Vietnamese People’s Well-Being During the COVID-19 Pandemic: An Online Survey

The COVID-19 pandemic, alongside the restrictive measures implemented for its control, may considerably affect people’s lives particularly vulnerable persons such as children, elderly and people with underlying diseases. This study aimed to assess the well-being of Vietnamese people after COVID-19 lockdown measures were lifted and life gradually returned to normal in Vietnam. An online survey was organized from 21 st to 25 th April 2020 among Vietnamese residents aged 18 and over. Data were collected concerning the participants’ health status, COVID-19 preventive behaviour, and consequences of the preventive measures. The WHO-5 Well-Being Index was used to score participants’ well-being.


Abstract Background
The COVID-19 pandemic, alongside the restrictive measures implemented for its control, may considerably affect people's lives particularly vulnerable persons such as children, elderly and people with underlying diseases. This study aimed to assess the well-being of Vietnamese people after COVID-19 lockdown measures were lifted and life gradually returned to normal in Vietnam.

Methods
An online survey was organized from 21 st to 25 th April 2020 among Vietnamese residents aged 18 and over. Data were collected concerning the participants' health status, COVID-19 preventive behaviour, and consequences of the preventive measures. The WHO-5 Well-Being Index was used to score participants' well-being.

Results
A total of 1922 responses were analyzed (mean age was 31 years; range: . Factors associated with a high well-being score included older age, eating healthy food, practising physical exercise, working from home, and adherence to the COVID-19 preventive measures. Female participants, persons worried about their relatives' health, and smokers were more likely to have a low well-being score.

Conclusions
The Vietnamese people continued to follow COVID-19 preventive measures even after the lockdown was lifted. Most respondents scored high on the well-being scale. However, the emergence of a new COVID-19 outbreak with an epicenter in Da Nang city is expected to increase public anxiety and mental health problems. It is clear that together with preventive measures, developing strategies to guarantee the wellbeing of the Vietnamese people's is equally important.

Background
On December 31, 2019, unexplained cases of pneumonia were reported in Wuhan City, Hubei Province, China by the World Health Organization (WHO) China Country O ce [1]. Three months later, WHO o cially declared the Coronavirus disease 2019 (COVID-19) outbreak as a pandemic with more than 118,000 con rmed cases and over 4200 death cases [2]. Prior to the identi cation of the rst COVID-19 case in Vietnam, the Vietnamese government pro-actively took measures to prevent the importation of the disease into the country. Health screening was organized at country entry points, people were advised to practice personal hygiene, and to wear a face mask in public places. Initially, around the end of January 2020, COVID-19 cases entered from China. In early March 2020, cases entered from Europe and America [3]. Faced with an increasing number of COVID-19 cases, on April 1 st 2020 Vietnam implemented a nationwide lockdown alongside other preventive measures such as keeping a minimum distance of 2m from others, staying at home, wearing a face mask, washing hands regularly, and restriction of gatherings. People from abroad who entered Vietnam were subject to compulsory isolation for 14 days [4]. Thanks to these measures, COVID-19 transmission stopped until July 25 2020, when new cases of COVID-19 infection appeared and local community transmission was detected in the city of Da Nang.
Worldwide, the COVID-19 pandemic and the associated preventive measures had a major effect on people's lives causing anxiety and stress, affecting daily life activities at home and workplaces, and restricting social relationships [5]. To investigate whether people were adhering to the preventive measures implemented by the Vietnamese government a rst online survey was performed March 31 st to April 6 th , 2020 at a moment lockdown measures were still in place. Results of this survey showed good preventive behaviour of the Vietnamese population [6]. The aim of the current study was to investigate the effect of the COVID-19 pandemic on the COVID-19 preventive behaviour and the well-being of the Vietnamese people when lockdown measures were lifted and life gradually returned to normal in Vietnam.

Study design
Cross-sectional study collecting data through an online survey in Vietnam from 21 st to 25 th April 2020.

Study procedures
Data of the study were collected via a web-based online survey tool developed by the ICPcovid consortium (https://www.icpcovid.com/). The website interface was designed to be easily accessible by various devices such as computers, tablets, and smart phones. The entire questionnaire could be lled in 10 minutes or less, and was totally anonymous (no identi cation information was collected). Eligible participants were Vietnamese aged 18 years or older, who were able to read and understand Vietnamese, and residing in Vietnam at the time of data collection. Snow-ball sampling was used to recruit the participants. The survey link was shared via various social media platforms to relatives, friends, and colleagues.
Different determinants of well-being were collected (sociodemographic characteristics, health status and determinants of health, adherence to preventive measures, consequences of the preventive measures) (Fig 1). The level of anxiety about the health of the participant and his/her relatives was measured by a 5-point Likert scale (1= not worried/afraid to 5= extremely worried/ afraid); a score of ≥3 was considered as moderate to high level of anxiety. Twenty yes/no questions were asked to assess the participant's adherence to the COVID-19 prevention measures.
Well-being was scored using the WHO proposed ve questions: "I have felt cheerful in good spirits", "I have felt calm and relaxed", "I have felt active and vigorous", "I woke up feeling fresh and rested", "My daily life has been lled with things that interest me". Each answer was rated on a scale range from 0 to Page 4/16 5. The overall score ranged from 0 to 25, with 0 representing the worst probable, and 25 representing the best probable well-being. A score below 13 indicated poor well-being (WHO, 1998) [7].
Data analysis IBM SPSS version 20 was used to analyze the collected data. Continuous variables were described by means and standard deviations (SD). Categorical variables were described by frequency (n) and percentage (%). Well-being was the dependent variable. Multiple logistic regression model was used to analyze which independent variables were predictors of poor well-being. First, age and gender were included in the model to adjust other covariates. Later, all factors available in the conceptual framework ( Figure 1) were kept in the model if they had a statistically signi cant relationship with the independent variables at p-value <0.05.

Characteristics of study participants
Of the 1934 responses obtained during the survey, 1922 were eligible for analysis. Participants lived in 46 of the 63 provinces and municipalities of Vietnam, with more than half residing in urban areas. The average age was 31 years (SD: 10; range: 18-76 years). 1376 (71.6%) of respondents reported living with children, and 286 (14.9%) with elderly persons (Table 1). The education level was higher in male than female but the rate of unemployment was lower in female than male ( Table 2).  (Table 3). Ninety seven (5.0%) reported di culties in obtaining food. Of the 135 people with an underlying disease, 9 (6.7%) encountered di culties to obtain medication (Table 3). Nearly 90% of participants were physically active during the pandemic and 74.4% of them practiced outdoor activities. About 80% of the 1376 participants who lived with children responded that they participated in activities with their children on a daily basis.  *Total number of respondents during the survey Adherence to community preventive measures also remained high during this second survey with rates ranging from 43.9% to 99.7% but most people continued going regularly to a market (Table 5). Three hundred and ten (16.1%) persons had a poor well-being score (overall well-being score less than 13). The mean scores for each item on the WHO well-being scale are summarized in Table 6. Factors associated with a high well-being score were: older age, eating more healthy food, physical activity, working from home, and adherence to the COVID-19 preventive measures. In contrast, male gender, being worried about their relatives' health, and being a smoker were all associated with poor wellbeing (Table 7).

Discussion
Despite the COVID-19 pandemic and the stringent restrictive measures that had been implemented in Vietnam, relatively few participants (16.1%) scored low on the WHO well-being score. This gure is lower than in Wuhan, China where 48.3% respondents scored low using the same scale [8]. In our study, the mean score of the 5 components was 17.35 ± 4.97 and this is higher compared to Austria, after four weeks of lockdown (15.05 ± 5.40) [9]. A similar study during a period of COVID-19 lockdown in the UK also found a lower mean WHO-well-being score (10.43 ± 5.40) [10]. The relatively moderate impact of the COVID-19 epidemic and the implemented preventive measures on the well-being of the Vietnamese may be because the epidemic in Vietnam was rapidly controlled and that the population accepted to adhere to the preventive measures.
The impacts of COVID-19 preventive measures on physical and mental well-being have been documented by many studies. Long-term adherence to these measures, as well as negative information about the epidemic may affect physical and mental well-being in the population [11]. Studies evaluating the mental health during lockdown periods in Austria and the US, showed that young people, women, the unemployed, and low-income people seemed to be more stressed than others [9], [12]. Certain participants in our study reported di culties in obtaining food or medication, feeling worried about their own health or that of their relatives, and experiencing violence or discrimination. These experiences most likely affected their well-being. The WHO Department of Mental Health and Substance Use has provided advice to improve mental and psychosocial well-being during the pandemic [13]. People in the community should sympathize and help those affected by the pandemic, avoid discrimination against infected people, and follow o cial COVID-19 information from local health authorities. Indeed, uncontrolled infodemics could make people feel anxious or distressed. In addition, healthcare workers should consider mental and psychosocial well-being as important as physical health.
Our multivariable analysis showed that better well-being was associated with eating healthy food, practicing physical exercise, and observing the COVID-19 preventive measures. Notably, increasing age was associated with better well-being ( Table 7), suggesting that the pandemic may be particularly detrimental to the well-being of younger individuals who may nd it more di cult to endure con nement compared to older persons. Similar ndings were recently reported in the USA where poor mental health and well-being during the COVID-19 pandemic was reported among persons below the age of 40 years [12]. Other studies have shown that among elderly people, worrying about the risk of infection or death as well as the challenges related to physical distancing have reduced their well-being [14] [15]. It is possible that in Vietnam, the successful interruption of COVID-19 transmission at an early stage of the pandemic, and the absence of reported deaths due to COVID-19 may have put the elderly population more at ease.
Female gender was also associated with poorer well-being in our study. This is similar with ndings from Austria, Denmark and the UK [9] [16] [17]. An explanation could be that women carry the double burden of having a job and household responsibilities [18].
Fear and worry about their relatives' health was associated with poor well-being. This re ects the concerns that respondents have for their loved ones as they do not want them to develop COVID-19.
Indeed, SARS-CoV-2 may spread rapidly among family clusters [19]. Understandably, being a smoker was also associated with poor well-being since some of the risk factors that increase the severity of COVID-19 disease (lung disease, cardiovascular disorders, diabetes) are more common among smokers. Therefore, quitting smoking is recommended, especially for those with underlying diseases [20]. The nding that physical activity was associated with a higher well-being score resonates with previous studies which found that physical activity improves mental well-being, in addition to reducing the risk of acute respiratory distress syndrome which is a major cause of death in COVID-19 patients [21].
In many countries, the COVID-19 pandemic resulted in reduced income and increased food prices. Food insecurity and di culties in accessing healthy food may lead to malnutrition and mental health problems [22]. However, Vietnam has a policy to control food prices and to guarantee food security by a wellorganized collaboration between the government, producers, and supermarkets [23]. This explains why only 5% of our respondents reported di culties in obtaining food, and that nearly 90% responded that they were regularly eating more healthy food during the outbreak.
Some limitations of the study should be mentioned. People with no or limited internet access were not able to participate in the research. Therefore, our respondents are not representative of the general population in Vietnam. The survey was launched in medical schools, which resulted in a large percentage of respondents being medical students and healthcare workers. Moreover in an online questionnaire, there is a risk for recall bias and/or submission of incorrect information by respondents.

Conclusion
Thanks to the strict preventive measures that were implemented in Vietnam and the excellent preventive behaviour of the Vietnamese people, the COVID-19 epidemic was rapidly controlled. After the lockdown measures were lifted, the Vietnamese people continued to follow COVID-19 preventive measures and most of them scored high on the well-being scale. However, after 99-days without community transmission, on July 25 2020, there were new cases of COVID-19 infection locally transmitted in the city of Da Nang [24] followed by the appearance of COVID-19 cases in several provinces and cities linked to the outbreak in Da Nang. This emergence of a new COVID-19 outbreak is expected to increase public anxiety and mental health problems. It is clear that together with preventive measures, developing strategies to guarantee the well-being of the Vietnamese people is equally important.

Declarations
Ethics approval and consent to participate Informed consent was assured, anonymity guaranteed during the survey. The study proposal was approved by the Ethical Review Committee of University of Medicine and Pharmacy, Hue University, Vietnam (No. H202/041 dated March 30th, 2020). Informed consent was not required because participants' personal information were not used in the analysis.

Consent for publication
Not applicable.
Availability of data and materials