Dang Hoang Minh et al.,

14. http://www.sdqinfo.com/py/sdqinfo/ 15. http://www.copmi.net.au/images/pdf/ b3.py?language=Vietnamese Research/sdq-english-uk-self-scoring.pdf 130 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

French version of the strengths and comparison. Perceived self-efficacy scales: 1-True, and 0-False, and then difficulties questionnaire (SDQ), is regarded as a positive resistance work out the mean score on a scale compare estimates of child mental resource factor. It is an operative of 0 to10, to measure the perceived health problems and SDQ scores construct; it is related to subsequent confidence of the children from 0 across France, US and UK. The French behavior therefore, is relevant for (being least confident) to 10 (being cut-off points for the scoring bands clinical practice and behaviour most confident) (Lynne Omes and were similar to those of the UK and change. Self-efficacy refers to an Lynda B. Ransdell, 2010)17. A higher US, with a few exceptions (peer individual's believes about his/her score indicates higher self-efficacy. relationship problems, prosocial agency or capacity to successful Higher scores mean the child behaviour)16. perform various tasks; reflects exhibits a higher self-efficacy; the person’s resilience and coping. highest level means the child is In Viet Nam, a number of studies Substantial research has suggested confident that he or she will perform used the symptom score method that self-efficacy is a proxy outcome tasks in different situations. for the children’s self-report version; indicator as alterations in self- however, the cut-off points are efficacy beliefs are closely associated Analysis methodology different depending on the targeted with changes in actual behaviour/ population. For example, Dang competence (Neil, 2011) as a result To identify symptoms of mental Hoang Minh et al. (2013) conducted of life experiences or programmatic health and self-efficacy of the the study on both parents and interventions. The scales that will be children as well as a number children samples; the cut-off points used for measuring resilience and of related elements, the Study for the “Abnormal” band was the self-efficacy as indicators of coping. uses the methods of descriptive same for both parents and children statistics (frequency distribution), (from 17 to 40) (Dang Hoang Minh et The best we could find was calculation of mean and total scores al., 2013). references to the name of the of scales, correlation analysis of Scale in a few sources of material, children’s mental health problems Meanwhile, a study by Yasong which is also translated differently and self-efficacy by demographic Du, Jianhua Kou, David Coghill by different authors. During the characteristic such as sex, age, (2008) on “The validity, reliability finalization of the Vietnamese education level, and residence area. and normative scores of the parent, translation of the Scale, the The Cronbach’s Alpha coefficient teacher and self report versions research team consulted a number is also used to test the reliability of the Strengths and Difficulties of experts in order to achieve the and intercorrelation between Questionnaire in China” set different optimal quality and accuracy of the observed variables in the scales, cut-off points for the “Abnormal” translation according to the original the consistency of the responses, to band for parents (17-40) as opposed English version. make sure that all the participants to the other two groups, teachers had the same understanding of the and children (18-40). To measure and identify the self- constructs of the SDQ. Correlation efficacy levels of children, this analyses of the mean total SDQ Self- Efficacy Scale Study uses the Self-Efficacy Scale. and SE scores by characteristics This Scale is also called Generalized of children were done using the Unlike with the SDQ, during the Self-Efficacy Scale (GSE) in a number method of one-way analysis of finalization of the research tools of English sources of material. variance (one-way ANOVA), a before commencing field study, the GSE is used to assess self-efficacy technique used to test the null research team did not have access in goal-setting, effort investment hypothesis that the sample groups to any Vietnamese version of the and persistence (Schwarzer and are drawn from populations with the Self-Efficacy Scale for reference and Jerusalem, 1995). The questions of same mean values, with a probability the Scale allow for classification of error of 5% (which means 95% and assessment of an individual’s reliability). Specifically: 16. The French version of the parent-reported adaptation, optimism and ability to SDQ was administered to the parents of a representative sample of 1,348 French deal with daily hassles or cope with •• Rates of children having children aged 6-11 years old.The response adversity or difficult situations in emotional and behavioural rate was 57.6%. The author’s performed life. This Scale consists of 10 items, three scoring methods and examined their association with socio-demographic for each of which there is a four data. French SDQ scores were compared choice response: 1-Not at all true; 17. Lynne Omes và Lynda B.Ransdell (2010) with SDQ scores from US and UK national A pilot study examining exercise self- surveys. The French cut-off points for the 2-Hardly true; 3-Moderately true; efficacy as a mediator for walking behavior scoring bands were similar to those of the and 4-Exactly true. We then divided in college-age women in Perceptual and UK and US, with a few exceptions (peer the responses to each item into two Motor Skills 110(3 Pt 2):1098-104 · June relationship problems, prosocial behaviour). 2010 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 131

problems, and strengths of the Sơ đồ 1: Phân loại điểm số SDQ cho trẻ từ 4-17 tuổi children (SDQ) (see diagram/table 1 as below) Tự hoàn thành Bình Mức ranh Bất thường thường giới •• Total Difficulties Scores (SDQ) Tổng điểm khó khăn 0-15 16-19 20-40

•• Correlation analysis between Điểm các vấn đề cảm xúc 0-5 6 7-10 the rates of children having Điểm các vấn đề hành vi 0-3 4 5-10 mental health problems and Total Điểm tăng động 0-5 6 7-10 Difficulties Scores by children’s demographic characteristics Điểm các vấn đề bạn bè 0-3 4-5 6-10 (SDQ) Điểm các vấn đề xã hội tích cực 6-10 5 0-4

•• Rates of children’s self-efficacy (SE Scale) A limitation of this Study is that of reliability, and form the basis for the data collection was carried out next analyses and verification. •• Mean scores and percentage among groups of children from 12 mean for self-efficacy items (SE to 17 years of age, but not among The Cronbach’s Alpha (CA) of the Scale) parents and teachers. Moreover, Total Difficulties Scores is 0.62, the individual and demographic which indicates an adequate level •• Rate of perceived self-efficacy of characteristics of the children of reliability of the Scales, and children (SE Scale). considered in the Study did not a correlation coefficient value include family living standards, greater than 0.4 (≥0.6) implies that •• Correlation analysis between parents’ occupations and level of comparative analysis is applicable18. the total score of self-efficacy education. This somehow limits by children’s demographic the ability to compare the study Notes on terminology characteristics (SE Scale) results against other studies which employed the SDQ method among “Having mental health problems” samples of parents and teachers as is a term widely used in medical well as children. At the same time, research. This term is used in this due to the lack of information on Study because it implies a wide family and parents’ characteristics, range of problems, from minor to this Study does not identify related serious, in absence of a thorough risk factors/factors influential diagnosis. The term “Having mental to children’s mental health and health problems” in this Study self-efficacy. implies the group of children having behavioural and emotional Before officially commencing the problems with SDQ scores within the field study, the research team Abnormal band, which ranges from had tested the validity of each 20 to 40. individual item and the whole questionnaire (which had been Self-efficacy translated into Vietnamese), to see whether each sample/child had the Depending on the approach, same understanding despite their the term “Self-efficacy” can be different responses by conducting translated into Vietnamese in a test survey to assess the reliability different ways, such as: “ si tu and validity of the questionnaire. Preliminary evaluation of reliability and validity of the questionnaire 18. Nunnally & Burnstein (1994) believe higher was done using the Cronbach alpha alpha values indicate higher levels of internal consistency; however, in general, coefficient through the use of the the standard for selection of a scale is an SPSS 12.0 data processing software, alpha value of higher than 0.6 (as cited by Nguyen Dinh Tho & Nguyen Thi Mai Trang, to remove observable variables 2009). As such, although the Cronchbach’s which do not qualify in terms of level alpha value of this study sample is relatively low (0.62), the questionnaire’s reliability is at an acceptable level. 132 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

chu” (similar to self-control), “su are determined to pursue and tu tin” (self-confidence), “su tu accomplish goals. When faced with quyet” (self-determination), “cái challenges, these children know tôi hieu qua” (the Self’s efficiency). how to be focused and succeed in Self-efficacy is one’s perception of performing tasks and reaching goals, and belief in their ability to create and make efforts and persist in the changes, and expectation to gain face of barriers. outcomes through their actions. A person with high self-efficacy Data collection and processing is one with high self-confidence, accurate self-assessment ability, Within the framework of the Study willingness to take risks and a on Mental Wellbeing of Children sense of accomplishment. Bandura and Youth in Viet Nam, in addition (1977) discovered the importance of to in-depth interviews and focus perceived self-efficacy, or in other group discussions with school words, personal capacity, in guiding children from 4 Secondary schools human behaviours. and 4 High schools in the 4 study sites, the research team also carried In this Study, a child’s “self-efficacy” out surveys using SDQ and SE implies “a child’s ability of self-control questionnaires with more than and belief in his/her own ability to 400 school children. The data were make decisions in every situation.” entered using the Epidata software Bandura (1986) has defined self- and double entry method, and then efficacy as one's belief in one's the data files were cross-checked ability to accomplish a task, or to identify any errors. After that, confidence in one’s own ability. To the data were transferred to the study children’s self-efficacy is to SPSS software to be processed and examine their perceived ability to analyzed. make decisions as to how to deal with school-related and daily life tasks, relationships with peers, and social relationships in general. Survey samples and characteristics Children with high self-efficacy are of study samples often not put off by adversities; they don’t avoid difficult tasks and

Figure 1: The mean age of children as the whole/full sample

Southern Viet Nam (n=196) 48.8

Region Northern Viet Nam (n=206) 51.2 Ho Chi Minh (n=78) 19.4 An Giang (n=118) 29.4 Dien Bien (n=104) 25.9

CityProvinces Ha Noi (n=102) 25.4 Rural (n=229) 57

Areas Urban (n=173) 43 Upper Sec. School (n=216) 53.7

Grade Lower Sec. School (n=186) 46.3 Girls (n=242) 60.2 Boys (n=160) 39.8 Gender 16+ (n=216) 53.7

Age <=15 (n=186) 46.2 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 133

Based on the Study objectives, appropriately. The data analysis have symptoms of headaches, the selected target groups include shows that a sizeable proportion stomach-aches or sickness; 25.6% secondary and high school aged of the school-aged children in the did not think they worried a lot; children, who met the required survey sample were facing emotional 42% disagreed with the statement criteria of sex, age and education difficulties/problems (Table 1). The “I often feel unhappy, down-hearted level, and were representative for percentage of children selecting or tearful.” 21% did not feel that they different residence areas. the “Certainly True” response to the were nervous in new situations or relevant items ranges from 11.9% easily lost confidence, and 41.8% said The total survey sample size to 35.3%. Specifically, 13.7%, of the it was not true that they were easily was 402 children (N = number children responded “Certainly True” scared or had many fears. of respondents). The following to the Item “I get a lot of headaches, provinces/cities were selected by stomach-aches or sickness”; 22.6% As such, a relatively high proportion the research team to be the study responded similarly to the Item of the children sample have sites: Hanoi City, Dien Bien province, “I worry a lot”, 11.9% to the Item “I somewhat abnormal emotional Hochiminh City, and An Giang am often unhappy, down-hearted or symptoms, one of the early signs province. In each site, the team tearful”, and as many as one third of affective disorders whose selected and interviewed children (35.3%) of all the children felt they main causes include physical and at two education levels – Secondary were nervous in new situations biological problems. Without timely and High school, from 12 to 17 years or lost confidence easily. 15.4% and adequate attention from of age. The total sample size was reported “I have many fears, I’m parents, family and school, these 402 children with a mean age of easily scared”. These symptoms of children are at risk of developing 15.07 (standard deviation 2.14), the nervousness, sadness, fear and worry affective disorders. youngest being 12 and the oldest would seriously affect their learning being 17. Girls make up 60.2% and ability and social development. Children with behavioural problems, boys 39.8%. In this Study, 46.3% and more seriously, conduct of the children were in Secondary Alongside these children, another disorders, often show symptoms school, and the rest 53.7% were in considerable number of children such as not caring about other high school. By residence area, the were also somewhat having people, having angry, violent or percentages of children living in emotional problems. Approximately aggressive behaviours towards peers, rural areas and urban areas were half of the children in the survey not conforming to social norms 43% and 57% respectively; 51.2% sample admitted it was “Somewhat such as playing truant from school, were from Northern Viet Nam and True” that they were facing emotional refusing to do homework etc., or 48.8% from Southern Viet Nam. By problems (with percentages having extreme behaviours such as study site, 25.4% of the children were ranging from 42% to 51.7%). 51.5% opposing to or breaking rules, lying from Hanoi, 25.9% from Dien Bien, of the participants responded or stealing/taking other people’s 29.4% from An Giang and 19.4% from “Somewhat True” to the Item related things etc. In this Study, the rate of Hochiminh City (Figure 1) to negative physical symptoms such children having conduct problems as headaches, stomach-aches or is quite high; the most common Data analysis findings sickness; 51.7% reported that they symptoms include getting angry worried a lot, and 46% often felt and losing their temper easily, lack Emotional Problems unhappy, down-hearted or tearful. of self-control, or not doing as one is 43.5% answered “Somewhat True” told. More than a fifth (21.4%) of the Among children, symptoms of to the Item “I am nervous in new children answered “Certainly True” to emotional problems usually include situations. I easily lose confidence” and the Item “I get very angry and often excessive fear, sadness, nervousness 42.8% to the Item “I have many fears, I lose my temper”, and nearly a third or upset. Anxiety disorders are m easily scared.” (28.4%) to the Item “I usually do as I also the most common problems am told.” Similarly, the numbers of among school-aged children, The percentage of children having participants selecting the “Somewhat especially secondary and high school “Normal” emotional symptoms True” response to these two items students, as they are in the period of was relatively low. The number were relatively high, 47.3% and 63.4% adolescence, when they are going of participants choosing the “Not in that order. What is noteworthy is through a lot of psycho-physiological True” response to the Items of the that only 8.2% of the 402 children in changes and development of social Emotional Problem Scale makes up the sample affirmed that they were skills. In this stage, children are at risk from only 1/5 to 1/2 (21% to 42%) of not incited by other people into in relation to difficulties in balancing the total sample size. Specifically, doing things. their emotions and behaving 34.8% affirmed that they did not 134 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

The majority of the children in the Item ‘I am constantly fidgeting or other peers, and withdrawal from sample did not think they had such squirming.’ Finally, 20.6% responded social relationships, these can be behaviours as fighting, bullying ‘Certainly True’ and as many as 60.2% early signs of depression. (making other people do what one responded ‘Somewhat True’ to the wants), or were accused of lying or Item ‘I am easily distracted, find it The Study findings suggest that a cheating, or taking things that were difficult on concentrate.’ significant portion of the children not theirs. 86.8% of the children were rather solitary, they only had responded ‘Not True’ to the Item ‘I At the same time, the number of one or a few good friends; they were fight a lot. I can make other people do children having good attention, not liked by other children their age, what I want’, 73.6% to the Item ‘I am judgement and ability to analyse preferred hanging out with adults, often accused of lying or cheating’, and complete tasks effectively is and some of them were even victims and as many as 90.5% to the Item remarkably low. The percentages of bullying by their peers. Data in ‘I take things that are not mine from of participants deciding on the Table 1 point out that almost half of home, school or elsewhere’. ‘Certainly True’ response to the Items the respondents liked or tend to play ‘I think before I do things’ and ‘I finish alone and avoid making friends and Although the number of children the work I'm doing. My attention communicating with other people. having symptoms of conduct is good’ were only 3.2% and 8.2% 9.2% of the children answered disorders such as fighting, bullying respectively. (making other people do what ‘Certainly True’ and 38.8% answered one wants), being accused of lying The number of children having ‘Somewhat True’ to the Item ‘I am or taking other people’s things negative symptoms such as not usually on my own. I generally play only made up a small proportion thinking before doing things, lack alone or keep to myself.’ 7.2% chose (ranging from 0.7% to 2.5%), if we of attention and low work efficiency the ‘Certainly True’ response and 22.1% take into consideration the shares was fairly large. More than half chose “Somewhat True” to the Item ‘I of participants who reported (57.7%) of the respondents chose have one good friend or more.’ “Somewhat True” to items related the “Not True” response to the Item to dishonesty and cheating such as ‘I think before I do things’, and that The number of children who felt ‘lying or cheating’ (23.9%) and “take figure for Item ‘I finish the work I'm that they were respected and liked things that are not mine” (8.7%), doing. My attention is good’ was by peers was rather small. Only 9.5% these are signs of conduct problems/ 21.6%. and 65.2% of the children responded disorders that need to be concerned ‘Certainly True’ and ‘Somewhat True’ by the family and school. Besides, a significant portion of to the statement ‘Other people my the sample chose to respond age generally like me’, while over 1/4 Hyperactivity/Inattention ‘Somewhat True’ to these Items: 39.1% (25,4%) of the sample thought it was to ‘I think before do things’, and two ‘Not True’. Hyperactivity/Inattention is one of thirds (70.1%) to ‘I finish the work I'm the common development disorders doing. My attention is good.’ This is Most of the participants liked or tend among children. Children having something to keep in mind, because to like to hang out with adults more hyperactivity problems often have these symptoms among children than peers. 21.6% and 44.3% of the overactive behaviours accompanied shall, to some extent, affect their children selected the ‘Certainly True’ by reduced attention; therefore, this learning ability and performance in and ‘Somewhat True’ responses to problem often seriously affects their school, especially in Viet Nam where the Item ‘I get on better with adults learning ability as well as causes they are often ignored by parents than with people my own age.’ That difficulties to their relationships with and schools and rarely addressed means only about a third (34.1%) out other people. with appropriate education of the total number of children in the methods. sample had good relationships with The data from Table 1 show that peers. about 2/3 of the children in the Peer problems sample had problems or symptoms Nearly half of the children were of Hyperactivity/Inattention. Friends are important to children, victims or at risk of being victims of Specifically, 17.9% selected the but a child’s circle of friends can have bullying by peers. 6.2% of the survey ‘Certainly True’ response and 46.5% positive and negative influences participants answered ‘Certainly True’ chose ‘Somewhat True’ to the Item on his or her behaviours. In their and 38.6% answered ‘Somewhat True’ ‘I am restless, cannot stay still for peer relationships, if a child shows to the Item ‘Other children or young long.’ 18.4% answered ‘Certainly True’ symptoms of loneliness, lack of people pick on me or bully me.’ and 32.6% “Somewhat True” to the willingness to make friends with Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 135

Table 1: The frequency distribution of the SDQ1912

Item Problems Not Somewhat Certainly N True True True

Emotional Problem SD3 I get a lot of headaches, stomach-aches or sickness 34,8 51,5 13,7 402 SD8 I worry a lot 25,6 51,7 22,6 402 SD13 I am often unhappy, down-hearted or tearful 42,0 46,0 11,9 402 SD16 I am nervous in new situations. I easily lose confidence 21,0 43,5 35,3 402 SD24 I have many fears, I’m easily scared 41,8 42,8 15,4 402 Conduct Problems SD5 I get very angry and often lose my temper 31,3 47,3 21,4 402 SD7* I usually do as I am told 8.2 63,4 28,4 402 SD12 I fight a lot. I can make other people do what I want 86,8 11,7 1,5 402 SD18 I am often accused of lying or cheating 73,6 23,9 2,5 402 SD22 I take things that are not mine from home, school or 90,5 8,7 0,7 402 elsewhere Hyperactivity SD2 I am restless, cannot stay still for long 35,6 46,5 17,9 402 SD10 I am constantly fidgeting or squirming 49,0 32,6 18,4 402 SD15 I am easily distracted, find it difficult on concentrate 19,2 60,2 20,6 402 SD21 I think before I do things 57,7 39,1 3,2 402 SD25 I finish the work I'm doing. My attention is good 21,6 70,1 8,2 402 Peer problem SD6 I am usually on my own. I generally play alone or keep 52,0 38,8 9,2 402 to myself SD11 I have one good friend or more 70,6 22,1 7,2 402 SD14 Other people my age generally like me 25,4 65,2 9,5 402 SD19 Other children or young people pick on me or bully me 55,2 38,6 6,2 402 SD23 I get on better with adults than with people my own age 34,1 44,3 21,6 402 Prosocial behaviours (Illustrated in Figure 2) SD1 I try to be nice to other people. I care about their 1,2 63,9 34,8 402 feelings SD4 I usually share with others (food, games, pens etc.) 4,2 59,2 36,6 402 SD9 I am helpful if someone is hurt, upset or feeling ill 1,7 48,0 50,2 402 SD17 I am kind to younger children 4,0 35,6 60,4 402 SD20 I often volunteer to help others (parents, teachers, 6,7 60,9 32,3 402 children)

19. SD7, SD21, SD25, SD11, SD14 have been reversed scored: Not True 0= 2; Somewhat True=1; Certainly True 2= 136 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

Prosocial behaviours The rates of children having mental al. (2013)20, which were 9.56 among health problems based on the SDQ adolescents ages 12-16 for the Most of the children in the survey scores self-report SDQ version (SD = 4.84, sample demonstrated prosocial N = 591), and 8.41 among children behaviours. The vast majority of the The children’s emotional, conduct ages 6-16 for the parent-report SDQ sample chose to respond ‘Certainly problems and difficulties version (SD = 4.73, N = 1320). True’ and ‘Somewhat True’ to all the Items of this Scale. The percentage of Figure 3 illustrates the distribution Table 2 presents the mean Total children answering ‘Not True’ to these of the total difficulties scores as Difficulties Score and separate Scores Items is very low, ranging from 1.2% calculated from the children’s self- for the individual Scales of Emotional to 6.7% only. It can be seen from report SDQ survey. The results show Problems, Conduct Problems, Figure 2 that 34.8% and 63.9% of the that the mean Total Difficulties Score Hyperactivity, Peer Problems and children responded ‘Certainly True’ of the children in the sample is 13.99, Prosocial Behaviours. Based on the and ‘Somewhat True’ respectively with a standard deviation of 4.76 (N instructions on ‘Interpreting Symptom to the Item ‘I try to be nice to other = 402), and a kurtosis of -0.058. The Scores and Defining “Caseness” from people. I care about their feelings.’ highest score is 29 and the lowest is Symptom Scores’, the Study results Similarly, 36.6% and 59.2% thought 4. it was “Certainly True” and ‘Somewhat True’ that they ‘usually share with This figure is higher than the mean 20. The Study by Dang Hoang Minh was an others (food, games, pens etc.).’ 50.2% Total Difficulties Scores produced by epidemiologic study on mental health of children in Viet Nam over a sample 591 and 48% chose the ‘Certainly True’ the Study of Dang Hoang Minh et children ages 12-16 and 1314 parents of and ‘Somewhat True’ responses to the children ages 6-16. It was carried out in 60 selected sites of 10 provinces representing Item ‘I am helpful if someone is hurt, the different regions of Viet Nam, including upset or feeling ill.’ 60.4% answered Hanoi, Hoa Binh, Thai Nguyen, Hai Phong, “Certainly True” and 35.6% answered Ha Tinh, Danang, Binh Thuan, Hau Giang and Hochiminh City. The Study used the ‘Somewhat True’ to the Item ‘I am Children Behaviour Checklist (CBCL) for kind to younger children.’ Finally, to parent-report, Strengths and Difficulties Questionnaire (SDQ) for parent-report and the last Item of the Scale, ‘I often child self-report, the Brief Impairment Scale volunteer to help others (parents, (BIS) (a tool to assess a child’s functional teachers, children)’, 32.3% and 60.9% impairment) for parent-report, and the Youth Self Report (YSR) – a tool to assess of the children thought it was children’s behaviours and emotions. It ‘Certainly True’ and ‘Somewhat True’, should be noted that the comparison of our respectively. Study’s results with those of Dang Hoang Minh is for the mere purpose of reference, because these two studies have different scales and representativeness.

Figure 2: The frequency distribution of prosocial behaviour items (%)

I often volunteer to help 32.3 60.9 6.7 others (parents. teachers children)

I am kind to younger 60.1 35.6 4.0 children

I am helpful if someone is hurt. upset or feeling ill 50.2 48.0 1.7

I usually share with others 36.6 59.2 4.2 (food. games. pens etc)

I try to be nice to others people. 34.8 63.9 1.2 I care about their feelings

Certainly true Some wthat true Not true Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 137

Figure 3: Distribution of the total difficulty score of the SDQ adolescents21 suggested that 99.1% of the children were considered ‘having problems’ according to their SDQ Total Difficulties Scores.

Compared to the results by Dang Mean = 13.9925 Hoang Minh et al (2013), the rate Std. Dey. = 4.76766 of children considered ‘abnormal/ N= 402 having problems’ in this Study is higher by 2.67 percentage points

Freuency (13.4% versus 10.73%) for the self- report SDQ version, but is almost equal to the parent-report figure (13.4% versus 13.2%). At the same time, it is higher than the rate of children ‘having problems’ produced by Amstadter et al. (2011) (9.1%). As such, with the figure ranging from 0.00 5.00 10.00 15.00 20.00 25.00 30.00 9.1% to 13.4%, it shows that less than Total sroceSD one tenth of the children in Viet Nam were ‘having problems’ according to their SDQ scores, and this result show that 66.9% of the children in al. (2013)found that, with a cut-off is in line with those of other Asian the sample scored in the “Normal” point of 15 being used to define likely countries, whose rates of children band, 19.7% scored in the ‘Borderline’ ‘cases’ with mental health problems, having mental health problems vary band, and the rest 13.4% scored in the rate of adolescents having from 10 to 20% (Sirath, Kandasamy, the ‘Abnormal’ band. problems stood at 10.73% (including Golthar (2010) as cited by Dang 3.89% in the ‘Abnormal’ band) for Hoang Minh et al., 2013). A number of other studies on the self-report version, and that mental health problems among figure as reported by parents was adolescents (ages 12-16) in Viet Nam 13.2%. Another study by Amstadter have also been conducted using the et al. (2011) among 1368 Vietnamese self-report and parent-report SDQs. 21. SD7, SD21, SD25, SD11, SD14 have been For example, Dang Hoang Minh et reversed scored: Not True 0= 2; Somewhat True=1; Certainly True 2=0.

Table 2: Mean scores, standard deviations of SDQ and Caseness (Symptoms score)

Mean, Standard Deviations Caseness (Symptoms score) Scale Mean Std. Dev Normal Borderline Abnormal Total difficulties (0-40) 13,99 4,76 66,9 19,7 13,4 (0-15) (16-19) (20-40) Emotional Problems (0-10) 4,34 2,32 68,7 11,7 19,7 (0-5) (6) (7-10) Conduct Problems (0-10) 2,63 1,29 77,4 15,2 7,5 (0-3) (4) (5-10) Hyperactivity (0-10) 3,85 1,92 81,6 10,0 8,5 (0-5) (6) (7-10) Peer problems (0-10) 3.16 1.58 62,4 30,6 7,0 (0-3) (4-5) (6-10) Prosocial behaviours (10-0) 6.96 1.66 80,6 14,9 4,5 (6-10) (5) (0-4) 138 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

This Study also recognizes that the Hoang Minh et al. (2013) (self-report On the contrary, the number of most common symptoms among 2.85% and parent-report 2.69%). children scoring in the ‘Abnormal’ the children are of Emotional The WHO Study in both developed band in the Peer problems Scale only problems. According to the SDQ and developing countries showed made up 7%, considerably lower Scores, the percentage of children that there is correlation between than the parent-report rate in the having ‘Abnormal’ emotional substance abuse and impulse- study by Dang Hoang Minh et al. problems stood at as high as 19.7%, control disorders and dropping (2013) (22.18%), but higher than the and this Scale’s mean score (4.34; out of school. In the case of Brazil, children self-report rate (3.18%). SD = 2.32) is also the highest among children with ADHD have high all Scales. The rate of children rates of failing exams, being Nevertheless, what is the most scoring ‘Abnormal’ in the Emotional suspended or expelled from school. noteworthy about this survey sample problems Scale is more than twice as A substantial number of children is that the percentage of children high as those in other Scales, which who dropped out from the first year having Borderline scores in the Peer suggests that emotional problems of primary school also suffered from problems Scale was 2-3 times as are what children struggle with the behavioural disorders and delayed high as that in other Scales (30.6% as most during adolescence, which is mental development (Kieling & cs, compared to 10-15% in other Scales). by nature the most difficult stage of 2013, as cited by Dang Hoang Minh et This indicates that a sizeable portion life for children to adapt themselves. al., 2013). of the children were on the threshold of suffering difficulties in developing This result is fairly similar to that of Regarding the Conduct problems social relationships. the study by Nguyen Anh Hong et al. Scale, the percentage of children on behavioural and social problems having ‘Abnormal’ scores is 7.5%, In terms of Prosocial behaviours, among Secondary school children higher than those in the Study by the majority of the children in the in Hochiminh City, which found that Dang Hoang Minh et al., 2013, which survey sample had positive social 16% of the children were having were 2.68% (children self-report) relationships (80.6% scoring in the emotional problems (as cited by and 3.36% (parent-report). However, ‘Normal’ band), while only 14.9% Lam & Weiss, 2007 – as cited by Dang this figure is significantly lower than and 4.5% were in the ‘Borderline’ Hoang Minh et al., 2013). the 24% rate of school children with and ‘Abnormal’ bands, respectively. behavioural problems in HCMC as The mean score for this Scale is 6.96 The rate of children having provided by Nguyen Anh Hong et al. (SD=1.66). Compared to study results Hyperactivity Scores within the (as cited by Lam & Weiss, 2007 – as by Dang Hoang Minh et al. (2013), the ‘Abnormal’ band was 8.5%, which cited by Dang Hoang Minh et al., rate of children having ‘Abnormal’ should be a matter of concern 2013). scores for the Prosocial Scale in this as it is remarkably greater than Study is higher (4.5% versus 2.18% the numbers produced by Dang (children self-report) and 2.69%

Figure 4: The frequency distribution of the SDQ total difficulties score and prosocial behaviour score (%)

20 15

0 0 1 2 3 4 5 6 7 8 9 10 SroceSD

Di culties score: Emotional Problem Di culties score: Conduct Problems Di culties score: Hyperactivity Di culties score: Peer problem Possitive scale: Prosocial problem Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 139

(parent-report)), and the mean score separate Scale Scores broken down Subscale Scores revealed noticeable is just slightly lower (6.96 versus 7.94 by the children’s demographic and differences between children from (SD=1.77) (children self-report) and social characteristics. The results different residence areas (Table 5). 8,43 (SD=1,76) (parent-report)). show that children of the older age The children in An Giang have a group and higher education level higher mean Total Difficulties Score Figure 4 represents the distribution face more problems than children than those in the other 3 areas of of the Difficulties Scores of each of the younger age group and lower Dien Bien, Hanoi and HCMC (14.67 problem Scale and the Prosocial education level. Girls appeared to versus 13.23 to 13.99). The children’s Scale Scores. As can be observed have more difficulties than boys. mean Total Difficulties Score is higher from the Prosocial Scale line (positive The mean Total Difficulties Score of in rural areas than urban areas, and scale), the majority of the children children age 16 or older is 0.8 point the South than the North. had scores of 5 to 9, whereas in the higher than that of those under 15 opposite direction, the Difficulties years old (14.36 vs. 13.56), and that of With regard to emotional problems, Scores lines (negative scales) show high school students is higher than the children in Dien Bien and An that the majority of the children that of secondary students (14.36 vs. Giang provinces scored higher in this stood at lower scores. For example, 13.56). The mean Total Difficulties Scale than those in the two biggest most of the children scored 2 to 5 Score of girls is higher than that of cities of Viet Nam – Hanoi and for the Emotional Problems and boys (14.15 vs. 13.75). Analysis using HCMC (4.75 and 4.66 versus 3.92 and Hyperactivity Scales, and scored the one-way ANOVA method shows 3.82). Similarly, the children in rural 2-4 for Conduct Problems and Peer no statistically significant differences areas also have a higher Emotional Problems Scales. between the mean total Difficulty Problems Scale score than those in scores between children of different urban areas (4.76 versus 4.15). The rates of children having demographic characteristics (Table emotional and conduct problems 3 & 4). The girls appeared to face more by demographic and social emotional problems than the characteristic The children’s conduct and boys, with scores for the Emotional emotional problems differed by Problems Scale of 4.77 and 3.67 Table 3, Table 4 and Figure 5 display residence area. Analysis of the Total respectively. In contrast, the boys the Total Difficulties Scores and the Difficulties Scores and the separate faced more peer problems than

Table 3: Mean scores (standard deviations) by characteristics of children

All children Age Sex/Gender Educational Level Scale (N=402) <=15 16+ Boys Girls (n=242) LSS USS (n=186) (n=216) (n=160) (n=186) (n=216) Total difficulty score 13,99 13,56 14,36 13,75 14,15 13,56 14,36 (4,76) (4,68) (4,81) (4,53) (4,91) (4,68) (4,81) Emotional Problem 4,22 4,22 4,44 3,67 4,77 4,22 4,43 (2,32) (2,26) (2,37) (2,15) (2,33) (2,26) (2,37) Conduct problems 2,63 2,62 2,64 2,65 2,62 2,62 2,64 (1,29 (1,38) (1,22) (1,42) (1,20) (1,38) (1,22) Hyperactivity 3,85 3,49 4,16 3,99 3,76 3,49 4,16 (1,92) (1,82) (1,95) (2,01) (1,86) (1,82) (1,95) Peer problems 3,16 3,22 3,11 3,42 2,99 3,22 3,11 (1,58) (1,56) (1,60) (1,56) (1,58) (1,56) (1,60) Prosocial * (P=0.024) * (P=0.011) * (P=0.024) 6,96 7,16 6,79 6,70 7,13 7,16 6,79 (1,66) (1,64) (1,67) (1,83) (1,52) (1,64) (1,67) 140 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam the girls, scoring 3.42 for the Peer among children in rural areas than boys, among rural areas than Problems Scale, as opposed to 3.11 than urban areas (7.15 versus 6.71), urban areas, and in the North than among the girls. The children in the and higher in Dien Bien and An in the South. Comparative analysis older age group (age 16 and older) Giang provinces than the rest, and results suggest a considerably higher showed more hyperactivity problems in the North than in the South. rate of ‘abnormal’ problems among than the younger ones (under 15 Correlation analysis results show rural children than urban children year olds) (scoring 4.16 and 3.49 differences between the prosocial (10.4% vs. 15.7%), and this difference respectively for the Hyperactivity scores of different children groups did not happen by chance (statistical Scale). by age, sex, level of education, significance p-value <0.05). study site and residence area. The children living in urban areas Boys, lower secondary students Figure 5 reveals differences in the and big cities seemed to have and rural children scored higher rates of children having ‘Abnormal’ more hyperactivity problems. The in the prosocial scale than the scores between the study provinces/ children’s Hyperactivity Scale score is other groups. These differences sites. The number is highest in higher in urban areas than rural areas are statistically significant (P<0.05, Dien Bien (18.3%) – a Northern (4.15 versus 3.62). Particularly, the P<0.001), which indicates that these mountainous province, and then score of HCMC is higher than those correlations did not happen by An Giang (15.3%) – a province in the of the other 3 provinces and city (4.14 chance (Tables 3 & 4). Mekong Delta, almost twice as high versus 3.66 – 3.89). as those in the other two sites (10,8% The data in Table 5 shows that the in Hanoi and 7,7% in HCMC) Concerning prosocial behaviours, percentage of children having (Figure 5). there are significant differences ‘Abnormal’ problems is considerably between children living in different higher among children age 16 or areas. The Prosocial score is higher older (14.8% vs. 11.8%), among girls

Table 4: Mean scores (standard deviations) by residence area

Provinces Areas Regions Scale Hanoi Dienbien An Giang HCMC Urban Rural Northern Southern (n=102) (n=104) (n=118) (n=78) (n=173) (n=229) (n=206) (n=196)

Total difficulty score 13,23 13,98 14,67 13,99 13,90 14,07 13,61 14,40 (4,55) (5,56) (4,41) (4,32) (4,40) (5,03) (5,08) (4,38) 3,93 4,75 4,66 3,82 4,15 4,76 4,34 4,32 Emotional Problem (2,33) (2,32) (2,28) (2,23) (2,31) (2,32) (2,35) (2,29) Conduct problems 2,62 2,36 2,71 2,91 2,69 2,59 2,49 2,79 (1,32) (1,36) (1,26 (1,16) (1,15) (1,39) (1,34) (1,22) Hyperactivity 3,77 3,66 3,89 4,14 4,15 3,62 3,71 3,99 (1,86) (2,08) (1,90) (1,79) (1,88) (1,92) (1,97 (1,86) Peer problems 2,89 3,20 3,39 3,11 2,90 3,36 3,04 3,28 (1,77) (1,62) (1,34) (1,57) (1,50) (1,61) (1,70) (1,44) *** (P=0.000) ** (P=0.009) Prosocial 6,58 7,53 7,01 6,61 6,71 7,15 7,06 6,85 (1,45) (1,56) (1,67) (1,82) (1,68) (1,62) (1,58) (1,74) Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 141

Table 5. Caseness (Symptoms score) by characteristics of children

Caseness (Symptoms score) Variable Normal Borderline Abnormal Total difficulty score 66,9 19,7 13,4 >=15 71,5 16,7 11,8 Age 16+ 63,0 22,2 14,8 Boys 70,0 18,8 11,3 Sex Girls 64,9 20,2 14,9 Lower Secondary School 71,5 16,7 11,8 Upper Secondary School 63,0 22,2 14,8

Area Urban 64,2 25,4 10,4 * (P=0.023) Rural 69,0 15,3 15,7 Northern Viet Nam 69,9 15,5 14,6 Region Southern Viet Nam 63,8 24,0 12,2

Figure 5: Caseness (Symptoms score) by provinces (%)

80 71.6 70 68.3 65.4 66.9 62.7 60

30 26.9 22 19.7 20 17.6 18.3 13.5 15.3 13.4 10.8 10 7.7

0 Ha Noi Dien Bien An Giang HCMC Total

Normal Borderline Abnormal

Self-efficacy Bassler & Brissie, 1987). When self- Educational and psychological efficacious students attain their researchers also believe that a Children’s self-efficacy goals, they continue to set even child with higher self-efficacy is more challenging goals (Schunk, more serious about studying and Self-efficacy is an important quality 1990). This can all lead to better works harder, and at the same time, to school-aged children. Those performance in school in terms more optimistic, less dependent or with higher self-efficacy are more of higher grades and taking more avoidant, more persevering and less motivated and determined in challenging classes (Multon, Brown anxious, hence better performance studying. There is a lot of research & Lent, 1991). Students with high in school and in life in general. As about how self-efficacy is beneficial academic self-efficacies might study such, an individual’s self-efficacy, can to school-aged children, college harder because they believe that have substantial influence on his or students can also benefit from they are able to use their abilities to her success or failure in studying and self-efficacy (Schunk, 1990; Multon, study effectively (Hoover-Dempsey, achieving life goals. Psychologists Brown & Lent, 1991; Hoover Dempsey, Bassler & Brissie, 1987). call it “the Effective Self” and consider 142 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam it a predictor of a student’s academic try hard enough’, ‘ If someone opposes enough confidence to cope with the performance. Moreover, children me, I can find the means and ways to situation is lower than those who with high self-efficacy are often get what I want”, “It is easy for me to thought they were able to handle less likely to depend on others or stick to my aims and accomplish my trouble, even very difficult problems. avoid difficult tasks, and are highly goals”, “I can solve most problems if When faced with unforeseen/ determined to pursue their goals. I invest the necessary effort”, “I can unexpected situations, only about When faced with barriers, they know remain calm when facing difficulties half of the children believed in their how to handle them or will try to because I can rely on my coping abilities to handle the problems that find every way possible to reach their abilities”, “When I am confronted with arose: 45.3% thought they ‘could deal goals regardless of the situation. a problem, I can usually find several efficiently with unexpected events’, solutions”, “If I am in trouble, I can and 53% believed that ‘Thanks to my Table 6 presents the data of how usually think of a solution”, and “I can resourcefulness, I know how to handle the children perceived their self- usually handle whatever comes my unforeseen situations.’ efficacy based on the 10 Items of way.’ The rates of children choosing the Self-Efficacy Scale. The results the ‘Moderately True’ and ‘Exactly True’ Meanwhile, when actively facing show that, except for the two Items responses to these Items are very trouble or problems, the majority of ‘I am confident that I could deal high, varying from 60.7% to 80.8%. of the children felt that they could efficiently with unexpected events’ On the contrary, the proportions of come up with their own solutions and ‘Thanks to my resourcefulness, children answering ‘Not at all True’ to (60-80%). In particular, in the face I know how to handle unforeseen the 10 Items are fairly low, ranging of difficulties or challenges, a great situations’ which have lower from 1.5% to 11.2%, while the mean number of children believed in their percentages of ‘Moderately True’ scores for these Items are quite high coping abilities; they thought that and ‘Exactly True’ responses, only (from 2.45 to 3.11), which suggests they could keep calm to solve the around 50% (45.3% and 53.0% that many of the children in the survey problems, as well as believed in their respectively), the responses to the sample have relatively high perceived efforts in dealing with difficulties, or 8 other Items reflect relatively high self-efficacy in life. their abilities to focus, pursue and perceived self-efficacy among the achieve their goals. children when challenged by difficult Overall, when caught in unforeseen/ situations, such as: ‘I can always unexpected situations, the number Theoretically, higher scores indicate manage to solve difficult problems if I of children thinking they had higher levels of self-efficacy. Analysis

Table 6: The frequency distribution, mean score and percentage mean of the children self - efficacy

Frequency (%) Mean scores Not at Hardly Moderately Exactly N all Mean % SD true true true true

I can always manage to solve difficult problems if I try hard enough 2,5 20,4 55,0 22,1 2,97 74,2 0,72 402

If someone opposes me, I can find the means and ways to get what 8,0 31,3 43,5 17,2 2,70 71,5 0,84 402 I want

It is easy for me to stick to my aims and accomplish my goals 3,0 29,9 45,8 21,4 2,86 67,5 0,78 402

I am confident that I could deal efficiently with unexpected events 11,2 43,5 34,3 10,9 2,45 61,2 0,83 402

Thanks to my resourcefulness, I know how to handle unforeseen 7,2 39,8 40,8 12,2 2,58 64,5 0,79 402 situations

I can solve most problems if I invest the necessary effort 4,0 15,2 46,5 34,3 3,11 77,7 0,80 402

I can remain calm when facing difficulties because I can rely on my 7,0 26,4 40,8 25,9 2,86 71,5 0,88 402 coping abilities When I am confronted with a problem, I can usually find several 4,2 25,9 47,0 22,9 2,89 72,2 0,80 402 solutions

If I am in trouble, I can usually think of a solution 1,5 25,1 50,5 22,9 2,95 73,7 0,73 402

I can usually handle whatever comes my way 4,2 23,6 37,1 35,1 3,03 75,7 0,87 402

Total score (0- 40) 28,38 71,0 4,23

* Percentage mean: Convert from the mean column to mean percentage out of 4 means Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 143

Table 7. The frequency distribution of the Perceived Self - Efficacy in 2 scales

False True N I can always manage to solve difficult problems if I try hard enough 22,9 77,1 402 If someone opposes me, I can find the means and ways to get what I want 39,3 60,7 402 It is easy for me to stick to my aims and accomplish my goals 32,8 67,2 402 I am confident that I could deal efficiently with unexpected events 54,7 45,3 402 Thanks to my resourcefulness, I know how to handle unforeseen situations 47,0 53,0 402 I can solve most problems if I invest the necessary effort 19,2 80,8 402 I can remain calm when facing difficulties because I can rely on my coping 33,3 66,7 402 abilities When I am confronted with a problem, I can usually find several solutions 30,1 69,9 402 If I am in trouble, I can usually think of a solution 26,6 73,4 402 I can usually handle whatever comes my way 27,9 72,1 402

results show a fairly positive level Figure 6. The frequency distribution of the total Self - Efficacy of self-efficacy among the sampled children: 7 out of the 10 items, as self-reported by the children, have a 80 mean percentage score of over 70%. Overall, the mean scores of the 10 items vary from 2.45 to 3.1122 (highest for the item ‘I can solve most problems 60 if I invest the necessary effort’). The Mean = 6.6617 mean total self-efficacy score among Std. Dey. = 22.3885 the children in this Study stood quite N= 402 high at 28.3823 (SD = 4.23) (within a 40 range of 16 to 40). Frequency

To understand the children’s perceived self-efficacy, the Study 20 bases on the rate of children who answered Moderately true and Exactly True to each item. As such, from the collected responses, we 0 would separate them into 2 groups: 0.00 2.00 4.00 6.00 8.00 10.00 12.00 1 – True and 0 – False. Specifically, the Total Self - E cacy 1-True group would include the two responses of Moderately true and Exactly true (score values of 3 and 4), Table 7 provides the rates of children Figure 6 illustrates the children’s and the 0-False group would include having ‘True’ answers to the items of perceived self-efficacy levels on a the other two responses, Not at all the Self-efficacy Scale. The analysis scale of 0-10. It can be seen from the true and Hardly true (score values of results show that more than 75% graph that the children’s self-efficacy 1 and 2). of the children had ‘True’ responses is relatively high, with a mean score to 2 out of the 8 Items, which are: ‘I of 6.66 (SD=2.23). Only 18.2% of the can always manage to solve difficult children have lower-than-average 22. In many samples the mean was around 2.9 problems if I try hard enough’ (77.1%) self-efficacy scores (0-4), 41% have (Ralf Schwaizer, 2014) and ‘I can solve most problems if I average scores (5-7), and 40% have 23. In a sample of N = 3,494 German high school students (12 to 17 years old), the invest the necessary effort’ (80.8%). mean scores of 8-10. These numbers mean was found to be 29.60, standard This figure for the rest of the Items imply a fairly high level of self- deviation equalled 4.0 (Ralf Schwarzer, only reached 45.3% - 73.4%. efficacy among the children. 2014). 144 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

Children’s Self-efficacy by Conclusions what children struggle with the demographic and social most during adolescence, which characteristics Studying mental health and self- is the most difficult stage of life efficacy among school-aged children for children to adapt. The rate of The analysis found that the self- is highly complicated, but plays a children having conduct problems efficacy levels of the children in critical role in the development of in this Study also appears to be quite this sample did not differ much mental wellbeing among children. high; the most common symptoms by age or education level, but To identify and assess mental health include getting angry and losing some differences were recognized and self-efficacy problems among temper easily, and lack of self- between different sexes and school-aged children in Viet Nam, control. That many of the children residence areas, as seen in Table 8 the research team used the two tools are somewhat prone to these The self-efficacy levels appear to of SDQ and SE Scale to collect and behaviours is a matter of concern be higher among children in urban analyse data. The study findings also to families and schools, because areas than those in rural areas. The contribute to verifying the relevance children with such conduct disorders children in urban areas showed of the SDQ in identifying mental will face difficulties not only in higher self-efficacy than those in health problems among children in building social relationships, but rural areas (mean score 6.86 (SD = Viet Nam. Preliminary analyses built also in their personal development. 2.30) versus 6.51 (SD=2.17). on samples of children aged 12-17 The majority of the children in the from secondary and high schools survey sample showed problems Results of correlation analysis show in 4 provinces/cities, representing or symptoms of hyperactivity. Very differences between self-efficacy the two regions of Viet Nam, have few of the children were confident levels by gender, province and allowed the authors to reach a that they possessed good attention, region, which are statistically number of conclusions as follows: judgement and ability to analyse significant (P<0.05, P<0.001, and complete tasks effectively. These P=0.000). The self-efficacy levels In terms of mental health signs are often ignored by parents seem to be higher among boys problems and schools and rarely addressed than girls, with a mean scores 6.99 with appropriate education (SD=1.93) versus 6.44 (SD=2.39) Of the four domains of behavioural methods. (P<0.05). The children in An Giang and emotional problems, this Study and Hochiminh City showed higher recognised emotional problems The analysis of children having self-efficacy than those in Hanoi as the most common symptoms mental health problems based and Dien Bien Province (P=0.001). among the children. The rate of on the SDQ scores found that The self-efficacy levels of those in children scoring ‘Abnormal’ in the number of children having the South were considerably higher the Emotional problems Scale is ‘Abnormal’ symptoms of Peer than those in the North (mean score more than twice as high as those problems was considerably lower 7.07 (SD 2.20) versus 6.26 (SD=2.20) in other Scales, which suggests than the figures provided by (P=0.000). that emotional problems are some other studies. However, the

Table 8: Mean scores (standard deviations) of SE by characteristics of children

Age Sex/Gender Educational Levels All children <15 Boys Girls (N=402) 15+ (n=216) LSS (n=186) USS (n=216) (n=186) (n=160) (n=242) * (P=0.015) 6.66 6.66 6.66 6.99 6.44 6.66 6.66 (2.23) (2.14) (2.32) (1.93) (2.39) (2.14) (2.32)

Provinces Areas Regions Hanoi Southern Dien Bien (n=104) An Giang (n=118) HCMC (n=78) Urban (n=173) Rural (n=229) Northern (n=206) (n=102) (n=196) ** (P=0.001) *** (P=0.000) 6.40 6.13 7.22 6.84 6.86 6.51 6.26 7.07 (2.31) (2.09) (2.15) (2.26) (2.30) (2.17) (2.20) (2.20) Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 145 percentage of children having having “Abnormal” symptoms by self-efficacy than the girls. Self- Borderline scores for the Peer age and residence area. This rate is efficacy also appeared to be higher problems Scale was 2-3 times as considerably higher among children among children in urban areas than high as that for other domains of aged 16 or older, girls, children in rural those in rural areas, and in the South problems. A significant portion of the areas, and in the North. Noticeably, than in the North. In the present children seemed to be rather solitary, the percentage of children having context of Vietnamese society, have few friends, not liked by other ‘Abnormal’ symptoms is highest in where globalisation is becoming children their age, prefer hanging Dien Bien – a Northern mountainous more widespread and children and out with adults, and especially, some province and An Giang – a province young people are being increasingly of them were even victims or at risk in the Mekong Delta. However, the exposed to a range of competing of being bullied by their peers. This correlation analysis results only worldviews, self-efficacy is becoming suggests that peer relationships are confirm the statistical significance of more and more important. This a difficult problem for school-aged the difference between the rates of self-efficacy needs to be, nurtured children. children in the “abnormal” band by and developed by parents, families region of residence. and schools, so that children can The behavioural and emotional grow up to be highly independent problems mentioned above Regarding prosocial behaviours, and confident in their own abilities differed according to the the majority of the children in to make decisions and cope with children’s demographic and social the survey sample had positive difficult situations in school and in characteristics. The children of social relationships. The mean life. the older age group and higher Prosocial Score is higher among education level face more problems children under 15 years of age, than those of the younger age group girls, secondary school students and lower education level; girls and children living in rural areas. appeared to have more difficulties Correlation analysis results suggest than boys. The girls faced more a link between factors such as age, emotional problems than the boys, sex, educational level, study site and while in contrast, the boys have region of residence of the children more peer problems than girls. and prosocial behaviours. Hyperactivity seems to be more of a problem among older children and Children’s self-efficacy and in urban areas and big cities. perceived self-efficacy

The total difficulties scores as Analyses have revealed a relatively calculated from the children’s positive perception of self-efficacy self-report SDQ of this sample is among the children in the sample, fairly high compared to the results both in unexpected/unforeseen of some other studies on mental situations and especially when health of children in Viet Nam in actively facing difficult problems, which SDQ was used. However, the although the number of children rate of children having ‘Abnormal’ having good self-efficacy in coping symptoms in this Study is in line with unexpected events is a bit with other studies on children in lower. Particularly, in the face of Viet Nam. Overall, this result is also difficulties and challenges, many within the range of rates of children of the children believed in their having mental health problems coping abilities. They could keep among children in Asian countries. calm to solve the problems, and were The children’s Total Difficulties confident in their own efforts and Scores differed by residence area; abilities to focus on pursuing and the children’s mean Total difficulties achieving their goals. Score is higher in rural areas urban areas, and in Southern Viet Nam than Correlation analysis results found Northern Viet Nam. statistically significant differences between self-efficacy levels of Similarly, the Study also discovered children by sex, province and region. differences in the rates of children The boys seemed to have higher 146 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

Nguyen Viet Thiem. 2002. References Community Mental Health. Post- graduate teaching material. Hanoi Amstadter, Richardson L, Meyer Medical University A, Sawyer G, Kilpatrick DG, Tran TL, Trung LT, Tam NT, Tuan T, Buoi Schwarzer, R. & Jerusalem, M. 1995. LT, Ha TT,Thach TD, Gaboury Generalized Self-Efficacy scale. In J. M, Acierno R. 2011. Prevalence and Weinman, S. Wright, & M. Johnston correlates of probable adolescent (Eds.), Measures in health psychology: mental health problems reported by A user’s portfolio. Causal and control parents in Viet Nam. In Psychiatry beliefs (pp. 35-37). Windsor, UK: Psychiatr Epidemiol. Feb. 46(2):95- NFER-NELSON 100, http://www.ncbi.nlm.nih.gov/ pubmed/20012859 Vu Dung. 2008. Psychology Dictionary. Encyclopedia Publishing Bandura, A. 1986. Social Foundations House of Thought and Action: A Social Cognitive Theory. Prentice Hall WHO. 2003. Investing in mental health. Geneva, World health Bandura, A. 1977. Self-efficacy: organization Toward a unifying theory of behavioral change, Psychological Nguyen Dinh Tho, Nguyen Thi Mai Review, Vol. 84, No.2, p.195-215, Trang. 2009. Principles of Marketing. https://www.uky.edu/~eushe2/ Labour Publishing House Bandura/Bandura1977PR.pdf Hoover-Dempsey, K. V., Bassler, School Mental Health Program, Mai O. C., & Brissie, J. S. (1987). Parent Huong Psychiatric Hospital, http:// involvement: Contributions www.maihuong.gov.vn/m/suc-khoe- of teacher efficacy, school tam-than-tre-em/62-chuong-trinh- socioeconomic status, and other suc-khoe-tam-than-hoc-duong.html school characteristics. American Educational Research Journal, 24(3), Dang Hoang Minh, Bahr Weiss, 417–435 Nguyen Cao Minh. 2013. Mental health of children in Viet Nam: Schunk, D. H. (1991). Self-efficacy and Situation and Risk Factors. National academic motivation.Educational University, University of Education Psychologist, 26(3–4), 207–231

Hoang Cam Tu, Dang Hoang Minh. Shojaei T, Wazana A, Pitrou I, Kovess 2009. Situation of mental health V. 2009. “The strengths and among secondary students in Hanoi, difficulties questionnaire: validation and the needs for school mental study in French school-aged children health counseling. Journal of Social and cross-cultural comparisons”. Soc Sciences and Humanities, Volume 25 Psychiatry Psychiatr Epidemiol. Sep, 44(9):740-7 Lynne Omes, Lynda B.Ransdell (2010) A pilot study examining exercise self- efficacy as a mediator for walking behavior in college-age women in Perceptual and Motor Skills 110 (3 Pt 2):1098-104. June 2010

Nicholas A Keks, Graham D Burrows. 1997. The essential practice of mental health care . Medical Journal Autralia (MJA), Volume 167, Issue 3 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 147 Annex 4: Policies and legal documents related to mental health, social work and children

Legislative documents addressing in Item 1: ‘Parents and guardians in the context that the Vietnamese children’s health care: have the responsibility to implement legal system currently puts people the regulations on health check, with mental disorders (schizophrenia vaccination, medical examination and and epilepsy) under the category of The Law on Child Protection, Care and treatment for children.’ people with disabilities, and these Education, first promulgated in 1991 patients are entitled to mental health and then amended in 2004, contains The 1989 Law on Protection of care policies under The National Target specific provisions on healthcare for People’s Health includes a number Program (NTP) on People’s Mental children, albeit without explicitly of provisions related to children’s Health Care, which was launched in addressing mental healthcare. Article healthcare and healthcare priorities 1999. 15 of the Law specifies: ‘Children have for children with disabilities and the right to health care and protection’ ethnic minorities. Item 1 of Article The 2006 Law on Gender Equality, (Item 1) and ‘Children under 6 years old 46 reads: ‘Children are entitled to be although does not directly provide are entitled to primary health care and managed by grassroots-level public for healthcare for boys and girls, does free medical examination and treatment healthcare system, vaccination, and have a number of related provisions at public medical establishments’ (Item medical examination and treatment which serve as legal grounds for 2). The Law also devotes 17 Articles services.’ Item 1 of Article 42 affirms children’s healthcare on the basis to describing the responsibilities of that ‘the State shall set aside an of gender equality. As put forward the State, the family and the society appropriate budget for strengthening by Article 18, Item 4, boys and girls in protecting and realizing the rights and expanding the healthcare network are given equal care, education and of children as stated by the Law. and services to ethnic minorities, provided with equal opportunities According to Item 4 of Article 27, ‘the especially the grassroots-level public to study, work, enjoy, entertain and State shall adopt policies to develop healthcare system in mountainous develop. Furthermore, this Article also the health cause, diversify medical and remote areas.’ Moreover, this Law implies the need to prevent mental examination and treatment services; also stipulates the responsibilities of health risks should discrimination exempt or reduce medical examination the family and society in healthcare between boys and girls exist in the and treatment as well as rehabilitation for children. As stated in Item 2 of family in terms of labour division, service charges for children; and assure Article 46, ‘the health sector has the especially in the Vietnamese culture medical examination and treatment responsibility to develop and strengthen where boys are often favoured with funding for children under 6 years old.’ the health care and protection network regard to housework sharing. This for children.’ The family’s role is defined can potentially result in feelings of Item 3 of Article 27 also identifies the in Item 3 of the same Article: ‘Parents inferiority/certain psychological and responsibilities of a number of State and guardians have the responsibility emotional difficulties faced by girls in management agencies involved in to implement the regulations on health their relationships with parents and the field of healthcare for children: check and vaccination according to brothers. Item 5 of the Article reads: ‘The Ministry of Education and Training the grassroots-level healthcare system’s ‘Female and male members in the has the responsibility to organize school plans, take care of children in times family have the responsibility to share healthcare. The Ministry of Health has of illness and follow the healthcare housework.’ the responsibility to coordinate with practitioner’s decisions in examination the Ministry of Education and Training and treatment for children.’ The 2007 Law on Domestic Violence in guiding the application of measures Meanwhile, Article 47 establishes Prevention and Control identifies to prevent school diseases and other the responsibilities of the State in domestic violence acts that are strictly ailments for children.’ Item 2 of the caring for children with disabilities: forbidden. This helps reduce the same Article assigns the duties of ‘The Ministry of Health, the Ministry of risks of violence not only between public medical establishments: ‘Public Labour, Invalids and Social Affairs and husband and wife, but also between medical establishments have the the Ministry of Education and Training parents and children – a factor that responsibility to guide and organize the have the responsibilities to organize the exacerbates children’s mental health primary health care, disease prevention care and application of rehabilitation risks. This is even more meaningful and treatment for children,’ while the measures for children with disabilities.’ given the present context of Viet responsibilities of the family in caring This legislative regulation is crucial to Nam, where the use of violence as a for children’s health are mentioned the mental health care for children form of discipline by parents to their 148 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam children is still relatively common. In The National Program of Action for given to poor, mountainous and particular, Item e) of Article 2 of this Children in the period of 2012-2020 remote areas in terms of preventive Law categorises forcing early marriage (following the Prime Minister’s medicine, primary care at grassroots as acts of domestic violence. As such, Decision No. 1555/QĐ-TTg of 17 healthcare units, medical services for if this regulation is well promoted and October 2013). This Program continues the poor and target populations of disseminated among ethnic minority with the research and improvement social welfare policies, protection of communities where child marriage of the welfare policy system in the the health of mothers and babies. In exists as a tradition, it will help fields of health, education, social this Strategy, such terms as ‘mental’, mitigate the risks of depression, which assistance, entertainment, sports, ‘suicide’ appeared under the category is a potential cause of suicide among tourism, information, communication of non-communicable diseases to be children who are forced to get married and realizing the child’s right to prevented and controlled; however, by their parents. participation. In relation to health, the there was a lack of specific objectives Program assigns the Ministry of Health of mental health care for children. to lead and collaborate with relevant Programmes, strategies and policies Ministries, departments and local The National Strategy on which have been the most influential authorities to promote and carry out Protection, Care, and Improvement to the healthcare for children in Viet objectives of nutrition and healthcare of the People’s Health in the period for children, develop child-related of 2010-2020, with vision to 2030 Nam in the past years: programs and proposals under the (Decision No. 35/2001/QD-Ttg of Ministry’s scope of management, 19 March 2001). This Strategy also The National Program of Action for develop nutrition and healthcare proposes various issues related to Children in the period of 2001-2010 programs for children, direct and children’s healthcare; nevertheless, was approved by the Prime Minister organise effective implementation specific provisions on mental in Decision No. 23/2001/QD-TTg of of health examination and treatment healthcare in general and mental 26 February 2001. The overall goal of policies for children under 6, children healthcare for children in particular the Program was to build a safe and in special circumstances, and poor are still absent. The Strategy sets healthy environment for Vietnamese children, provide rehabilitation for important objectives of reforming children to have the opportunity to children with disabilities, and pilot and improving Viet Nam’s healthcare be protected, cared for, educated and types of health services specifically system towards Equity – Efficiency develop in all fields, and have a better designed for children. – Development: Ensuring that all life. Some of the Program’s objectives citizens, especially the poor, ethnic addressed children’s entertainment The National Strategy on minorities, children under six, target needs, an aspect that promotes Protection, Care, and Improvement populations of social welfare, people the mental wellbeing of children. of the People’s Health in the period living in underprivileged, remote, The Program also emphasised of 2001-2010 (Decision No. 35/2001/ isolated areas and vulnerable groups the necessity of strengthening QD-Ttg of 19 March 2001). This Strategy have access to basic and quality health communication activities to raise the set forth fundamental viewpoints care services; Reforming operation awareness and sense of responsibility and objectives for the development mechanism and health financing in of families, schools, State agencies, of the health sector and healthcare public institutions and accompanied financial and social organisations for people and children. The Strategy by rationalising the roadmap toward and individuals in protecting, caring paid a lot of attention to children as universal health insurance to quickly for and educating children; the a target group. Seven out of the 21 adapt to the socialist-oriented market importance of counselling, social work health indicators to be achieved by economy in health care activities; and direct mobilisation of families 2010 were directly related to children; Reducing morbidity, mortality and and communities to improve their however, the main concerns included disability; contain infectious diseases, skills to protect, care for and educate healthcare for children under 6, keep common diseases and emerging children; focusing on communication reduction of mortality death rate diseases under control. The Strategy and education activities in ethnic among children, and improvement stresses the objectives of limiting and minority groups, mountainous of children’s nutrition and issues of step by step controlling the risk factors areas, islands and disadvantaged prenatal and postpartum care for of non-communicable diseases, or specially disadvantaged areas in mothers. The Strategy clearly stated environment, lifestyle and behaviour- terms of socio-economic conditions, that the State played the leading induced diseases, food safety, and other population groups who role in investing in the health sector hygiene, nutrition, and school health face limitations in fulfilling their and step by step increasing the problems. The mentioning of school responsibilities to children. proportion of public spending on health problems (albeit in absence health sector. The top priorities were of specific criteria and guidance) Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam 149 shows that this is an important overall goal of establishing and In terms of responsibilities, the Circular policy basis for the development of developing the social work profession defines 5 social work responsibilities programs related to mental health in the healthcare sector, contributing of hospitals, namely: (1) Support, risk prevention for school children, to the improvement of quality and consult patients and their families on such as school violence, and mental efficiency of the protection, care and issues related to social work during problems related to studying stresses. enhancement of the health of the the healthcare service provision Moreover, like the previous National people. process; (2) Provide information, Strategies and Programs, this Strategy communication and education about continues to raise the responsibility of In this document, MOH stresses that the law (communicate to patients strengthening the healthcare human planning for the development of the about policies and legislations resources for rural, mountainous, social work profession within the related to healthcare services); (3) remote and isolated, border areas and healthcare sector for the period of Raise and receive funds (to support islands. 2011-2020 is highly necessary to put disadvantaged patients); (4) Support Decision No. 32 of the Prime Minister health staff; (5) Provide social work into practice, which will contribute to training (for interns, health staff Legal documents relevant to social addressing urgent healthcare needs, etc.); (6) Organize a network of social work in healthcare sector improving service quality as well as work volunteers for the hospital; and increasing people’s satisfaction with (7) Organize the hospital’s charity 1. Decision to approve the Plan healthcare services. and social work activities in the for “Development of the Social community (if any). Work Profession, period 2010 – The Document also mentions that in 2020”. recent years, a number of National- In terms of organisation of hospitals’ level hospitals have initiated social social work activities, the Circular On 25 March 2010, the Prime Minister work activities with the participation specifies that based on the number signed Decision No. 32/2010/QD-TTg, of existing health staff and volunteers of beds, capacity of human resources, approving the Plan for Development in supporting doctors in classifying budget and areas of specification, of the Social Work Profession in the patients, providing consultation and the hospital director shall decide on period of 2010 – 2020. The goal of referrals, caring for patients to help establishing or report to the relevant the Plan is to develop social work lessen their difficulties in accessing authority to decide on establishing as a profession in Viet Nam, which and using healthcare services etc. one of the following organizational encompasses establishing a network However, the current social work structures: a Social Work Department of social work officials, staff and activities in the healthcare sector are within the Hospital, or a Social Work collaborators that is adequate in terms still spontaneous, lacking planning Team under a hospital Ward, or the of both quantity and quality, together and regulation by legal documents. Nursing Department, or the General with developing social work service Those who participate in the provision Planning Department of the hospital. provision structures at all levels, of social work services, despite their contributing to the development of devotion and experience, are mostly In terms of human resources, the an advanced social security system. untrained for the job, hence lack Circular requires that the Social Work This is a critical legal document to professionalism and efficiency. Department/Team should consist of the development of the social work officials and staff with specialisation profession in Viet Nam within the 3. Circular No. 43/2015/TT-BYT in social work, or in communication, health sector. regarding regulations on the health or other social sciences with responsibilities and organization additional training on social work. 2. Decision No. 2514-QĐ-BYT of social work activities in on approving the Plan for hospitals. This Circular has been in effect from 01 “Development of the Social Work January 2016. Profession within the healthcare sector, period On 26 November 2015, the Ministry of 2011-2020” Health issued Circular No. 43/2015/TT- BYT, determining the responsibilities On 15 July 2011, the Ministry of and organisation of social work Health promulgated Decision No. activities in hospitals. This document 2514-QĐ-BYT on approving the Plan provides regulations on hospitals’ for “Development of the Social Work social work responsibilities and forms Profession within the healthcare of organisation. sector, period 2011-2020” with the

for every child 152 Mental health and psychosocial wellbeing of children and young people in selected provinces and cities in Viet Nam

INVITATION

n the occasion of the visit to Viet Nam of the N eputy ecutive irector Mr mar bdi the N epresentative Mr oussouf bdelelil reuests the pleasure of the company of

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at a dinner reception on Monday, 5 December, 2016 at 19:00 at rill estaurant otte ower rd loor Address: ieu iai treet a inh anoi

Ms ing itnione mbassador of anada Mr runo ngelet mbassador ead of the elegation of the uropean nion Mr raig hittic mbassador of ustralia Ms iren erme risen mbassador of Norway Ms eatrice Maser mbassador of witerland Mr usmane ione orld an ountry irector

RSVP: Ms Nguyen hi rang Tel: or Email: nttranguniceforg

he reen ne N ouse Tel: im Ma a inh istrict Fax:

a Noi Viet Nam Email: hanoiregistryuniceforg

Follow us: Overseas Development Institute UNICEF Viet Nam ebsite httpswwwuniceforgvietnam 203 Blackfriars Road Add: Green One UN House, aceboo httpswwwfaceboocomunicefvietnam London SE1 8NJ 304 Kim Ma, Ba Dinh, Ha Noi outube httpswwwyoutubecomunicefvietnam

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ebsite httpswwwuniceforgvietnam

Email: hanoiregistryuniceforg a Noi Viet Nam

Fax: im Ma a inh istrict

Tel: he reen ne N ouse

RSVP: Ms Nguyen hi rang Tel: or Email: nttranguniceforg

Mr usmane ione orld an ountry irector

Ms eatrice Maser mbassador of witerland

Ms iren erme risen mbassador of Norway

Mr raig hittic mbassador of ustralia

Mr runo ngelet mbassador ead of the elegation of the uropean nion

Ms ing itnione mbassador of anada

Address: ieu iai treet a inh anoi

loor at rill estaurant otte ower

on Monday, 5 December, 2016 at 19:00

at a dinner reception

------

reuests the pleasure of the company of

the N epresentative Mr oussouf bdelelil

N eputy ecutive irector Mr mar bdi

n the occasion of the visit to Viet Nam of the

INVITATION

for every child