The implementation of evidence-based policy is being encouraged in all public sectors, including health care, in many developed countries. (1) Although the use of evidence-based practice started in medicine its influence is now being seen in public health, especially in the delivery of health services. It is also influencing health policy more broadly. According to some practitioners: "Clinical practice in many countries is being transformed by evidence-based medicine, and a similar transformation in health systems is desperately needed". (2) In the United Kingdom and other developed countries much attention has been paid to the role evidence can have in improving health policy, but there is little research on the progress of evidence-based policy in developing countries. Additionally, the fields of public health and care for people with mental illness are rarely examined to ascertain the extent of the existence of evidence-based policy.
The theory of evidence-based policy has developed rapidly during the past decade. It is now recognized that the policy process (particularly the nature and role of stakeholders) must be understood (3) and that evidence needs to be credible and useful if it is to influence policy-makers. The policy process is not linear, flowing from problem identification through solution to policy-making, but it is iterative and interactive and involves a wide range of actors. (4) The analytical framework for this paper (5,6) considers four interrelated factors that determine whether evidence is likely to be adopted by policy-makers:
* the political context (the process of developing the policy including the role of civil society and power relations within society)
* the evidence itself (including its relevance, method of communication of the evidence, and its source)
* the links used to influence policy and disseminate evidence (including advocacy coalitions, knowledge communities and other networks)
* the external influences on the policymakers (including donors).
We use this framework to analyse how and whether evidence was used to develop health-care policies for people with mental illness in Viet Nam.
Context, resources and key players
There is little published evidence about the extent and nature of mental health problems in Viet Nam. We briefly consider the evidence for different population groups. Only two prevalence studies of maternal mental health have been published. Fisher et al. found that 33% of women attending general health clinics in Ho Chi Minh City were depressed, and 19% explicitly acknowledged suicidal ideation. (7) These levels were much higher than those found in developed countries (where the level is typically 10-15%) and much higher than Vietnamese clinicians had anticipated: for sampling purposes the clinicians had estimated the prevalence to be 1%. This indicates that although Viet Nam may have a culture that proscribes the discussion of emotions or in which distress is associated with shame or stigma, (8) women were willing to reveal their level of distress to interviewers. Results from a nationwide survey of 2000 mothers of one-year-olds (in both rural and urban areas) found a 20% prevalence of depression or anxiety as measured by an instrument validated in Viet Nam. (9) The same study also measured mental health among children and found that 20% had poor mental health. McKelvey et al. emphasized that mental health services for children in Viet Nam were particularly limited due to the prioritization of other health problems, such as infectious diseases and malnutrition. (10)
A national community-based study of 5584 young people aged 14-25 years found that a quarter reported feeling so sad or helpless that they could no longer engage in their normal activities and they found it difficult to function. (11) This study included a slightly higher percentage of females than males; additionally, as many as 34% of girls from ethnic minority groups reported symptoms of depression. …