The use of vignettes in studies on mental disorders in low‐ and middle‐income countries in the East Asia and the Pacific region: A scoping review

Abstract

To scale up mental health services in low‐ and middle‐income countries (LMICs), understanding mental disorders in the local culture is critical. “Vignettes” are short texts describing a hypothetical character or situation to which respondents give their opinion, and are a potentially useful technique to explore perceptions of mental disorders in the context. We aimed to review how studies using vignettes have been conducted to understand mental disorders in LMICs in the East Asia and the Pacific region. Medline, PsycInfo, EMBASE, CINAHL, and CENTRAL were searched for articles published by April 2024. We included studies that used vignettes to assess mental disorders in LMICs in the region. We excluded studies that used vignettes that did not intend to elicit participants' opinions on the vignettes. A scoping review was conducted according to Preferred Reporting Items for Systematic reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR) guidelines. Two researchers performed title/abstract and full‐text screening, and one researcher extracted data. The database search yielded 1547 articles, and 55 articles were included in the review. The majority of the studies used an observational, quantitative design. The most common disorders studied using vignettes were depressive disorders, schizophrenia, and anxiety disorders. The main purposes of using vignettes were to explore the identification of mental disorders, explanatory models, help‐seeking, and stigma of mental disorders. Two‐thirds of the studies used vignettes and questions to elicit opinions on vignettes that originated from previous studies. Enhanced vignette utilization to understand mental disorders in the context contributes to generate knowledge for the promotion of mental health services in LMICs.

INTRODUCTION

The disease burden of mental disorders is substantial in low‐ and middle‐income countries (LMICs). The Global Burden of Disease Study reported that mental and substance use disorders accounted for 16.6%, 17.5%, and 19.2% of years lived with disability in upper middle‐income, lower middle‐income, and low‐income countries in 2021, respectively. ¹ To address the burden, the World Health Organization has launched the Comprehensive Mental Health Action Plan 2013–2030, and has been promoting the Mental Health Gap Action Plan since 2008. ² , ³ To close the treatment gap for mental disorders, scaling up mental health services especially to the community level is considered essential. ³ However, LMICs face challenges in scaling up mental health services. Experts noted the importance of the consideration of the culture in mental health service development in LMICs, particularly at primary care settings. ⁴ , ⁵

To establish mental health services at the community level where the general population can seek help, it is essential to have a thorough understanding of how mental disorders are perceived, how people cope with mental disorders, to whom people seek help, and how people behave towards people with mental disorders in context. The perceptions individuals have about an illness and its treatment are called explanatory models. These models are important for understanding the cultural influence on the relationship between patients and health services. ⁶ Explanatory models and help‐seeking strategies are shaped by culture. ⁵ For those who have nonmedical explanatory models for mental disorders and seek help from alternative resources such as traditional healers or community leaders, mental health services at health facilities are not the place to seek help. Knowledge on the general population's perception and behavior would help develop formal mental health services more accessible from the general population. However, these factors are difficult to investigate because of the stigma attached to mental disorders and people's reluctance to talk about their real experiences.

A survey technique, “vignette,” is defined as short stories about hypothetical characters or situations to which the respondent is asked to respond. ⁷ Vignettes are a common method used to explore people's perception and behavior in context to explore a sensitive topic. The use of hypothetical characters or situations minimizes the invasiveness of the survey process for respondents. Vignettes have been used in various areas of health research to understand perceptions of specific health conditions, the behavior of health workers, ⁸ , ⁹ and the decision of caregivers, etc. ¹⁰ Vignettes have also been repeatedly employed in research in high‐income countries (HICs) to understand the awareness, explanatory models, help‐seeking strategies, and stigma towards mental disorders. ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ They have also been used to show the change in the awareness and stigma towards mental disorders over time. ¹² , ¹⁴ , ¹⁷

In LMICs, vignettes are also considered as a potentially effective technique for understanding perceptions, attitudes, and behaviors towards mental disorders. As perceptions and attitudes towards mental disorders are thought to be more influenced by the culture and less dominated by the medical model compared to HICs, the potential usefulness of the vignette technique may be even greater. However, how mental disorders have been studied using vignettes in LMICs is not known. This scoping review aimed to understand the use of vignettes in mental health research, focusing on LMICs in the East Asia and the Pacific region, where the treatment gap of mental disorders is high despite the significant current and future disease burden. ¹⁸ This scoping review aimed to understand the use of vignettes in mental health research, focusing on LMICs in the East Asia and the Pacific region. The target region was selected to conduct a scoping review in a region to minimize context variations. To the best of the authors' knowledge, no scoping review with the same aim has been conducted in these regions.

METHODS

This scoping review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR) statement.

Identifying relevant studies

To identify the published literature, Medline, PsycInfo, EMBASE, CINAHL, and CENTRAL were searched in April 2024. One search specialist developed the search strategies for the databases. For the search, “mental disorder,” “mental,” “vignette,” and the list of LMICs were used. To enable future scoping review in other regions with comparability, the search strategies were designed to include the entire list of LMICs not limited to the East Asia and the Pacific region. The search strategies used in this study are provided as Supporting Information S3: Supporting Material 1.

Inclusion and exclusion criteria

Inclusion criteria were (1) studies investigating mental disorders and psychological symptoms specific to a study area using vignettes, (2) studies conducted in 22 LMICs based on the list of 2024 World Bank list of economies in the East Asia and the Pacific region, ¹⁸ (3) studies which were published as full‐text original articles, and (4) written in English. The 22 countries include Cambodia, China, Fiji, Indonesia, Kiribati, Democratic People's Republic of Korea, Lao People's Democratic Republic, Malaysia, Marshall Islands, Federated States of Micronesia, Mongolia, Myanmar, Papua New Guinea, Philippines, Samoa, Solomon Islands, Thailand, Timor‐Leste, Tonga, Tuvalu, Vanuatu, and Viet Nam. ¹⁸ Exclusion criteria were (1) studies which included specific case presentations (e.g., case reports and illustrative case presentations), (2) studies which used texts of a hypothetical case with other purposes than eliciting opinion (e.g., anchoring vignettes), and (3) studies which were conducted in multiple countries without an aim to investigate opinion about mental disorders in each country.

Screening

All the searched articles were uploaded to Rayyan (Rayyan Systems Inc., MA, USA). Two authors (A.A. and M.S.) independently performed title and abstract screening, and disagreements were resolved by discussion. The two authors then screened the full text.

Data extraction

One author performed data extraction (A.A.).

Study characteristics included author, year of publication, country, study design, study population, sample size, purpose for using vignettes, disorders depicted in vignettes, and number of vignettes. For studies that have multiple study components and used vignettes in a part of them, data were extracted from the components where vignettes are used. Studies that did not clearly report qualitative data collection and qualitative analysis methods were categorized as quantitative studies.

Availability of vignette texts, methodology used to develop vignettes, and methodology used to determine survey items were collected. Limitations of the use of vignettes in the included studies were extracted.

Study population, purpose of vignette use, methodologies used for vignettes and survey items, and limitations stated in the articles were categorized. The categories were revised during and after the data extraction process.

Summarizing the results

The characteristics of the included studies were summarized in a table. The studies were then categorized according to country, study population, vignette diagnosis, purpose of vignette use, availability of vignette texts, vignette development methodology, and survey item development methodology. The study population, the purpose of using vignettes, and the limitations of the studies were analyzed and categorized by one author (A.A.) using content analysis. ¹⁹

RESULTS

Search results

A total of 2347 articles were retrieved from five databases. After removing 800 duplicates, the remaining 1547 articles underwent title and abstract screening. At the stage of title and abstract screening, 346 articles were included without considering the region of the study sites, and 105 articles were included considering the region of the study sites. A total of 1442 articles were excluded according to the inclusion and exclusion criteria. Three articles written in non‐English language and one article with a different publication type (protocol) were not retrieved. During the full‐text screening, 42 articles were excluded. In the end, 55 articles were included in this study. ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁴ , ⁵⁵ , ⁵⁶ , ⁵⁷ , ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁶¹ , ⁶² , ⁶³ , ⁶⁴ , ⁶⁵ , ⁶⁶ , ⁶⁷ , ⁶⁸ , ⁶⁹ , ⁷⁰ , ⁷¹ , ⁷² , ⁷³ , ⁷⁴ The screening process is shown in Figure 1.

Figure 1.

Flow diagram of the screening process.

Included studies

The included studies were published between 1980 and 2024. Of which, 3 studies were published before 2000, ²⁰ , ²¹ , ²² 4 studies between 2000 and 2009, ²³ , ²⁴ , ²⁵ , ²⁶ 34 studies between 2010 and 2019, ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁴ , ⁵⁵ , ⁵⁶ , ⁵⁷ , ⁵⁸ , ⁵⁹ , ⁶⁰ 14 studies were published after 2020. ⁶¹ , ⁶² , ⁶³ , ⁶⁴ , ⁶⁵ , ⁶⁶ , ⁶⁷ , ⁶⁸ , ⁶⁹ , ⁷⁰ , ⁷¹ , ⁷² , ⁷³ , ⁷⁴

A total of 54 studies were observational studies, ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁴ , ⁵⁵ , ⁵⁶ , ⁵⁷ , ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁶¹ , ⁶² , ⁶³ , ⁶⁴ , ⁶⁵ , ⁶⁶ , ⁶⁷ , ⁶⁸ , ⁶⁹ , ⁷⁰ , ⁷¹ , ⁷² , ⁷³ , ⁷⁴ and one study was an intervention study. ⁴⁰ Thirty‐six studies used quantitative methodology only, ²⁰ , ²¹ , ²³ , ²⁴ , ²⁶ , ³⁰ , ³¹ , ³² , ³⁵ , ³⁶ , ⁴¹ , ⁴² , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁶ , ⁵⁷ , ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁶¹ , ⁶² , ⁶³ , ⁶⁵ , ⁶⁶ , ⁶⁸ , ⁶⁹ , ⁷⁰ , ⁷¹ , ⁷² while 18 studies used qualitative methodology. ²² , ²⁵ , ²⁷ , ²⁸ , ²⁹ , ³³ , ³⁴ , ³⁷ , ³⁹ , ⁴³ , ⁴⁴ , ⁴⁵ , ⁵⁴ , ⁵⁵ , ⁶⁴ , ⁶⁷ , ⁷³ , ⁷⁴

Forty‐seven studies were conducted in a single country. ²¹ , ²⁴ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵² , ⁵³ , ⁵⁴ , ⁵⁵ , ⁵⁷ , ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁶¹ , ⁶² , ⁶³ , ⁶⁴ , ⁶⁵ , ⁶⁶ , ⁶⁷ , ⁶⁸ , ⁶⁹ , ⁷⁰ , ⁷¹ , ⁷² , ⁷³ Eight studies were conducted in multiple countries. ²⁰ , ²² , ²³ , ²⁵ , ³⁴ , ⁵¹ , ⁵⁶ , ⁷⁴ Seven studies were conducted to make comparisons of mental disorder identification and other aspects with those of HICs such as the United States and Australia. ²² , ²³ , ²⁵ , ³⁴ , ⁵¹ , ⁵⁶ , ⁷⁴ A majority of studies used vignettes with multiple purposes ²⁰ , ²¹ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵³ , ⁵⁴ , ⁵⁵ , ⁵⁷ , ⁵⁸ , ⁶¹ , ⁶² , ⁶³ , ⁶⁴ , ⁶⁵ , ⁶⁷ , ⁶⁹ and used vignettes describing multiple disorders. ²⁰ , ²¹ , ²³ , ²⁷ , ²⁹ , ³⁰ , ³¹ , ³⁴ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴⁴ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵⁷ , ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁶¹ , ⁶² , ⁶³ , ⁶⁵ , ⁶⁷ , ⁶⁸ , ⁷¹ The number of vignettes ranged from 1 to 16, without considering the random alternation of the demographics of vignettes (Table 1).

Table 1.

Characteristics of the included studies.

No.	Author year	Country	Population	Sample size	Purpose of the use of the vignettes	Diagnosis of the vignettes	Number of vignettes
Observational, quantitative studies
1	Wig et al. (1980) 20	Philippines, India, Sudan	Key informant	198 (Philippines 98, India 50, Sudan 50)	Stigma, identification of similar cases in the community based on the vignettes	Schizophrenia, psychosis, depressive disorder (depressive psychosis, depressive neurosis), bipolar disorder (mania), intellectual disability (child), epilepsy (child)	7
2	Khare et al. (1988) 21	Malaysia	Key informant	180	Mental disorder identification, stigma, identification of similar cases in the community based on the vignettes	Schizophrenia, psychosis, depressive disorder, bipolar disorder (mania), intellectual disability, epilepsy	6
3	Kurihara et al. (2000) 23	Indonesia, Japan	General population	143 (Indonesia 77, Japan 66)	Stigma	Schizophrenia, depressive disorder, anxiety disorder (OCD)	5
4	Mas and Hatim (2002) 24	Malaysia	University student (medicine)	193	Stigma	Schizophrenia	1
5	Lotrakul and Saipanish (2009) 26	Thailand	Medical doctors (not psychiatrists, psychiatrists)	467 (medical doctors [not psychiatrists] 434, psychiatrists 33)	Mental disorder identification, help‐seeking	Depressive disorder	1
6	Liu et al. (2011) 30	China	Medical doctors (psychiatrist), health workers (mental health)	70	Mental disorder identification, help‐seeking	Schizophrenia, depressive disorder	2
7	Minas et al. (2011) 31	Malaysia	Health workers (not mental health)	654	Stigma, health workers' clinical practice towards the vignettes	Unspecified mental disorder, diabetes	2
8	Wong and He (2011) 32	China	General population	522	Mental disorder identification, explanatory model, help‐seeking	Schizophrenia	1
9	Wong et al. (2012) 35	China	General population	522	Mental disorder identification, explanatory model, help‐seeking	Depressive disorder	1
10	Yang et al. (2012) 36	China	General population	160	Mental disorder identification, stigma	Schizophrenia	4
11	Wang et al. (2013) 38	China	General population	1953	Mental disorder identification, explanatory model, help‐seeking, stigma	Schizophrenia, depressive disorder, bipolar disorder (mania), anxiety disorder (GAD)	5
12	Luo et al. (2014) 41	China	General population	848	Mental disorder identification, stigma	Other substance use disorder, individuals without mental disorders	4
13	Williams et al. (2014) 42	China	University student (medicine)	163	Mental disorder identification	Schizophrenia, depressive disorder, suicidal ideation with cancer	3
14	Wu et al. (2016) 46	China	Medical doctors (not psychiatrist)	374	Mental disorder identification, explanatory model, help‐seeking, stigma	Anxiety disorder (GAD)	1
15	Yu et al. (2016) 47	China	General population	2052	Mental disorder identification, explanatory model	Depressive disorder, anxiety disorder, alcohol‐related disorder	3
16	Chen et al. (2017) 48	China	Caregivers of individuals with mental disorders	402	Mental disorder identification, explanatory model, help‐seeking	Schizophrenia, depressive disorder	2
17	Wu et al. (2017) 49	China	Health workers (not mental health)	1123	Mental disorder identification, explanatory model, help‐seeking, stigma	Schizophrenia, depressive disorder, anxiety disorder (GAD)	3
18	Boge et al. (2018) 50	Viet Nam	General population	729	Help‐seeking	Schizophrenia, depressive disorder	2
19	Liu et al. (2018) 51	China, United States	Student (nursing)	310 (China 158, United States 152)	Help‐seeking	Schizophrenia, depressive disorder	2
20	Martensen et al. (2018) 52	Viet Nam	General population	455	Stigma	Schizophrenia	1
21	Nguyen Thai and Nguyen (2018) 53	Viet Nam	University student (public health, sociology)	350	Mental disorder identification, help‐seeking	Depressive disorder	1
22	Woodcock and Jiang (2018) 56	China, Australia	Trainee teachers	240 (China 101, Australia 139)	Stigma	Child learning disability	8
23	Huang et al. (2019) 57	China	Han Chinese general population	1812	Mental disorder identification, explanatory model, help‐seeking	Schizophrenia, depressive disorder	2
24	Li et al. (2019) 58	China	General population	412	Explanatory model, help‐seeking, stigma	Schizophrenia, depressive disorder	2
25	Luo et al. (2019) 59	China	Health workers (mental health)	418	Stigma	Other substance use disorder, individuals without mental disorders	2
26	Wu et al. (2019) 60	China	Health workers (not mental health)	1123	Stigma	Schizophrenia, depressive disorder, anxiety disorder (GAD)	3
27	Deng et al. (2020) 61	China	General population	1066	Mental disorder identification, stigma	Other substance use disorder, hypertension	2
28	Hao et al. (2020) 62	China	Health workers (not mental health)	601	Mental disorder identification, help‐seeking, stigma	Schizophrenia, depressive disorder, anxiety disorder (GAD)	3
29	Martensen et al. (2020) 63	Viet Nam	Elderly people	771	Mental disorder identification, Stigma	Schizophrenia, depressive disorder	2
30	Huang et al. (2021) 65	China	Elderly people	173	Mental disorder identification, help‐seeking	Depressive disorder, bipolar disorder (mania)	2
31	Yang et al. (2021) 66	China	Left‐behind adolescents (adolescents whose parents have both migrated to the urban and live with their grandparents or other families)	1469	Mental disorder identification	Depressive disorder	1
32	Li et al. (2022) 68	China	Women with young children	67	Emotional reaction	Child internalizing and externalizing behaviors	16
33	Nishio and Marutani (2022) 69	Cambodia	General population	346	Mental disorder identification, explanatory model, help‐seeking, emotional reaction	Psychosis	1
34	Datu (2023) 70	Philippines	High school students	293	Stigma	Pervasive developmental disorder	1
35	Hao et al. (2023) 71	China	Caregivers of individuals with mental disorders	607	Stigma	Schizophrenia, depressive disorder, anxiety disorder (GAD)	3
36	Li et al. (2023) 72	China	Health workers (not mental health)	8314	Stigma	Depressive disorder	1
Observational, qualitative studies
37	Niemi et al. (2010) 27	Viet Nam	Women with young children, health workers (not mental health)	18 (women with young children 9, health workers [not mental health] 9)	Explanatory model, help‐seeking, identification of similar cases in the community based on the vignettes	Depressive disorder (depression, postnatal depression)	1
38	Swami et al. (2010) 28	Malaysia	Malay Malaysian general population	342	Mental disorder identification, explanatory model, help‐seeking	Depressive disorder	2
39	Loo and Furnham (2012) 33	Malaysia	Chinese Malaysian general population	409	Mental disorder identification, explanatory model, help‐seeking	Depressive disorder	2
40	Loo and Furnham (2013) 37	Malaysia	Indian Malaysian general population	314	Mental disorder identification, explanatory model, help‐seeking	Depressive disorder	2
41	Niemi et al. (2015) 43	Viet Nam	Health workers (not mental health), elderly women	28 (health workers 12, general population 16)	Explanatory model, help‐seeking	Depressive disorder (perinatal depression)	1
42	Abrams et al. (2016) 44	Viet Nam	Health workers (not mental health), perinatal women	26 (health workers 12, perinatal women 14)	Explanatory model, help‐seeking	Depressive disorder (postpartum depression), anxiety disorder (antenatal anxiety)	2
43	Shoesmith and Pang (2016) 45	Malaysia	General population	378	Mental disorder identification, explanatory model, help‐seeking	Depressive disorder	1
44	Qiu et al. (2018) 54	China	Women (depressive and not depressive women)	416	Mental disorder identification, explanatory model, help‐seeking	Depressive disorder	1
45	Surjaningrum et al. (2018) 55	Indonesia	Health workers (not mental health, mental health), perinatal women	62	Identification of similar cases in health services based on the vignettes, similar personal experience, feasibility of task sharing	Depressive disorder (perinatal depression)	4
46	Handoyo et al. (2021) 64	Indonesia	Key professionals (medical doctors, psychologist, teachers, religious leaders)	18	Explanatory model, stigma	Intellectual disability	2
47	Nguyen (2023) 73	Viet Nam	General population	325	Explanatory model	Dementia	2
Observational, mixed method studies
48	Fry and Nguyen (1996) 22	Viet Nam, Australia	University student (nursing)	187 (Viet Nam 93, Australia 94)	Stigma	Depressive disorder	1
49	Angermeyer et al. (2004) 25	Mongolia, Russia	General population	849 (Mongolia 474, Russia 375)	Explanatory model, stigma, emotional reaction	Schizophrenia	1
50	van der Ham et al. (2011) 29	Viet Nam	Questionnaire; general population FDG: general population, relatives of individuals with mental disorders	Questionnaire 200, FGD 76	Stigma	Schizophrenia, depressive disorder, anxiety disorder (GAD), alcohol‐related disorder, diabetes	5
51	Loo et al. (2012) 34	Malaysia, United Kingdom, Hong Kong	General population	440 (Malaysia 150, United Kingdom 150, Hong Kong 140)	Mental disorder identification, help‐seeking	Schizophrenia, depressive disorder (adult, child), anxiety disorder (OCD, social phobia), child attention‐deficit/hyperactivity disroder (ADHD), child daily troubles	9
52	Gong and Furnham (2014) 39	China	General population	212	Mental disorder identification, help‐seeking, stigma	Schizophrenia, depressive disorder (adult/child), bipolar disorder, anxiety disorder　(OCD/social phobia), child ADHD, stress, child daily troubles	9
53	Cheung et al. (2022) 67	China	General population	123	Help‐seeking, stigma	Alcohol‐related disorder, other substance use disorder	2
54	Ip et al. (2024) 74	China, United States	Women with young children	108 (China 56, United States 52)	Explanatory model	Child externalizing behaviors	6
Intervention study
55	Jie et al. (2014) 40	China	Health workers (mental health)	99	Mental disorder identification, help‐seeking	Schizophrenia, bipolar disorder	2

Abbreviations: ADHD, attention‐deficit/hyperactivity disorder; FDG, focus group discussion; GAD, generalized anxiety disorder; OCD, obsessive–compulsive disorder.

Study site, population, purpose of the use of vignettes, and vignette diagnosis

In terms of study sites, 29 studies were conducted in China excluding Hong Kong Special Administrative Region and Macao Special Administrative Region, ³⁰ , ³² , ³⁵ , ³⁶ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵¹ , ⁵⁴ , ⁵⁶ , ⁵⁷ , ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁶¹ , ⁶² , ⁶⁵ , ⁶⁶ , ⁶⁷ , ⁶⁸ , ⁷¹ , ⁷² , ⁷⁴ followed by 10 studies in Viet Nam ²² , ²⁷ , ²⁹ , ⁴³ , ⁴⁴ , ⁵⁰ , ⁵² , ⁵³ , ⁶³ , ⁷³ and 8 studies in Malaysia. ²¹ , ²⁴ , ²⁸ , ³¹ , ³³ , ³⁴ , ³⁷ , ⁴⁵ Among the 22 LMICs in the East Asia and the Pacific region, studies from eight countries, namely Cambodia, China, Indonesia, Malaysia, Mongolia, Philippines, Thailand, and Viet Nam, were found (Table 2).

Table 2.

Summary of study area, study population, diagnosis of vignettes, and purpose to use vignettes of the included studies.

	Number of studies
Country
Cambodia	1
China	29
Indonesia	3
Malaysia	8
Mongolia	1
Philippines	2
Thailand	1
Viet Nam	10
Population
General population	23
Specific population
Key informant	2
Perinatal women, women with young children	5
Elderly people	3
Students (high school, university, trainee teacher)	7
Individuals with mental health symptoms	1
Caregivers and families of individuals with mental disorders	3
Health workers
Medical doctors (not psychiatrists)	2
Medical doctors (psychiatrists)	2
Health workers (not mental health)	9
Health workers (mental health)	4
Key professionals	1
Disorders depicted in vignettes
Schizophrenia/psychosis	26
Depressive disorder	36
Bipolar disorder	6
Anxiety	12
Alcohol‐related disorder	3
Other substance use disorder	4
Intellectual disability	3
Mental disorders among children	4
Purpose of the use of the vignette
Mental disorder identification	29
Explanatory model	22
Help‐seeking	28
Stigma	27

Note: A table listing the studies for each category is provided as Supporting Information S1: Table 1.

In terms of study population, 23 studies were conducted among general populations, including general populations of specific major ethnic groups. ²³ , ²⁵ , ²⁸ , ²⁹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴¹ , ⁴⁵ , ⁴⁷ , ⁵⁰ , ⁵² , ⁵⁷ , ⁵⁸ , ⁶¹ , ⁶⁷ , ⁶⁹ , ⁷³ Among specific populations, the common study populations were health workers not specialized in mental health, ²⁷ , ³¹ , ⁴³ , ⁴⁴ , ⁴⁹ , ⁵⁵ , ⁶⁰ , ⁶² , ⁷² followed by students ²² , ²⁴ , ⁴² , ⁵¹ , ⁵³ , ⁵⁶ , ⁷⁰ and perinatal women and women with young children. ²⁷ , ⁴⁴ , ⁵⁵ , ⁶⁸ , ⁷⁴ Only one study was conducted among individuals with mental health symptoms, ⁵⁴ and three studies were conducted among caregivers and families of individuals with mental disorders (Table 2). ²⁹ , ⁴⁸ , ⁷¹

Regarding the disorders depicted in vignettes, 36 studies used vignettes for depressive disorders, ²⁰ , ²¹ , ²² , ²³ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³³ , ³⁴ , ³⁵ , ³⁷ , ³⁸ , ³⁹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵³ , ⁵⁴ , ⁵⁵ , ⁵⁷ , ⁵⁸ , ⁶⁰ , ⁶² , ⁶³ , ⁶⁵ , ⁶⁶ , ⁷¹ , ⁷² 26 studies used those for schizophrenia and/or psychosis, ²⁰ , ²¹ , ²³ , ²⁴ , ²⁵ , ²⁹ , ³⁰ , ³² , ³⁴ , ³⁶ , ³⁸ , ³⁹ , ⁴⁰ , ⁴² , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵⁷ , ⁵⁸ , ⁶⁰ , ⁶² , ⁶³ , ⁶⁹ , ⁷¹ and 12 studies used those for some form of anxiety disorder, including generalized anxiety disorder, specific phobia, obsessive–compulsive disorder, etc. ²³ , ²⁹ , ³⁴ , ³⁸ , ³⁹ , ⁴⁴ , ⁴⁶ , ⁴⁷ , ⁴⁹ , ⁶⁰ , ⁶² , ⁷¹ Only four studies used child vignettes, such as a child with a depressive disorder, neurodevelopmental disorder, and internalizing or externalizing problems (Table 2). ²⁰ , ³⁴ , ³⁹ , ⁵⁶

In terms of the purpose of using vignettes, four main categories were found. First is mental disorder identification, which refers to whether study participants identify vignettes as having mental disorders or not. Second is explanatory models, which refer to what kind of explanation or causes study participants have for vignettes. Third is help‐seeking, which refers to what kind of support or treatment study participants seek for vignettes or believe to be effective for vignettes. Fourth is stigma, which refers to what kind of stereotypes, attitudes, and behaviors study participants have for vignettes. Using vignettes, 29 studies investigated mental disorder identification, ²¹ , ²⁶ , ²⁸ , ³⁰ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵³ , ⁵⁴ , ⁵⁷ , ⁶¹ , ⁶² , ⁶³ , ⁶⁵ , ⁶⁶ , ⁶⁹ 22 studies investigated explanatory models, ²⁵ , ²⁷ , ²⁸ , ³² , ³³ , ³⁵ , ³⁷ , ³⁸ , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁴ , ⁵⁷ , ⁵⁸ , ⁶⁴ , ⁶⁹ , ⁷³ , ⁷⁴ 28 studies investigated help‐seeking, ²⁶ , ²⁷ , ²⁸ , ³⁰ , ³² , ³³ , ³⁴ , ³⁵ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵³ , ⁵⁴ , ⁵⁷ , ⁵⁸ , ⁶² , ⁶⁵ , ⁶⁷ , ⁶⁹ and 27 studies investigated stigma. ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁹ , ³¹ , ³⁶ , ³⁸ , ³⁹ , ⁴¹ , ⁴⁶ , ⁴⁹ , ⁵² , ⁵⁶ , ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁶¹ , ⁶² , ⁶³ , ⁶⁴ , ⁶⁷ , ⁷⁰ , ⁷¹ , ⁷² Other purposes which were not included in the four categories were emotional response to vignettes, ²⁵ , ⁶⁸ , ⁶⁹ identification of similar cases in the community based on vignettes, ²⁰ , ²¹ , ²⁷ , ⁵⁵ similar personal experiences with vignettes, ⁵⁵ feasibility of task sharing in responding to vignettes, ⁵⁵ and clinical practice of health professionals with vignettes. ³¹ Most studies had multiple purposes for using vignettes (Table 2).

Methodology of vignette and survey item development

At least one vignette text was included in the main text or in supporting material in 31 studies. ²⁰ , ²¹ , ²² , ²⁴ , ²⁶ , ²⁷ , ³⁰ , ³¹ , ³² , ³⁴ , ³⁶ , ³⁷ , ³⁹ , ⁴¹ , ⁴³ , ⁴⁴ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵³ , ⁵⁴ , ⁵⁶ , ⁵⁷ , ⁵⁸ , ⁶⁰ , ⁶¹ , ⁶⁴ , ⁶⁵ , ⁷² , ⁷³ , ⁷⁴ Regarding the vignette development process, five main procedures were found. First, vignettes were developed based on vignettes used in previous studies, a procedure used in 36 studies. ²¹ , ²⁵ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴³ , ⁴⁵ , ⁴⁶ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁴ , ⁵⁶ , ⁵⁸ , ⁶⁰ , ⁶² , ⁶³ , ⁶⁴ , ⁶⁶ , ⁶⁸ , ⁶⁹ , ⁷¹ , ⁷³ , ⁷⁴ Vignettes which were used in the studies directed by Anthony Jorm were the most frequently used among the included studies, ¹¹ , ⁷⁵ , ⁷⁶ , ⁷⁷ , ⁷⁸ followed by those used in the studies by Matthias Angermeyer. ¹³ , ⁷⁹ , ⁸⁰ , ⁸¹ Second, vignettes were developed based on international diagnostic criteria such as International Classification of Diseases, 10th revision, the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM‐III‐R), the DSM‐IV, and the DSM‐V. ⁸² , ⁸³ Twenty‐nine studies employed the procedure. ²³ , ²⁵ , ²⁷ , ²⁸ , ³⁰ , ³² , ³³ , ³⁵ , ³⁷ , ³⁹ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵⁷ , ⁶⁰ , ⁶¹ , ⁶² , ⁶³ , ⁶⁵ , ⁶⁶ , ⁶⁹ , ⁷¹ Third, vignettes were developed through some form of cultural adaptation or cultural validation, with 31 studies utilized the procedure. ²⁰ , ²¹ , ²² , ²⁷ , ²⁸ , ²⁹ , ³³ , ³⁴ , ³⁶ , ³⁷ , ³⁹ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵³ , ⁵⁴ , ⁵⁷ , ⁵⁸ , ⁶⁰ , ⁶¹ , ⁶³ , ⁶⁴ , ⁶⁵ , ⁶⁶ , ⁶⁸ , ⁷² , ⁷³ The most common method of cultural adaptation was the use of local names for vignette characters. Other methods included the use of expressions from local screening tools in vignettes and the validation of the cultural appropriateness of vignettes by local experts, etc. Fourth, vignettes were validated by mental health experts for their diagnosis accuracy. ²⁵ , ⁵⁷ , ⁶³ Fifth, vignettes were validated through pilot testing. ²⁰ , ²⁵ , ⁴⁷ , ⁵³ , ⁶⁴ Some studies did not explain how the vignettes were developed at all (Table 3).

Table 3.

Development of vignettes and survey items used for the vignettes.

	Number of studies
Vignette
Vignette text provided	31
Based on vignettes in previous studies	36
Based on international diagnostic criteria	29
Cultural adaptation	31
Diagnostic confirmation by psychiatrists/mental health specialists	3
Pilot test	5
Questionnaire items/interview items
Based on previous studies	39
Cultural adaptation, validation, and/or confirmation of psychometric properties	20

Note: A table listing the studies for each category is provided as Supporting Information S2: Table 2.

Regarding the development of survey items used to elicit opinions on vignettes, two main procedures were identified. First, survey items were developed based on previous studies. Second, survey items were developed through some form of cultural adaptation, validation, and/or confirmation of psychometric properties among the study population. As examples of cultural adaptation, locally relevant items such as traditional healers were added to help‐seeking questionnaires, or locally unavailable treatments and services were removed. Thirty‐nine studies used survey items based on previous studies, ²⁰ , ²² , ²³ , ²⁴ , ²⁵ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴¹ , ⁴⁵ , ⁴⁶ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁴ , ⁵⁶ , ⁵⁹ , ⁶⁰ , ⁶¹ , ⁶² , ⁶³ , ⁶⁵ , ⁶⁶ , ⁶⁷ , ⁶⁹ , ⁷¹ , ⁷² , ⁷⁴ such as Anthony Jorm's questionnaires on causes and sources of help‐seeking ¹¹ , ⁷⁵ , ⁷⁶ and Bruce Link's questionnaires on social distance. ⁸⁴ , ⁸⁵ Twenty studies used survey items after cultural adaptation, validation, and/or confirmation of psychometric properties among the study population (Table 3). ²⁹ , ³⁰ , ³² , ³⁵ , ³⁶ , ³⁸ , ³⁹ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁶ , ⁵⁹ , ⁶² , ⁶³ , ⁶⁷ , ⁷¹ , ⁷²

Sixteen studies reported limitations of the use of vignettes in their study. ²⁷ , ³¹ , ³⁴ , ³⁸ , ³⁹ , ⁴¹ , ⁴⁴ , ⁴⁵ , ⁴⁷ , ⁵¹ , ⁵² , ⁵⁴ , ⁵⁹ , ⁶¹ , ⁷³ , ⁷⁴ Limitations were (1) the cultural validity of the vignettes when vignettes based on studies originally conducted in HICs or vignettes based on international diagnostic criteria were used, ²⁷ , ³⁴ , ³⁹ , ⁴⁴ (2) the possibility that responses to vignettes may not reflect the attitudes or behaviors of study participants in the real world, ³¹ , ³⁸ , ⁵⁹ , ⁷⁴ (3) the limitations of quantitative studies and the need for qualitative studies, ⁴⁵ , ⁵¹ , ⁷³ (4) a number of vignettes used in a study being inadequate to comprehensively understand societal perspectives on mental disorders, or being too large to prevent contamination of opinions between vignettes, ⁴⁷ , ⁵¹ (5) the influence of additional information included in vignettes, ⁴¹ , ⁶¹ and (6) vignettes not being simple enough for study participants. ³⁹ , ⁵⁴

DISCUSSION

Summary of the results

This scoping review identified 55 studies conducted in eight LMICs in the East Asia and the Pacific region, and published between 1980 and 2024. Most studies were observational, and quantitative methods were common. Vignettes of individuals with depressive disorder, schizophrenia, and anxiety disorder were often used to examine mental disorder identification, explanatory model, help‐seeking, and stigma. Vignettes were often developed based on vignettes from previous studies and international diagnostic criteria with cultural adaptation or validation. Survey items used to elicit opinion on vignettes were also frequently obtained from previous studies with cultural adaptation or validation.

This review shows that a significant number of vignette studies have been conducted in LMICs in East Asia and the Pacific, demonstrating the usefulness of the methodology. Although the number of studies has increased since 2010, the majority of the included studies until April 2024 were conducted in China, Viet Nam, and Malaysia. As culturally bounded explanatory models and help‐seeking strategies are assumed in LMICs in the region, vignettes are a useful technique to explore study participants' opinions without using the diagnosis of mental disorders of interest. And information obtained from a vignette study, such as awareness level, explanatory models, help‐seeking strategies, and stigma, can be used to develop culturally adapted mental health services. Given the above usefulness of the methodology, more vignette studies in different areas are expected in the future.

In terms of mental disorders portrayed in the vignettes, depressive disorders, schizophrenia, and anxiety disorders were the most common. This reflects the mental disorders with higher priority in LMICs, as indicated by the World Psychiatric Association survey, ⁸⁶ and also the mental disorders with higher years lived with disability, as indicated by the Global Burden of Disease Study. ¹ On the other hand, some experts noted that health workers in nonspecialized settings often see people with mild and nonspecific symptoms combined with psychosocial distress and physical health problems that are difficult to diagnose as specific mental disorders. ⁴ Simplified treatment guidelines based on diagnosis such as the Mental Health Gap Action Plan, which are developed to promote the scale‐up of mental health services, cannot tell health workers how to respond to these cases. ² Understanding these difficult‐to‐diagnose cases would be informative when considering how to address the challenges to community mental health services. In addition, vignettes are considered useful for exploring perceptions, attitudes, and behaviors towards atypical cases, which are thought to be more diverse.

In order to conduct vignette studies more effectively, this review raised a number of points. First, linguistic validation and cultural adaptation or validation should be emphasized. As shown, the majority of the included studies developed vignettes based on vignettes used in previous studies conducted in HICs. Linguistic validation is especially important when vignettes are translated into a language that belongs to a different linguistic system than the original language, as there may not even be corresponding words. However, only some studies reported the translation procedures in detail. Cultural adaptation or validation was not performed or reported in some studies. Furthermore, the most common method of cultural adaptation is the use of local names for vignette characters, which might not be deep enough. Some studies raised concerns about the use of vignettes developed for use in HICs or based on international diagnostic criteria, which may differ from the local expression of the corresponding mental disorders. ²⁷ , ³⁴ , ³⁹ , ⁴⁴ The appropriateness of vignettes in the study area and the ease of vignettes for study participants should be ensured and reported. The development of original vignettes should also be encouraged, with appropriate reporting of the development process. Second, the use of qualitative methods such as in‐depth interviews and focus group discussions can be emphasized to gain deeper insights into the study topic. However, qualitative methods in LMICs are challenged by the availability of competent data collectors and the comfort level of participants to express or discuss their opinions. In case of quantitative studies, survey items, especially questionnaires developed in HICs, need to be used with caution as they may not be able to capture deeper ideas related to the research question. Like vignettes, linguistic validation and cultural adaptation or validation are also important for questionnaires. They may not cover all possible options or may include unavailable options in the study settings. Third, the importance of local researchers' and mental health professionals' roles should be recognized. To conduct a study investigating perceptions of mental disorders in context, local researchers and mental health professionals with cultural psychiatry perspectives are essential. Furthermore, their roles are indispensable to achieving the aforementioned two points. More than three quarters of the studies included in this review had at least one author affiliated with a local institution. When an international team conducts a study, it is important to codevelop it with local researchers and mental health professionals based on local challenges to utilize the results for the study area's practice or policy. In summary, investigating how mental disorders are perceived in LMICs requires developing a research team that includes local researchers or mental health professionals, designing a study based on local issues, and ensuring the linguistic and cultural appropriateness of vignettes and questions. Conducting such studies continuously will ultimately lead to a deeper understanding of how mental disorders are perceived within the local context.

Based on the results of this review, to improve the reporting of vignette studies, we recommend reporting (1) at least one vignette text, (2) the original study if vignettes were obtained from previous studies, (3) the process of translation and cultural adaptation or validation if vignettes were obtained from previous studies, and (4) the process of vignette development and validation of diagnostic accuracy if vignettes were originally developed. Similar points were noted from a scoping review on the development and use of research vignettes in qualitative studies among health workers. ⁹ Our recommendation is also applicable to future vignette studies in LMICs in other regions.

As a possibility of future research, based on the accumulation of vignette studies in East Asia and the Pacific, the similarities and differences in explanatory models and help‐seeking strategies can be investigated. This allows extrapolation of the evidence. Furthermore, vignette studies can be used to assess change in awareness, explanatory models, help‐seeking strategies, and stigma towards mental disorders over time. This may be used to measure the effectiveness of large‐scale mental health awareness‐raising or anti‐stigma campaigns in the future. Scoping reviews with the same aim in other regions are also a future research focus, although some of the findings and recommendations based on the findings can be extrapolated to vignette studies in other regions.

Limitations

This scoping review has a few limitations. First, this review used the search term “vignette” to identify relevant articles. If other terms were used for vignettes, these articles were not included, and the quality may have been compromised. However, alternative terms for vignettes, such as “case” or “situation,” possess minimal specificity, thereby hindering the identification of relevant vignette studies when employing these terms as search criteria. In addition, some of the previous scoping reviews that focused on vignettes also used “vignette” as the only search term and effectively reported the results. ⁹ , ⁸⁷

Second, some of the included studies did not fully report on their vignettes and how they developed the vignettes. Therefore, it is not possible to distinguish between missing procedures and underreporting. The reporting of the development and use of vignettes need to be strengthened.

Third, data extraction and categorization of extracted data were performed by one author (A.A.). This reduced the reliability of the data extraction.

CONCLUSIONS

This study demonstrated that a considerable number of studies used vignettes to investigate the perceptions of mental disorders in context in LMICs in the East Asia and the Pacific region. However, despite the aim to understand mental disorders in context, most studies were quantitative studies using vignettes obtained from previous studies. To conduct these studies, it is important to design the study based on local challenges with local researchers or mental health professionals. It is also important to ensure the linguistic and cultural appropriateness of the vignettes and question items as well as to consider the use of qualitative methodologies. Understanding mental disorders in context via studies that effectively use vignettes would generate valuable knowledge that contributes to the development of culturally appropriate mental health services in LMICs.

AUTHOR CONTRIBUTIONS

Ai Aoki, Maiko Suto, and Kimihiro Nishino designed the study. Ai Aoki and Maiko Suto performed the screening of the articles. Ai Aoki performed the data extraction. Ai Aoki drafted the first manuscript. All authors critically reviewed the analysis and the manuscript. All authors approved the final manuscript.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS APPROVAL STATEMENT

Not applicable.

PATIENT CONSENT STATEMENT

Not applicable.

CLINICAL TRIAL REGISTRATION

Not applicable.

Supporting information

Supporting Information.

Supporting Information.

Supporting Information.

Aoki A, Suto M, Nishino K, Yamamoto E, Takehara K. The use of vignettes in studies on mental disorders in low‐ and middle‐income countries in the East Asia and the Pacific region: a scoping review. Psychiatry Clin Neurosci Rep. 2025;4:e70211. 10.1002/pcn5.70211

DATA AVAILABILITY STATEMENT

Data sharing is not applicable as no new data were generated in this study. The search strategies used in this review are provided as Supporting Information S3: Supporting Material 1.