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Vietnamese women living in Canada : contextual factors affecting Vietnamese women’s breast cancer and.. 2004

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VIETNAMESE WOMEN LIVING IN CANADA: CONTEXTUAL FACTORS AFFECTING VIETNAMESE WOMEN'S BREAST CANCER AND CERVICAL CANCER SCREENING PRACTICES by TAM TRUONG DONNELLY B.ScN., Dalhousie University, 1985 M.ScN., The University of British Columbia, 1998 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Individual Interdisciplinary Graduate Studies) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA July 2004 © Tarn Truong Donnelly, 2004 Abstract The aims of this qualitative research were to explore (a) how Vietnamese women participate in breast cancer and cervical screening, what leads Vietnamese women to seek health care, from whom they seek help, and the social support networks that they draw upon to foster their health care practices, (b) whether Vietnamese women find the current preventative cancer services suitable and accessible to them, (c) how Vietnamese women's breast cancer and cervical cancer screening practices are influenced by social, cultural, political, historical, and economic factors which are shaped by the conceptualisation of race, gender, and class, and (d) how differences between Vietnamese women's perspectives and those of health care providers influence women's health care experiences. By 2001, the estimated number of Vietnamese immigrants living in Canada was 151,410, approximately half of them women. Data from the U.S. and Australia show that breast cancer and cervical cancer are major contributors to cancer morbidity and mortality among Vietnamese women. Studies also suggest that Vietnamese women are at risk due to their low participation rate in these cancer preventative screening programs. Informed by Kleinman's explanatory model, postcolonialism, and feminism, in-depth interviews were conducted with 15 Vietnamese Canadian women and 6 health care providers. The study reveals the following major factors determining how Vietnamese women participate in breast cancer and cervical cancer screening programs: cultural conceptualisations of health and illness, social values and beliefs about the woman's body and social relationships; gendered roles and expectations; diminished social support networks; low socioeconomic status; and inaccessibility of health care services. At the theoretical level, I propose that health care professionals should (a) recognise that women of different ethno-cultural background are active participants in health care, (b) put less emphasis on western rationality and more on the recognisation that women's health care decision making is a dynamic process that varies under different circumstances, and (c) recognise that women's health care behaviour is influenced not only by their cultural knowledge and values, but also by their socially constructed position, race, gender, and class. At the practical level, I propose (a) that collaborative working relationships with physicians and improved physician-patient relationships are essential for successful promotional strategies for Vietnamese women, and (b) that a health education strategy must incorporate Vietnamese women's different ways of knowing. At the institutional level, increasing accessibility to these cancer preventive programs demands that health care policy makers increase institutional funding to support programs that provide services to immigrant women. Recommendations for future research include (a) a population-based survey to assess the current status of Vietnamese Canadian women's breast and cervical cancer screening practices, and to investigate the relationship between identified factors and Vietnamese women's cancer screening practices, (b) the development and implementation of a health promotion and disease prevention program that incorporates the findings of this study into its promotional strategies, and (c) an experimental study to evaluate the effectiveness of the newly developed promotional strategies on breast and cervical cancer screening among Vietnamese Canadian women. Table of Contents Abstract ii Table of Contents iv List of Tables ix Acknowledgements x Dedication xi Prelude xiii Chapter One: Introduction 1 Chapter Two: Literature Review 10 A. Vietnam: A Brief History 11 B. Vietnam: Religion and Culture 13 1. Confucianism 14 2. Mahayana Buddhism 15 3. Taoism 16 4. Christianity 16 5. Communal Life 17 6. Vietnamese Family Practices and The Changing Status of Vietnamese Women 19 7. Conceptualisation of the Female Body: Body as an Experiencing Illness Agent 24 C. Vietnamese Living in Canada 28 1. Economic Experiences 29 2. Social-Cultural Experiences 33 3. Health and Health Care Experiences 35 D. Breast Cancer and Cervical Cancer 37 1. Mortality and Incidence Rates 38 2. Vietnamese Canadian Women's Health Care and Cancer Screening Practices 39 E. Research Questions 42 Chapter Three: Theoretical Questions 43 A. Kleinman's Explanatory Model: Medical System as Cultural System 44 iv 1. The Popular Sector of Health Care 46 2. The Professional Sector of Health Care 46 3. The Folk Sector of Health Care 47 4. Explanatory Models (Ems) 47 B. Postcolonial-Feminist Scholarship: Its Relevance in Addressing Health Care Issues 49 1. Postcoloniaiism 50 2. Understanding Colonisation and Racialisation 51 3. Postcolonial Scholarship 56 4. What is Postcolonial Research? 57 5. Black Feminism 58 Chapter Four: Research Methods 65 A. Research Participants 65 B. Gaining Access and Developing Rapport 6 6 C. Method of Data Collection 68 D. Research Interviews 69 E. Data Interpretation, Coding, and Analysis 7 2 F. Representation of The Research Results 7 5 Chapter Five: Cultural Influences: Knowledge and Values 80 A. Cultural Knowledge and Values about Women's Bodies 80 1. The Private Body: Embarrassment, Hesitation, and Sexual Morality Discourses 80 2. The Body Is an Experiencing Agent: The Embodiment Experience 87 B. Cultural Conceptualisation of Health and Illness 88 1. "Health is Gold" (Sue khoe la vang) 89 2. Vietnamese Women's Conceptualisation of the Causes of Disease and Illness 91 Disease and Illness are Caused by the Imbalance of The Body 92 Disease and Illness are Caused by the Invasion of Bacteria 94 Disease and Illness are Predetermined by a Higher Power 97 C. Beliefs and Values about The Health Care Provider and Patient Relationship 98 D. Conclusion 101 Chapter Six: Gendered Roles and Expectations 104 v A. Vietnamese Social Relationships 1 0 4 B. Ms. Lyn's Story 1 1 1 C. Conclusion 1 1 4 Chapter Seven: Social Support Networks 1 1 8 A. Formal Social Support Networks 1 1 9 1. General Social Institutional Support 11 9 2. Formal Health Care Support Networks 1 2 4 B. Informal Social Support Networks 1 2 6 C. Social Discrimination 132 1. Cross-Ethnic Group Discrimination Experiences 132 2. Within Ethnic Group Discrimination Experiences 136 D. Conclusion 1 4 0 Chapter Eight: Socioeconomic Influence.... I 4 3 A. The Vietnamese Women's Economic Profiles 1 4 3 B. Women Participants' and Health Care Providers' Perspectives I 4 4 C. Socioeconomic Status Influences on Health and Health Care Behaviour 147 1. Low Socioeconomic Status and Health 150 2. Low Socioeconomic Status and Health Care Behaviour 152 D. Conclusion 155 Chapter Nine: Health Care Responsibility and Accessibility 161 A. The Canadian Health Care System 162 1. Foundational Values Underlying the Canadian Health Care System 162 2. Restructuring of The Canadian Health Care System 163 B. Shared Responsibility 1 6 6 1. Health Care Responsibility: The Women's Perspectives 167 2. Health Care Responsibility: The Health Care Providers' Perspectives 170 3. Inaccessibility of Health Care Services to Immigrant Women 173 Chapter Ten: Discussions, Recommendations, and Conclusion 179 A. Vietnamese Canadian Women: Health Care Decision Making Process 180 1. Recognition Stage 181 vi 2. Negotiation Stage 182 3. Integration/Resistance Stage 184 4. What Leads Women to Seek Health Care 187 5. Why Women Cannot Seek Health Care 188 6. From Whom do They Seek Help? 190 7. Women Participant's Experience on Breast Cancer and Cervical Screening 192 B. Promotion Strategies for Breast and Cervical Cancer Screening 193 1. Women Are Active Participants Of Health Care 193 2. Give Less Emphasis on Western Rationality 194 3. Socially Constructed Position, Race, Gender, and Class Affect Health Care Behaviour 197 C. Implications for Practice 198 1. Developing Collaborative Working Relationships 198 2. Considering Women's Different Ways Of Knowing 199 3. Increase Funding To Support Programs That Provide Services To Immigrant Women 202 D. Recommendations for Future Research 207 E. Conclusion 208 References 214 Appendices 228 Appendix A. Breast Cancer Screening Procedures For Women Over 40 Years of Age 227 Appendix B. Ethics Approval Form 230 Appendix C. Coding System 231 Appendix D. Women Participants' Socio-demographic Data 232 Appendix E. Vietnamese Woman's Consent Letter 234 Appendix F. Vietnamese Women's Consent Letter in Vietnamese 234 Appendix G. Initial Interview Questions for Vietnamese Women 235 Appendix H. Initial Interview Questions For Vietnamese Women in Vietnamese 238 Appendix I. Socio-Demographic Data Form 240 Appendix J. Socio-Demographic Data Form in Vietnamese 244 Appendix K. Initial Interview Questions For Health Care Providers 246 vii Appendix L. Health Care Provider's Consent Letter 24 Appendix M. Community Agency Project Information Letter For Recruitment Of Vietnamese Canadian Women's Participants 24 Appendix N. Community Agency Project Information Letter For Recruitment Of Vietnamese Canadian Women's Participants in Vietnamese 25 Appendix O. Community Agency Project Information Letter for Recruitment of Health Care Provider's Participants 25 viii List of Tables Table 1.1. 2001 Canada, British Columbia, and Vancouver Population Profile 7 Table 2.1. 1991 Canadian-Born and Vietnamese-Bom's Occupational Distribution 31 Table 2.2.1996 and 2001 Vietnamese Women's Occupational Distribution 32 Table 2.3. 1996 and 2001 Vietnamese Female's Income 33 Table 4.1. Health Care Provider Participants' Profile 65 Table 5.1. Papanicolaou Smears: Women Participants' Examination Pattern 81 Table 5.2. Mammography: Women Participants' Examination Pattern 82 Table 5.3. Clinical Breast Examination: Women Participants' Examination Pattern 82 Table 5.4. Breast-self Examination: Women Participants' Examination Pattern 82 Table 7.1. 2001 Vietnamese's Self-Employment Data 123 List of Figures Figure 10.1. Vietnamese Women's Health Care Decision Making Process 181 ix Acknowledgments This study was a collaborative effort including many people beside myself. Foremost are the women and men who participated in the study, giving their time, opening their hearts, shedding their tears, and sharing their worlds. To them, I offer my humble gratitude and hope that this dissertation, in some small way, repays them for their insights and trust. Several noble friends and mentors traveled with me on my journey, to whom I now bow in deepest gratitude. My heartfelt appreciation to Dr. Joan Anderson, my research supervisor and my most persistent intellectual power source. Dr. Anderson's vision and courage have inspired me to get to where I am today. Thank you for showing me the path, for sharing your wisdom, for caring, and for letting me know how theory could be linked to research and practice. I also offer my deepest appreciation to Dr. William McKellin, also my research supervisor - my most persistent source of encouragement. Dr. McKellin's endless prodding, pulling, and caring helped me to see the end of my journey. Thank you for keeping me together in mind and in text, and for lighting my path. My special thanks go to Dr. Bonnie Long, Dr. Gregory Hislop, and Dr. Nancy Waxier-Morrison - my research supervisory committee members. Thank you for your insights, for staying with me all the way, for cheering, and for seeing in me more than I could. For institutional support, I am grateful to the National Cancer Institute of Canada for the PhD Research Studentship Award, which provided me with funding from the Canadian Cancer Society. Above all, my deepest thanks to my children, Delmar, Jasmine, and Nakisa for enduring, encouraging, and reminding that what I was doing was good and significant, and for reassuring me that I am a good mother even when my work became stressful. In dedication to.. my parents - Tran Thi Ngoc Ann and Truong Cao Thanh for their courage, wisdom, and phuc due; my beloved late husband - Robert Lee Donnelly for his love and courage; my children - Delmar, Jasmine, and Nakisa for their hope and encouragement; Mehran Zabihiyan for his love and support; Shirley and Robert Donnelly for their affection and trust; my brother - Truong Cao Thien for his creativity and imaginations. xi Prelude It's beginning with my last gaze Upon the land I once called "home" Sadness Gladness Fear But my new home will be filled with laughter, warmth, and security. I envisioned. Look at me! Can you see a silent smile? Yes, I laugh but my laughter has no sound Yes, I am warm...within these walls Secure...if my loved ones around Please! Sir, which way do I go? Left?... Right? Back or forth? Back and forth Back and forth. Loss.... in this strange world. I cannot tell you how I feel my anguishes, my joys, my wishes For words piled up inside Cannot come out! cannot come out! cannot come out! I am locked up inside. Talk to me in any language...yours, mine, ours. I will only smile and nod. But the sound of your voice means that your are present and that you care. It fills this empty space that keeps me locked up inside. For without voices... You Me We are all locked up inside. Tarn Truong Donnelly xii Chapter One: Introduction An increase in the number of immigrants to Canada has changed Canadian social structure and approaches to health service delivery. Ensuring that immigrants from different ethnocultural backgrounds have equal access to appropriate health care services is an important issue for both the government and health care disciplines (British Columbia Ministry of Health and Ministry Responsible for Seniors, 1997). Between 1979 and 1985, approximately 85,000 South East Asian refugees arrived in Canada, most of them Vietnamese. "Refugees" as defined by the Citizenship and Immigration Canada (CIC), are people in or outside Canada who fear returning to their country of nationality or habitual residence. These are persons needing protection. Canada, through its refugee protection system, provides safe haven to those with a well-founded fear of persecution, or are at risk of torture or cruel and unusual treatment or punishment (Citizenship and Immigration Canada, 2004). By contrast, the term "immigrants" refers to persons who seek lawful admission to Canada to live as permanent residents (Citizenship and Immigration, 2004). Most ofthe Vietnamese who came to Canada between 1975 and 1985 were refugees. It is important to note that in this dissertation, I use the term "immigrant" to cover persons who are admitted to Canada in either the refugee or the immigrant category. I have given much thought to the use of this term. While I fully realized that the experience of a refugee versus an immigrant might be different due to the legal differences for immigration, I decided to use this term to cover Vietnamese refugees and immigrants because as my data show, Vietnamese who came to Canada as refugees and Vietnamese who came to Canada as immigrants (the majority of them came under family class category) face similar cultural, language, and economic challenges. Furthermore, even though Vietnamese who arrived as refugees received more support from the government than those who arrived as immigrants who received support from family members, this kind of support only lasted for a short time. Thus, there are very few differences in the eligibility for services and other institutional support by both groups. Although the term immigrant can generate negative stereotypical assumptions, using the term "immigrant" enabled me to avoid the term "refugee," a word which often implies that a refugee is usually a "survivor of oppression, plunged into poverty, purified by their suffering, and boundlessly grateful for safe haven" (Beiser, 1999, p. 170). The problems arise when there is evidence to show that the refugees are not "pure" or not "grateful" to the host society. There is a growing public ambivalence towards refugees. 1 Despite the fact that many Vietnamese refugees have successfully integrated into Canadian society and are good citizens, public misinformation about Vietnamese gang-related problems casts shadows on their image (Beiser, 1999). Sympathy turns to negativity and doubt. Not only are Vietnamese now viewed as trouble makers by some Canadians, but they are also viewed as a burden. A national survey by the Gallup organization of Canada in 1994 revealed that 39% of Canadians believe that "refugees were using up more than their share of the country's health and social services" (Beiser, 1999, p. 168-169) and 43% feel that the presence of Southeast Asian refugees in Canada costs the Canadian taxpayers too much money (Beiser, 1999). Furthermore, one-quarter of the Gallup poll respondents do not believe that "Southeast Asian refugees are interested in giving something back to Canada" (Beiser, 1999, p. 169). By 2001, the estimated number of Vietnamese immigrants living in Canada was 151,410 and 25,675 of these immigrants made their home in British Columbia (Statistics Canada, 2001 Census). Before coming to Canada, the majority of these immigrants suffered from poor health, disadvantaged economic situations, limited education, and lack of adequate medical care. Data from the U.S. and Australia show that breast cancer and cervical cancer are major contributors to cancer morbidity and mortality among Vietnamese women, especially cervical cancer. Studies have also suggested that Vietnamese women are at risk due to their low participation rate in cancer preventative screening programs. The new Health Goals for British Columbia were developed in 1997 as the result of an extensive public consultation process. The Ministry of Health's mission is "to maintain and improve the health of British Columbians by enhancing quality of life and minimising inequalities in health status" (British Columbia Ministry of Health and Ministry Responsible for Seniors, 1997, p. 5). Equality is a basic social value underlying the Canadian health care system. Equality in health care means that, in principle, all citizens should be given equal access to health care regardless of wealth, race, gender, or ethnic origin (Storch, 1996). However, according to the 1991 BC Royal Commission on Health Care and Cost, there is evidence that immigrants living in British Columbia do not have equal access to health care services. Many health care providers have recognised that immigrants often encounter difficulty accessing health care services and provision. Barriers to access the health care delivery system include limited language skills, different cultural health beliefs and practices, lack of cultural acceptance and appropriate health care services, and lack of social resources (Anderson, 1998; Hirota, 1999; Stephenson, 1995). Furthermore, ethnic inequality, unequal health care provider-client power relations, restructuring of the health care system with its emphasis on lowering health care costs have been identified as barriers to providing health care services for Asian immigrants. Despite the fact that BC's health care system has changed its services to some extent to accommodate the health care needs of the different ethno-cultural background clients, the BC Provincial Health Officer's 1996 Annual Report of 1995 revealed that "the health care needs of adults and children living in...ethnic neighbourhoods are not being well-served by the current system" (p. 1). Anderson and her colleagues (1993) argue that a significant number of immigrant women had difficulty in their encounters with health care professionals. The women, especially non- English speakers, were unable to obtain the services they needed because health care professionals often failed to understand that the position and condition in which the women worked and lived could be a major deterrent to the appropriate management of illness. As a result, the current health care system, which is based on the Western ideology of health and illness, frequently fails to accommodate the health care needs of clients of different ethno-cultural backgrounds (Anderson, 1991). In addition, dominant mainstream cultural conceptualisations can also situate and define immigrants' experiences within the health care system (Donnelly, 1998). In this dissertation, I use the term "health care providers" to mean health care professionals who provide health care to immigrants either directly or indirectly. In Canada, breast cancer is the second leading cause of cancer-related death for Canadian women over 50 years of age (National Cancer Institute of Canada: Canadian Cancer Statistics, 1998, 2003). Approximately 21,100 women developed breast cancer and 5,300 women died of this disease in 2003 (BC Cancer Agency, 2003). Breast cancer is primarily a disease of older women. The estimates for 2000 indicate that for all types of cancer, only 1 % of new cases and 0.3% of deaths occur prior to age 20 (National Cancer Institute of Canada: Canadian Cancer Statistics, 2000). The risk of developing breast cancer increases with increasing age. According to the 2000 Canadian Cancer Statistics, for breast cancer, 22% of cases occur in women under age 50, 45% occur in women aged 50-69, and 32% in women aged 70 and over. Although data on Vietnamese Canadian women's breast cancer incidence and mortality rate are limited, study shows that even though Asian American women's breast cancer incidence rate is lower than that of American women, the mortality rate tends to be higher for Asian American women (Perkins, Morris, & Wright, 1996 cited in Wismer, 1999). Even though cervical cancer is not ranked as the leading cause of cancer-related death, it is among the most common cancers for women in the countries where Papanicolaou (Pap) smears are not 3 routinely performed (BC Cancer Agency, 2000). Studies from the U.S. have revealed that the incidence and mortality rate for cervical cancer is notably higher for Asian American women than for White American women (McPhee, Stewart, Brock, Bird, Jenkins, & Pham, 1997; Perkins et al., 1996 cited in Wismer, 1999). Studies from Australia also indicate that Vietnamese-born women have a significantly higher incidence of cervical cancer (Cheek, Fuller, Gilchrist, Maddock, & Ballantyne, 1999; Lesjak, Hua, & Ward, 1999). The Canadian national forum on cervical cancer screening in 1995 confirms that the Pap test reduces the incidence of cervical cancer significantly (Lee, Parsons, & Gentleman, 1998), and early detection can reduce breast cancer mortality by 25-30% (BC Cancer Agency, 1999, 2004). This points to the necessity for early detection and treatment of these diseases in its early stages. Early detection of breast cancer and cervical cancer through screening is recommended by the Canadian Department of Health and Fitness, the Canadian Public Health Association, the Canadian provincial cancer agencies (Appendix A, p. 227), and the United States 1996 Preventative Services Task Force (Wismer, 1999). Women over 20 are recommended to have regular annual clinical breast examination (CBE) by doctors or qualified health professional (BC Cancer Agency, 2004). It has been suggested that women over age 20 should also practice breast self examination (BSE) monthly (Liu, 1999). However, monthly BSE is more controversial. Recently, it has been argued that BSE might not be an effective prevention measurement due to its inaccuracy. There is evidence to show that BSE does not reduce mortality from breast cancer and may increase women chances of having a benign breast biopsy (Thomas, Gao, Ray, Wang, Allison, Chen, Porter, Hu, Zhao, Pan, Wu, Coriaty, Evans, Lin, Stalsberg, & Self, 2002). Although 70% of breast cancers occur in women over 50 with no risk factors (i.e., family history of breast cancer, not having children, having first baby after age 30), regular mammography is recommended for women according to their age/risk group or at least every 2 years after the age 50 (BC Cancer Agency, 2004). Cervical cancer is much less common than breast cancer, largely because of the success of cervical cancer screening (BC cancer Agency, 2004). Pap tests are recommended at least every 2 years by the BC Cancer Agency for all sexually active women until age 69. Women over 69 may stop having regular Pap smear if all their previous smears have been normal (BC Cancer Agency, 2004). In North America, Asian women's preventive care needs remain poorly understood and their health problems have received less attention (Taylor, Hislop, Jackson, Tu, Yasui, Schartz, Teh, Kuniyuki, Acorda, Marchand, & Thompson, 2002). Data from Statistics Canada 1994/1995 National Population 4 Health Survey illustrate that Asian women are less likely to have Pap tests and the number of Asian-born women who never had a Pap test were almost nine times higher than those of Canadian-born women (Lee, Parsons, & Gentleman, 1998). A community-based survey of 776 Chinese women in British Columbia (Hislop, Teh, Lai, Labo, & Taylor, 2000) revealed that the proportion of Chinese women receiving Pap testing is lower than the provincial average (74% of the women had at least one previous Pap smear and 56% had a smear within the last 2 years). Although the U.S. national surveys which investigate mammography and Pap test use from 1987 and 1992 show a decrease in differences in screening practices by ethnicity (Martin, Calle, Wingo, & Health, 1996), the 1993/1994 Behavioural Risk Factor Surveys revealed that the group of "Asian/Other" women were less likely to have mammography compared to the general American women (Davis, 1996 cited in Wismer, 1999). I conducted a thorough literature review but was unable to locate Canadian data on Vietnamese women's breast cancer and cervical cancer screening. The sparse data from the U.S. and Australia suggest that Vietnamese women have a lower rate of participation in these cancer screening services (Cheek et al., 1999; Jenkins, Le, McPhee, Stewart, & Ha, 1996; Lesjak, Hua, & Ward, 1999; Yi, 1994). Studies from the U.S. indicate not only that Vietnamese women's cancer screening practices are not up to the recommended guidelines, but also that they were less likely to have had screening tests for these cancers compared to the general American women's population (Jenkins, Le, McPhee, Stewart, & Ha, 1996; Yi, 1994). The result from a telephone survey of 933 Vietnamese women living in California shows that 70% of these women had at least one clinical breast examination, whereas only 30% had a mammogram and 53% had a Pap test (McPhee et al., 1997). A more recent study by Sadler, Dong, Ko, Luu, and Nguyen (2001) with 275 Vietnamese American women revealed that the rate of having a mammogram among these women was below recommended level and only 36% reported having adequate knowledge about breast cancer screening. Furthermore, a questionnaire survey of 355 (Lesjak et al., 1999) and an interview survey of 199 Vietnamese-born women living in Australia (Cheek et al., 1999) revealed that the Vietnamese women had a lower level of participation in cervical cancer screening than that of the general population women. This low rate of screening suggests that Vietnamese women may be at risk for lack of early detection and treatment of cancer in its early stages. It has been obvious to the health care professional that successful treatments and effective health care can only be achieved if it is appropriate and accepted by the person who receives health care. This 5 awareness is essential, especially in providing health care to clients of a different culture. Different views of health, illness, and priorities between health practitioners and clients can create obstacles to helping relationships if a mutual solution cannot be reached. The point to remember is that, "the benefits of Western biomedicine cannot be realised unless practitioners are able to provide care in such a way that it is socially and culturally acceptable to their clients" (Anderson, 1990, p. 137). As such, it is important to include in any health inquiry both the clients' and the health care providers' perspectives. This study was conducted in Vancouver, British Columbia (BC), Canada. Vancouver is located on the west coast of BC, the westernmost of Canada's 10 provinces. It is know for its spectacular mountain skyline, Pacific Ocean view, blooming flowers and mildest weather in Canada. The city's mean temperatures average 20° C in the summer and 2°C in the winter. Beautiful views and mild temperatures have attracted many immigrants who came from warm climate countries. As a result, Vancouver is quite cosmopolitan with a mix of many multicultural groups. The immigrant population makes up 38% of Vancouver's 1,986,965 total population. Regarding the diversity of language, 61.2% of the population speak English, 1.3% speak French, and 37.5% speak non-official languages (British Columbia Ministry of Communities, Aboriginal, & Women's Services, 2001). A profile of immigrants in BC communities in 2001 shows that 50% of female immigrants are employed and the average income of these employed women is $24,790 per year. The three top occupations for female immigrants were clerical (12%), general sales and services (12%), and manufacturing machine operators (5%) (BC Ministry of Communities, Aboriginal, & Women's Services, 2001). More recent data show that Vancouver has experienced the largest increase in low income of all metropolitan areas in Canada (Statistics Canada, 2000). Furthermore, 37.4% of all recent immigrants were in low income; double the proportion of 17.8% two decades earlier (Statistics Canada, 2000). 6 Table 1.1 2001 Canada, British Columbia, and Vancouver Population Profile Canada British Columbia Vancouver Total population 29,639,035 3,868,875 1,986,965 Immigrant population 5,448,480 1,009,820 38,289 Share of total population 18% 26% 38% Vietnamese population 151,410 25,675 22,140 Share of total population 0.5% 2.5% 3% Source: Statistics Canada, Census of Population and Housing BC Stats The purposes of this research were: 1. To explore how Vietnamese women participate in breast cancer and cervical screening. Specifically, what leads Vietnamese women to seek health care and from whom do they seek help, and what social support networks do they draw upon to foster their health care practices. 2. To explore whether Vietnamese women find the current preventative cancer services suitable and accessible to them. 3. To explore how Vietnamese women's breast cancer and cervical cancer screening practices are influenced by social, cultural, political, historical, and economic factors which are shaped by the conceptualisation of race, gender, and class. 4. To explore how differences between Vietnamese women's perspectives and those of health care providers influence women's health care experiences. Vietnamese Canadian women's health care practices and the ways in which they participate in breast cancer and cervical cancer screening programs are influenced by their cultural knowledge and values about their bodies, about health care provider-client relationships, and their conceptualisations of health and of what causes diseases and illnesses. An understanding of how their cultural knowledge and values shape their world view and experiences can help the promotion of breast cancer and cervical cancer screening among these women. 7 It has been pointed out that different conceptualisations of health and the sources of illness can pose a barrier to seeking treatment from Western health care (Stephenson, 1995; Uba, 1992). LaBun (1988) in an earlier qualitative study conducted with Vietnamese women living in Canada revealed that Vietnamese women's understanding of health influenced the ways in which they view and use Western medicine and traditional health care practices. Studies by Maltby (1998) and Stephenson (1995) showed that the Vietnamese conceptualisation of health and illness, cultural beliefs, values, and expectations towards treatment shaped the ways in which they practice health care. Stephenson's study also revealed that the different environments and circumstances from which Vietnamese immigrants come created many health problems and barriers to accessing health care. To understand how a different culture and cultural conceptualisations of health, illness, and disease influence Vietnamese women's health care decision making, I draw on the explanatory model developed by Arthur Kleinman (1978, 1980). Kleinman's explanatory model provides the conceptual framework for an understanding of how clients from different ethnocultural backgrounds practice health care. As immigrants, and as women who came from a so-called Third World country, Vietnamese women's situated social position is one that is marginalised and subordinated to the mainstream society. To investigate how contextual factors —cultural, social, political, historical, and economic— at the intersection of race, gender, and class influence Vietnamese Canadian women's lived experiences and health care practices, I draw on postcolonialism and feminism. The main method of investigation was individual in-depth interviews with Vietnamese Canadian women and health care providers. The interviews were conducted with 15 Vietnamese women and 6 health care providers. In the present study, eight women came to Canada as refugees and another seven women came via the sponsorship program under family class. The findings of this research will be disseminated to health care professionals, health care policy makers, and other scholars interested in the areas of migration, gender, and health. The findings will also be used to develop a program of research that aims to develop cultural appropriate and acceptable cancer preventive service for Vietnamese Canadian women. This research will provide information on the utilisation of health care services and women's social support networks that foster health care practices, on women's health-seeking behaviour and decision-making, and on pertinent changes in policies and institutional practices. It may contribute to the empowerment of Vietnamese Canadian women through making their voices heard, and to improving quality and accessibility to health care services for Vietnamese immigrant women. 8 An understanding of cultural knowledge, values, patterns of family kinship, religion, and of social, political, and historical processes will assist in identifying health care strategies that could be applied to health promotion and disease prevention among Vietnamese immigrants. In the following chapters, I explore some of these issues in the hope of shedding light on Vietnamese women's responses to living in Canada, and the ways in which they practice health care. This research was approved by the University of British Columbia Ethics Review Committee (Appendix B, p. 229). Each participant was given an explanation of the study before informed consent was obtained. To preserve anonymity, all identifying information was removed from transcripts and code numbers were used (Appendix C, p. 230). All participant names used in this dissertation are pseudonyms. The following is the outline of chapters in this dissertation. Chapter two is the review of literature. In this chapter, I highlight certain historical, cultural, economic, social, and political issues affecting settlement and adaptation processes of Vietnamese immigrants. To situate this research in the Canadian context, I discuss some of the experiences of Vietnamese women living in Canada and their knowledge of breast cancer and cervical cancer, and of screening for these cancers. In chapter three, I address the theoretical perspectives that underlie this research. Chapter four reveals the method that was used for data collection and analysis. The results of this dissertation are discussed in chapter five, six, seven, eight, and nine. Chapter five addresses how culture knowledge and values influence Vietnamese women's lives and health care practices. Chapter six underscores the influence of gendered roles and expectations on the Vietnamese women's health care practices and cancer preventative screening. Chapter seven addresses social support networks that women draw upon to practice health care. In chapter eight, I discuss how socioeconomic status affects Vietnamese women's health care practices. Chapter nine clarifies how the women participants and their health care providers view health care responsibility. I show how being "different" affects health care services provided to immigrant women. Chapter 10 is the concluding chapter and includes my discussion and recommendations. 9 Chapter Two: Literature Review Vietnam, an "S" shaped country of Southeast Asia, covers 33,000 sq. kilometers. Three quarters of the country are covered in mountains and hills. The rest is open plains and crop growing deltas. There are two main deltas, the Red River Delta in the northern part of the country and the Mekong River Delta in the South. The country is 1,600 kilometers long and 50 kilometers wide in its narrowest part. With the Truong Son mountain to the West, the Pacific to the East, and powerful China to the North, Vietnam is considered a strategic position in the heart of Southeast Asia, and is a "crossroad" between Western and Eastern civilisation (Huu Ngoc, 1996). About 86% of the population is Viet - the main ethnic group. The rest consist of numerous ethnic minority groups including Thai, Tho, Lu, Nung, Nhang, Meo, Muong, Yoa, and Lalos (Huu Ngoc, 1996; Sharma, 1988). The participants in the present study are ofthe Viet ethnic group. Although appearing on the surface to have some common identity, there is diversity among Vietnamese Canadian women, who come from different backgrounds, have different experiences, and encounter different obstacles. Thus the information in this section represents an admittedly selective rather than exhaustive account of Vietnamese social, cultural, historical, and religious issues and experiences. My emphasis is on general factors that influence and/or construct the lives of Vietnamese in Canada. To understand Vietnamese immigrants' health care experiences and cancer preventative practices in Canada, one must understand the historical, cultural, economic, social, and political issues affecting their settlement and adaptation processes in Canada. This chapter is divided into four main sections. In the first part of this section I review some general information on Vietnamese historical issues. The second section addresses Vietnamese cultural and religion tradition. It explores how certain cultural conceptualisations and religious principles might have shaped the Vietnamese social relation and experiences. This section also briefly describes Vietnamese kinship patterns, family dynamics, the development and expectations of gender roles. I address how the female body is conceptualised in both Western and Eastern world, which influence the ways in which Vietnamese women participate in breast and cervical cancer screenings. To locate this research in the Canadian context, the third section addresses some of the experiences of Vietnamese living in Canada. Special attention is paid to the Vietnamese women's experiences. In the fourth section I review some general breast cancer and cervical 10 cancer information. I descibe what is known currently about Vietnamese women breast and cervical cancer screening practices. A. Vietnam: A Brief History To briefly capture the Vietnamese historical path, Huu Ngoc has provided this summary: One thousand years of Chinese domination; 900 years of national independence; 80 years of French colonisation; 30 years of war of independence and revolution; and since 1975, a period of rebuilding the country's social and economic structure (Huu Ngoc, 1996, p. 352). Vietnam's one thousand years under Chinese domination lasted from 111 B.C. until the tenth century. During this time, numerous revolts led by either mandarins or peasants resulted in brief periods of independence. Among the most memorable revolts was the Trung Sisters' quest for national unification and independence in 41 A.D. However, Chinese rule did not end until Ngo Quyen defeated the Chinese in 931 A.D. and became King of Dai-Viet - the independent Vietnam (Sharma, 1988). The next 900 years of national independence, which extended from 938 to 1858 A.D., were marked by peasant resistance to the feudal lords and landowners, civil wars, and defending the country against Chinese invasions. It was also the period where Vietnamese Emperors expanded their territories to the South. In Vietnam's state of independence, Chinese influence nonetheless remained significant, manifesting itself especially in the mandarin education system, in religion, and in cultural patterns (Nguyen Khac Vien, 1974; Sharma, 1988). The French colonial control of Vietnam extended from 1885 to 1954, leading to the establishment of French Indo-china. The French, with total control of Vietnam, systematically administered the colonial regime that consisted of intense exploitation of the country's economy (Sharma, 1988). Rubber and other crop plantations, coal, and mineral mines were developed to supply the French market with raw materials. Thousands of Vietnamese peasants were driven from their land and forced to work in the difficult and dangerous conditions on these plantations. A folksong revealingly sings: "It's easy to go to the rubber plantations, But hard to return from there. Men left their hides, women their bones." (Mai ThiTu, 1990, p. 191) 11 Not only did the entire Vietnamese economy change under the French rule, but the societal structure did as well. The French presence created two main groups of people - a group that consisted of French-educated individuals who benefited from the presence of the French, who also enforced French rule and embraced Western technologies and knowledge, and indigenous peasants who worked as servants and labourers. The gap between rich and poor was also widened by the introduction of capitalism. However, the changing picture of the Vietnamese society would not be complete without mentioning other impacts of the French on Vietnam. Western technology was introduced under French direction. A network of new roads, railroads, and ports were developed. The French government reinforced and modernised the dike systems, and built extensive irrigation and drainage work. Public services such as hospitals, schools, and scientific research institutes were developed. Public sanitation was also improved and outbreaks of epidemic diseases were less frequent (Hammer, 1966). As a result of these changes, the Vietnamese population doubled and Vietnam's production of rice and corn increased greatly. One can argue that the French rulers brought about these changes to benefit themselves - they needed to increase the production of raw material to export to France and therefore did not have Vietnamese people's interests in mind when they forced these changes. It is a fact that "under French direction, Vietnam became a large-scale exporter of agricultural products and raw materials. The country assumed a typical colonial economy" (Hammer, 1966, p. 116). During the 30 years war of independence and revolution from 1945 to 1975, Vietnam was in shambles. As Gloria Christie (1996) quite accurately stated, "the country... industry had been largely destroyed, the economy was shattered ... the population was dislocated and fragmented, agriculture was disrupted to a large degree... and social structure distorted" (p. 49) In reading Vietnamese history, one is astonished at the long record of cultural domination and the Vietnamese people's persistent resistance to it. From its beginning Vietnamese history seems filled with wars against foreign forces to achieve national independence. A Vietnamese artist observed, "Vietnam wars are always people's wars. We always seem to be fighting nations much bigger and more powerful than [we are]. That means everyone must be united and everyone must participate in the struggle...Our struggles are far more political than military" (Luce, 1990, p. 169). Significantly, everyone including women and children participated in these wars. The legendary story of the two sisters (Hai Ba Trung) - Trung Trac, Trung Nhi, and later on - Ba Trieu, changed 1 2 Vietnamese history as women were then recognised not only for their economic contributions, but also for their roles as leaders. Images of Vietnamese women leaders remain prominent in numerous insurrections and resistances to invasions of foreign nations. It is misleading to construct an image of Vietnam as a country which has always been subjected to invasion by others. Vietnam had also followed its own course of colonising other lands. Dating back to the Ly, Tran, and Le dynasties, from the 11 th century to the 17 th century, the need for more rice-growing fields, the expansion of economic markets and military potential led the Vietnamese of the North to colonise the South, across the Transversal Pass (Deo Ngang) to the heart of Mekong River Delta, leading to the shape of Vietnam today (Huu Ngoc, 1996). B. Vietnam: Religion and Culture It is essential to review Vietnamese religious make up because religious principles have not only had an impact on how Vietnamese women are perceived and situated within a society, but have also shaped their experiences within the family system and kinship organisation. The influence of gender roles and expectations on Vietnamese women's health care behaviour is revealed when one examines how religious principles influence women's beliefs and values, and social position. In general, religious beliefs and practices in Vietnam reflect its long history of indigenous development and colonial domination. Religious beliefs in Vietnam are primarily a combination of Confucianism, Taoism, Buddhism, Catholicism, and Protestantism. Vietnamese people have also traditionally worshiped nature and ancestors. The concept of heaven "Troi" is connected with morality and justice. It is a place where one will eventually be judged. Reward will be given to moral, dignified, and caring souls. Punishment will be given to the soul of individuals who, when alive, did not respect their parents, and were immoral and uncaring. Because the majority of the Vietnamese are Confucians and Buddhists, Confucianism and Buddhism weave heavily into Vietnam social fabric. The integration of these teaching principles shape Vietnamese social practices and social relationships. All of which, in turn, have directly or indirectly influenced how Vietnamese women practice health care and participate in breast and cervical examinations. 13 1. Confucianism Many Vietnamese are influenced by and practice Confucianist principles. "For the Vietnamese, Confucianism represents much more than a doctrine inscribed in venerable texts; it is a legacy of history, a fundamental legacy to be understood, [and at times] fought against and overcome in the course of the historical change" (Nguyen Khac Vien, 1974, p. 16). Confucius taught that man is a social being, formed by society, and bounded by social obligations. The Confucianism code of ethics and morals for people consists of many specific duties (Rutledge, 1985). These duties are to serve the King, honour the parents and the elders, be faithful to the spouse, take care of the family, serve the country, and help to maintain peace in the world. Individual tasks are, then, to study, improve one's self, so that they can assume those duties and fulfill social obligations (Nguyen Khac Vien, 1974). As observed by Nguyen Khac Vien (1974), "Confucianism was something that was lived. On the columns of houses, on engravings, on the doors of monuments, inscriptions reminded us at each step ofthe teachings ofthe Confucian tradition. Confucian expressions and quotations abounded in everyday language as well as in literature" (p. 16). For ten centuries Confucianism was the intellectual and ideological backbone of Vietnam. Confucianism was the official doctrine of the traditional Vietnamese educational system which was open to all persons except theatrical people and women (Nguyen Khac Vien, 1974). As a result, women were excluded from attaining an education and administrative positions. Under Confucianism, Vietnamese society was divided into two main categories - one that consisted of a small group of literate elite and the other much larger group of peasantry (FitzGerald, 1972). Vietnamese history is filled with the depiction of peasantry struggle. As observed by Nguyen Khac Vien, "the peasants' struggle for their rights weaves in and out of Vietnamese history like a piece of red thread. Unless we can grasp the concept of peasants' struggle, we cannot understand Vietnamese history" (1972, p. 20). Thus, Confucian orthodoxy brought extreme pressure to submit to authority. In the name of Confucius, Vietnamese peasants and women were denied a number of rights and subjected to numerous tests of discipline. Under feudal society, the high value placed on education, which is internalised by Vietnamese people, is directly linked to Confucianism and the societal administrative system. Education was highly valued among the Vietnamese because of the conception that education would not only make the individual a better person, but also bring status, power, and wealth to the family. Therefore, many 1 4 families, no matter how poor, did everything they could to send their children (mostly boys) to school. When a child showed promise, the family would make great economic sacrifices to enable him to continue his studies. This child then devoted all of his time to studying. He was exempted from physical work. To have a mandarin in the family was the highest honor and economically beneficial for the whole clan. Therefore, for centuries, to become a mandarin was the greatest ambition a boy could have. As for Vietnamese girls, a verse from a popular folk song gives us insight into their hopes and dreams: "I long for the brush and desk of the scholar, and not for lush rice fields and fish-filled ponds" (Nguyen Khac Vien, 1974. p. 29). The very best that a girl from a "good family" could hope for was to marry a scholar on the chance that he would one day become the mandarin. Nevertheless, a girl who married a scholar had a very difficult life. Because her husband devoted all his time to studying, she was the sole supporter of the family, also looking after the children and her in-laws. Many of them worked from early morning till the late hours of the night. Moreover, a woman was governed by the "Three Obedience" code of conduct - dictated by Confucianist. As young child, she was to obey her father; as a wife, she was to obey her husband; and as a widow, she was to obey her eldest son (xuat gia tong phu, ma phu tu thi tong tu) (Eisen, 1984; Thuy, 1976). This code denied her the possibility for self-determination and independence. 2. Mahayana Buddhism It is important to note that Confucian and Buddhist practices and beliefs are not exclusive. About 70% of Vietnamese are considered Buddhist (Rutledge, 1985). The founder of Buddhism is Siddhartha Gautama Buddha. The essential teaching of Siddhartha Gautama is comprised in eight principles - the Eightfold Path which are "right views, right aims or intentions, right speech, right action, right livelihood, self-discipline, self-mastery, and contemplation" (p. 32), and the Four Noble Truths which are "(1) existence (life) is suffering; (2) suffering is caused by inherently insatiable desires; (3) desire must be suppressed in order to end suffering... [and] (4) the way to achieved this is to follow the Eightfold Path" (Ashby, 1955 cited in Rutledge, 1985, p. 32). Buddhism was the dominant religion of Vietnam until the thirteenth century. Towards the end of the thirteenth century, Buddhism went into decline. By the fifteenth century, it was no longer the dominant religion and Confucianism took over (Nguyen Khac Vien, 1974, p. 21). During the French colonisation period, Buddhism was not supported by the French government. After the separation of the country in 1954, Buddhism diverged in the North and in the South. In the South, Buddhist monks engaged quite actively in political action and notoriously several Buddhist monks set themselves on fire to protest certain political actions and the repression of Buddhism by the government. In the North, the practices of Buddhism, although not encouraged by the communist government, were integrated as part of the religious life of the people. 3. Taoism Taoism taught that the human being and the universe are in harmony. There are unchangeable laws that govern the universe and nature, and individuals should try to live within these laws as best they can. Because one cannot change laws and forces of nature, it is best that one should stoically accept one's fate in life. The world and humanity exist through the interaction of two forces - Yang and Yin. "Yang is masculine, active, warm, dry and positive; while Yin is feminine, dark, cold, inactive and negative" (Rutledge, 1985, p. 30). Women, in the eye of Taoists, were viewed negatively since they were associated with dark, cold, inactive, and negative forces. Although Taoism pressured the Vietnamese to be passive, to accept their fate for the benefit of unity and harmony, from a psychological perspective, Lao Tze's teaching might have provided Vietnamese people with coping strategies that deal with difficult life circumstances. In many cases, there was perhaps nothing that a peasant or a woman could do to change the oppression in their lives. 4. Christianity A missionary, Father Alexander de Rhodes, first brought Christianity to Vietnam in 1626. It grew under the French colonial regime (Rutledge, 1985). In 1954, many Christians from the North of Vietnam migrated to the South. In the South, Christianity had a dominant status, because the South Vietnamese government and its president's family were Christians. Meanwhile, under the communist regime, Christianity in the North went into decline. Since Christianity was conceptualised as French - the coloniser's religion, its practices were not welcome and came under attack by Vietnamese writers. Several stories and books depicting immoral practices and corruption ofthe church organisations were published. Although Christmas was still celebrated by the people to some extent, certain Christian practices were perceived quite negatively. 1 6 5. Communal Life Vietnam culture and tradition are generally influenced by ethical and moral codes taken from Confucianism, Taoism, Buddhism, and Christianity. However, the two dominant religious ideologies that govern the life of Vietnamese are Confucianism and Buddhism. Every traditional village has a "dinh" (Communal House), which represents Confucianism and a "chua"(Pagoda) which represents Buddhism. Confucianism places emphasis on "strict social hierarchy, absolute loyalty to the loyal dynasty and the family, and ...conformity to rules prescribed by the village," whereas Buddhism places emphasis on "compassion and universal kindness where hatred did not dissolve into hatred but into love" (Huu Ngoc, 1996, p. 309). Vietnamese cultural practice and production are socially constructed, and derived from social activities. Vietnamese communal life in general, often centered on the village, was lively and cohesive. Villagers' main activities were organised around the growing of rice in irrigated fields. Collective organisation of agricultural waterworks and clusters of houses provided stable, organised communities that gave support to each household in the village. This form of collective life in the villages often consisted of several thousand people linked by clans' affiliation. Labour trade between families in the clan during harvesting season was the norm. Traditionally, the leaders of these villages were often Confucian scholars (Nguyen Khac Vien, 1974). From 1945 to 1975, under communism in the North, French then U.S. control in the South, leaders were often the officers of the government in power. After 1975, with the fall of the South Vietnamese government, Communist Party Members took total control of the country's administrative system. In a more contemporary Vietnam, the village remains an informal association of families and forms the individual basic community in the rural areas (FitzGerald, 1972), whereas in urban areas only relatives from both sides of the family form the individual's informal social support network. The Vietnamese words, "dat nuoc" - "daf meaning land and "nuoc," water, communicates how valuable land and water are to the Vietnamese people. Their lives depend on the fertility of their land and the amount of water they have. Most of the country's 33,000 sq. kilometers are covered in forest and mountain land; the remainder of the land has to support its population of about 40 to 50 million people. Vietnam's main agriculture is the cultivation of rice in the irrigated water fields. The land is the most valuable possession that one can own and water is the gift that "Ong Troi" (the God of heaven) can give. 17 However, if water is almost as valued to Vietnamese people as oil to the Westerner, it is also one of the fiercest enemies of the North Vietnam people. "The Red River delta, cradle of North Vietnamese civilisation was periodically threatened by great floods" (Nguyen Khac Vien, 1974, p. 20). The Red River is very unpredictable. It could be as gentle and loving as a mother giving milk to her child, or it could be as fierce as the angry Genie when it is swelled with water during the rainy season. To survive, the North Vietnamese people had to build thousands of miles of dikes along the river and in all of its surrounding provinces. During the rainy season, from May to October, the water level could rise a foot a day. Annual rain fall averages about 72 inches (Nguyen Khac Vien, 1974). During the dry season, if a dry spell lasted 15 days longer than usual, the whole crop would be lost, creating famine in many provinces. Thus, the people of North Vietnam constantly fought with unpredictable weather to survive in this harsh land (Nguyen Khac Vien, 1974). The lives of the North Vietnamese people were fundamentally shaped by the wars and invasions they endured, their constant struggle with nature and floods, and severe economic problems. Into this social milieu, communism was established and further changed the culture such that new social relations replaced the traditional social hierarchy. Compared to the people of North Vietnam, the people of South Vietnam had relatively easy lives. Their land was more fertile, there were fewer people, and the Mekong River was much more subdued and regulated than the Red River of the North. Therefore, their production of rice and other crops was much higher than the North. Before the American war started, they were able to export 1.5 million tons of rice annually. However, the war also created economic problems along with many other difficulties. By 1965, South Vietnam started to import rice instead of export it (Sharma, 1988). Although evidence shows that over the years, there are many changes within the Vietnamese social structure (Hirschman & Loi, 1996), for many Vietnamese, Confucianism and Buddhism weave heavily into their social fabric and the family remains the basic social structure - the foundation of their society. To some Vietnamese, to leave the land and the family is to leave one's personal identity and to lose a place in life. The wars have not only destroyed the Vietnamese land, but the Vietnamese society, and it destroyed the traditional Vietnamese family. All of these factors influence the Vietnamese people's health care practices and behaviour. 18 6. Vietnamese Family Practices and The Changing Status of Vietnamese Women Vietnamese economics, history, religion, and politics influence people's kinship patterns and family dynamics. Centuries of struggle with an unpredictable nature, frequent warfare, and economic problems created many changes in the Vietnamese social structure. Some changes are viewed as positive, while others as negative. Whatever the changes might be, the Vietnamese are remarkable for their persistence and fierce determination to conquer difficulty and to preserve their families. Although one can never generalise that all Vietnamese follow a universal pattern, there are certain common characteristics of the Vietnamese family structure and gender dynamics. The ethnically Vietnamese kinship system is patrilineal and patrilocal. However, it has been shown that comtemporary Vietnamese kinship system is more complex, such that one cannot categorize Vietnamese families into any model (Luong, 1984). Traditionally, Truong toe - the head of a family, who hold titles to the land, was always a male. In a contemporary Vietnamese society, which follows socialist perspective, chu ho is used. The term Chu ho is usually refered to "the person who represents the household in dealings with the larger community" (Hirschman & Loi, 1996, p. 235). A survey conducted in 1991 by Hirschman and Loi (1996) in Vietnam shown that many Vietnamese women held such a title at the time the survey was taking place. The authors also found that "female headship in Vietnam is not primarily a sign of absent husbands and disadvantaged economic conditions" (Hirschman & Loi, 1996, p. 236). However, as it has been pointed out, chu ho is often responsible for household activities in dealings with government agencies (such as fills out forms, pays taxes and fees). Women's chu ho may not enjoy high social status or hold decision-making power within the household (Hirschman & Loi, 1996). From a more personal experience, my grandmother (from my mother's side) was a chu ho - the head of a household which was consisted of herself, my grandfather, my family, and two uncles. Aside from taking care of the family activities of daily living, my grandmother was also responsible for attending community meetings and volunteer works. Other women (my mother and I) were responsible for helping my grandmother with housework. Furthermore, the political climate of Vietnam under communism might have impacted people's decision on who would be the best person in the family to be chu ho. Especially after the fall of Thieu regime in the South, many Vietnamese men (who work for former U.S. controlled government) found themselves facing difficulties in dealings with the government officials. Thus, although the war and the social constitution have changed Vietnamese family structure over the years, Confucian 19 thoughts and tradition remain in existence (Hirschman & Loi, 1996). In both North and South of Vietnam, family members still live close to one another to form informal social support networks. To understand the Vietnamese family dynamics, its gendered roles, and its expectations, it is important to examine the changing status of Vietnamese women throughout different historical periods. It is also important to keep in mind that information on Vietnamese culture is often contradictory because it reflects different perspectives. Some traditional Vietnamese literature might not accurately portray Vietnamese women and their role within the family and society, because these writings are often the product ofthe Confucian elite male (Coughlin, Walsh, & Cook, 1996). Contemporary Vietnamese literature, on the other hand, might be the reflection of the Communist Party Members, with their Marxist- Leninist perspective. The status of Vietnamese women has been discussed from different perspectives. As Judith Shepherd (1992) points out, there are authors such as Marr (1981), in his book entitled Vietnamese Tradition on Trial, who felt that, in general, Vietnamese women have held a relatively high status, and they were able to retain their status under various colonial societies. However, Mai Thi Tu (1990) in The Vietnamese Women: Yesterday and Today does not share this view. Mai clearly points out that Vietnamese women were expected to be submissive, and have been oppressed by men throughout different eras in Vietnamese history. Under Chinese domination and the Confucianist formation, Vietnamese society is a highly hierarchical patriarchal society. For many centuries, Confucian emphasis on duty and family and class hierarchy denied women social and political equality. For decades, a woman existed mainly in and for her family and society. A comment by Mrs. Hai, one ofthe study's participants, illuminates this traditional ideology at work: Mrs. Hai: For me. I am most concerned about my children... I think about the family situation for my children. I am concerned with looking after the family, eating, and cooking. Because I am a woman, I have to pay attention to those things...Vietnamese women, we go to the market, we cook. We organise our family. We take care of the family financial situation, how to spend, making sure we don't have too much debt. I think Vietnamese women spend more carefully. They don't just spend the money for whatever. We know how to control the family financial situation. If we have money we know how to save it for the future. We don't spend all our money. We are concerned with our children's future. We are also concerned with our parent from both sides [the wife and the husband sides]. We are concerned with our sisters and brothers. We are also concerned with our friends, people around us, and the people at the church, (pause). That's it. (Translated and edited quote from W-Hai-3-A-1) 20 The Vietnamese women's fate under the feudal society was uncertainty, and dependent on men's will. A young girl would listen to her mother sing of the certain fate of Vietnamese women: "A woman is like a drop of rain No one knows whether it will fall into a palace Or the mud of the rice fields" (Folksong. Cited in Mai Thi Tu, 1990, p. 186) Confucianism had many negative effects on the social position of Vietnamese women in their society. Under the Confucian legacy, Vietnamese women were put in a social position that denied them power and independence. They were not allowed to own land and were denied education, and thus could not assume any administrative position (Eisen, 1984; Mai Thi Tu, 1990). The Confucian ideal of a desirable woman was one who was "Cong, Dung, Ngon, Hanh." Cong means versatility in the home. A desirable girl possessed many talents to perform a wife's duty - she was a good cook, a good seamstress, able to make money, and a hard worker. Dung means beauty - a desirable girl would have not only physical beauty, but inner beauty as well. Ngon means speech - a desirable girl should speak with an eloquent, soft voice; she would never talk in an angry tone. Hanh means "good" behaviour (Thuy, 1976). A desirable girl was a gentle and caring individual, who would act kindly toward any living thing. It is clear that these standards were very difficult to achieve. For centuries, Vietnamese women internalised and lived with these Confucian ideologies. They were expected to raise the children and participate in all of the family activities that were inclusive to women (Mai Thi Tu, 1990). However, the women's economic contributions granted them a higher status than Chinese women. As suggested by Chi, "the most distinctive characteristic of the Vietnamese culture in comparison with other East Asian cultures [was] the active role of the women in the Vietnamese society. In theory, a Vietnamese female is supposed to be as submissive to male authority as her Chinese sisters. However, there is a great difference between theory and practice" (Cited in Shepherd, 1992, p. 88). Exploitation of women under a feudal society also manifested itself in the practice of polygamy and concubines (Eisen, 1984; Mai Thi Tu, 1990). Under feudal society, Vietnamese men were allowed to have as many wives as they could afford. Wealthy men can have several wives and concubies (Hammer, 1966). It was not uncommon to see a rich man with several wives living in the same household. These wives and the children can also form a family labour force. However, the French and later, the communist government abandoned this practice of polygamy. The most famous Vietnamese literary masterpiece by 21 Nguen Du depicted a life full of suffering, hardship and exploitation of a talented and beautiful girl - Kieu. In her sorrow, Kieu cried for both herself and her friend: "How tragic is the destiny of women! Creator, why are you so cruel to us? Wasted are our green years, withered our pink cheeks. This woman who lies here was in her lifetime the wife of all, Yet, after her death, her soul wanders in loneliness. (Cited in Mai Thi Tu, 1990, p. 188) Under the French rule, Vietnamese women's lives and status were not improved. Colonisation brought new forms of exploitation which were added to their suffering from age-old traditions. According to Eisen (1984), Vietnamese women's lives under the colonial regime were unbearable. Peasant women lived in such poverty and starvation that they were forced to work on the French owned plantations and mines. It was estimated that by 1945, 60% of the plantation workers were women. The conditions in mines were so brutal that they were referred to as "hell on earth." Increased poverty also forced thousands of women into prostitution and slavery. For a few pounds of rice, a man could buy a woman as a slave or concubine. Prolonged and extreme exploitation by the French rulers, coupled with the Japanese's invasion toward the end of the Second World War in 1945 led to the unforgettable famine in which two million people died of starvation within a year (Eisen, 1984; Kolko, 1971). The French rulers destroyed Vietnam's land, its social structure, and the country's basic foundation - the Vietnamese family. Husband and wife, parents and children were separated due to poverty and war. In one of the most popular novels written from an anti-colonial perspective - Tat Den (The Light is Out), a peasant women's life was portrayed in all its misery and heartache. In order to get the money to pay a corrupt official, the mother was forced to sell her daughter for one piastre (less than a dollar) (Eisen, 1984). At the 1954 Geneva Accords, both the French and the Communist Vietnamese signed the "Agreement on Cessation of Hostilities." This agreement was intended to settle military hostilities between the French and the Vietnamese. However, the most important feature ofthe agreement, which changed many Vietnamese people's lives, was the establishment ofthe demarcation line along the 17th parallel. This line divided the country to that of the North and that of the South (Kolko, 1971). 22 Following the 1954 Geneva Accords, the life and status of Vietnamese women became differentiated between the North, which was under communist regime, and the South, which was under American control. Women in the North were actively involved in the struggle for national liberation and later, the Central Committee ofthe Vietnam Communist Party. The Party recognised women's problems and declared that equality of the sexes was one of its 10 revolutionary principles (Mai Thi Tu, 1990). Ho Chi Minh, the founder of the Vietnamese communist regime, urged women not only to recognise their oppressive sources, but also to actively resist these forces. Thousands of peasant women participated in the military against the French and then the Americans. Vietnamese women's contributions in armed insurrection and/or production work to support soldiers fighting in the wars were not ignored. Many were publicly rewarded by the Communist Party Members and by Ho Chi Minh himself. Women's lives remained difficult as they continued to till the land, look after the children and the parents, and undertake tasks formerly reserved for men, but for many of them, their status was no longer that of slavery and their dignity was not degraded. On the one hand, the Vietnam Worker's Party recognised that "one must work out a practical plan, raise the women's ideological, cultural and technical level, help them to free themselves from the burden of household chores, thereby assuming an even bigger role in the administration of production work and state affairs" (Mai Thi Tu, 1990, p. 196); on the other hand, Ho Chi Minh advised that "the woman should not wait for a government or party decree to liberate her; she must struggle for her own freedom" (Ho Chi Minh, cited in Mai Thi Tu, 1990, p. 197). However, even with these new ideologies and discourses, many women who lived in the North of Vietnam continued to suffer. Mrs. Chi who lived in the North of Vietnam testified: Mrs. Chi: "nong dan" (peasants) women were suffered the most and the poorest. Especially, "nong dan" women whose husband died in the war. When the husbands die in battle, their wives were left with the children. These wives were among the most suffered ... During the day, at work, they were still smiling and talking. At night, they were crying. You know, in one village, there were few hundreds of these women, each one of them had 7 or 8 children. These women, their husband had died or soon will die. They (the husbands) would get drafted then few months later, a letter would come home to their wives telling them that their husbands had died. They were the ones whom suffered to a great extreme. They cried at night, sometimes I heard them cry all night .... Yes, Vietnamese women suffered a great deal. You know there were villages that didn't have even one man alive. If there was one man who survive and came back to the village as a disabled soldier, that village is very lucky .... Oh God, there was an old woman, she had 7 sons. All of them died. She could not bear it when her last son died. She took a chair to the village community house ... She cried out her pain publicly and blamed the government for her suffering. She yelled out loud of her pain "Oh the government, I have 7 children, you killed all of them. You, the government, you took all 7 of them. Who is going to look after me now?" She was around 60 or 70 years old. She was old and weak ... but she still had to work on the rice field. Seven children, all of them died. How painful. (Translated and edited from W-CN-3-A-1) 23 The life of Vietnamese women from the South took a different direction. During the war, under the South Vietnamese government regime and America, women of the South were also among the greatest victims (Mai Thi Tu, 1990). The war had destroyed the family and the land. In the countryside, the crops and the rice fields were ravaged with toxic chemicals, houses were burned, men, women and children were killed. Thousands of women in the villages were victims of rape. Thousands of villagers fled their homes to live in concentration camps. Nearly half a million women became prostitutes to survive, many of them turning to drugs to cope with their suffering (Mai Thi Tu, 1990). Women whose husbands were soldiers in the South government army were also left with the responsibility of looking after their family. In the next section, prior to a more in-depth discussion of the literature review on Vietnamese women's breast cancer and cervical cancer screening issues, I will address how women's body is conceptualised in both Western and non-Western societies. How people deal with illness is directly linked to the ways in which they view how bodies are conceptualised and experienced (Csordas, 1994), and the ways in which women view and practice breast and cervical cancer preventive care are influenced by their embodiment experience. Here, the term "embodiment" refers to "a methodological standpoint in which bodily experience is understood to be the existential ground of culture and self, and therefore, a valuable starting point for their analysis" (Csordas, 1994, p. 269). 7. Conceptualisation of the Female Body: Body as an Experiencing Illness Agent In Western cultures, the conceptualisation of the human body is shaped by Western science and biomedicine. Western science and medicine have largely functioned within the mechanistic Cartesian worldview and philosophy of dualism. This perspective treats all "living organisms as physical and biochemical machines, to be explained completely in terms of their molecular mechanisms" (Capra, 1982, p. 121). Within this view, the human body in Western society is seen as a complicated "machine" with physical and chemical interactions (Capra, 1982; Good & Good, 1993). This mechanistic conception of the body and its functions centralise the biological/physical body, all the while pushing the mind to the background of clinical theory and practice (Scheper-Hughes & Lock, 1987). Moreover, Descartes' philosophy of dualism views the human body as composed of two separate entities: the palpable body and the intangible mind (Holden, 1991; Scheper-Hughes & Lock, 1987). Disease and illness are parts of either a malfunctioning mind or a body that can be treated independently from the rest of the body (Capra, 1982; Good & Good, 1993). The healthy or sick body, the normal or abnormal body are often 24 differentiated based on physical symptoms. Thus the human body is the site of problems that need to be identify and treated (Good & Good, 1993). The scientific medicine conceptualisation of body as a biological organism with hierarchically organised system of control impacted how changes in the body are perceived (Martin, 1990). In particular, changes in women's bodies are often described using negative metaphors that denote failure or breakdown of body control system; for example, menopause is seen as ovaries become "unresponsive", as the body's failure to produce the female hormone estrogen (Lock, 1993), and menstruation is seen as failure to produce offspring (Martin, 1990). In non-Western cultures such as Chinese culture, there are a variety of body concepts, and the most prominent has its root in Confucianism and Taoism (Ots, 1994). Thomas Ots (1994) explains some Chinese key concepts of body through the discursive practice of traditional Chinese medicine. In Chinese medicine, the heart and mind are the two important elements of both body and its social well being. While the heart is considered the most important internal organ, the mind is placed within the heart. Through harmony and balance of the Seven Emotions, body unity and function are achieved. These emotions are said to express themselves through bodily changes. Any amount of excess emotion, which disrupts the harmony, is considered pathogenic. Excessive emotion damages internal organs and compromises the heart-mind relationship. Thus, emotional behaviour is heavily stigmatised. According to Taoism, excess emotion and desire, which are external elements, affect the body health and well being. To be strong and healthy, one must take care of one's body by eliminating emotions and desires, by staying calm and becoming unattached (Ots, 1994). Within Taoism, one's mind is thought to travel in the body through fixed routes. To Chinese, the physical body is, then, the basic working material. "Should he achieve the purest clarity of heart-mind, yet his body fall ill, he could never reach the stage of shenxian, thus, he could not become a Spirit-Immortal" (Ots, 1994, p. 119). As Ots suggests, even though Chinese body concepts somewhat similar to the basic pattern of subject-object relation of the West, their specific understanding of the lived body is different than those of Westerners. Traditional Vietnamese medicine has also adopted the Chinese "heart-mind controls emotion" model. Thus, Vietnamese also strive to attain an emotion-free body. Since the expression of strong emotion is discouraged, a Vietnamese woman may smile or appear calm when she may actually experiencing inner turmoil (Calhoun, 1986; Waxier-Morrison, Anderson & Richardson, 1990). In addition, a healthy body is achieved through balancing Am (yin) and Duong (yang), or Dark and Light, or Female 25 and Male and the equilibrium of "hot" and "cold." The notion of "hot" and "cold" does not refer to temperature, but to the nature of the elements. Excess in either hot or cold can cause damage to the body's internal organs, which in turn manifests as physical symptoms. For example, excess "hot" cause constipation, dark urine, or hoarseness; a "weak heart" may cause fainting, dizziness, or anxiety; a "weak kidney" may cause sexual dysfunction; and "weak nerves" may cause headache (Waxier-Morrison et al., 1990). Because the soul and the body are considered to be one, alteration or removal of a body part is believed to cause the soul to escape from the body and death to result (Waxier-Morrison et al., 1990). Margaret Lock (1993) compared the current discourses about female aging in both North America and in Japan. Her analysis revealed that female body discourses are not only profoundly shaped by cultural beliefs about the aging body and its function in a particular society, but they are also products of what she termed "local biologies" and medical discourse. Examining how the aging body is conceptualised in North America, Lock observes that the dominant discourse focuses almost exclusively on the biochemical processes of aging - which is often viewed as universal, inherently anomalous, and potentially pathogenic, and as having implications for future ill health. Aging of the female body, from the biomedical perspective, has often been discussed in light of physical changes (such as menopause and menstruation) that take place with the disappearance of the 'female' hormone, as well as its negative consequences, its replacement therapy, and recently, its cost to the national economy (Lock, 1993). Although aging is a natural and unavoidable process, within Western biomedical discourse, aging is something that is unwelcome. Discussion about female menopause as "a progressive physical deterioration" of women's body caused by "ovarian deficiency", is often about loss, failure, and senility (Lock, 1993). These discourses convey an ideology which emphasises that aging is unnatural and unhealthy. On the contrary, women in Japan have been viewed as biologically endowed with the ability to nurture. Thus, women's life cycle is celebrated with what they accomplish in terms of nurturing ability and services for others rather than for themselves (Lock, 1993). Because aging itself is not thought of as anomaly, but as a natural part of life, a social state of maturation, attention towards changes in women body are primarily concerned with future ability to work and to contribute to society. Distress of the female aging body is not entirely linked to the decreased in hormone level, but rather due to a destabilisation of the autonomous system which affect both sexes. As such, menopause is not only discussed much less frequently in Japan, but when it is discussed, the focus is much different than in the West. For example, stiff shoulders, headaches, and ringing in the ears are discussed instead of "hot flashes" (Lock, 1993). Thus, women's bodily concepts are not universal and static but are culturally specific. Not only has the conceptualisation of body reflected particular cultural beliefs and values, but also the scientific knowledge about health and illness that are particular to that culture. In Western societies, individualism, natural science and the biomedicine model shape the ways in which women's body are perceived and experienced. However, in other cultures such as Chinese, Vietnamese, and Japanese cultures, different cultural values, and understanding of health and illness have resulted in different understandings of women's lived bodily experience. Not only do different individuals and societies embody illness in different way, but the ways through which individuals embody illness varies in different social, cultural, political, economic, and historical contexts. How individuals embody illness is also very much dependent upon how one knows and lives one's diagnosis and prognosis (Gordon, 1990). In other words, it is the nature of the illness and what it means to an individual of a particular culture that influence how one experiences and practices health care. There are many ways that one might experience illness. Some individuals might experience disease as a breakdown and rupture in everyday life, other see disease as disembodied (a mental effort to keep disease at a "distance" by not knowing its name and its diagnosis or denial), while still others embody an illness, inhabiting it, and/or co-habiting it (Gordon, 1990). The nature of cancer, its social stigma and the social, cultural context in which patients live influence their embodiment of illness and practices (Gordon, 1990). Because cancer is viewed as an incurable disease, cancer is often associated with suffering, pain, hopelessness, and death, therefore, it often evokes strong emotional reactions. In some cultures, the battle with cancer is the fight between "good" and "bad," between "malignant" and "benign"; "cancer is an illness of divisions, of disunity, of otherness" (Gordon, 1990, p. 276). Although the more recent view of cancer as a challenge, as an illness that can be beaten with early diagnosis such as breast cancer and cervical cancer, knowing one's diagnosis of cancer evokes images of future separation and isolation from the social networks (Gordon, 1990). In a society where social relationships are fundamental this is social death itself. Viewed in this context, the experience of cancer is that of disembodiment in which cancer is viewed as the "other," as something that is from "outside" to "inside," which at times, can be best managed by denial or avoidance. 27 Thus, "the body [is] simultaneously a physical and symbolic artifact, ... both naturally and culturally produced, and ... securely anchored in a particular historical moment" (Sheper-Hughes & Lock, 1987, p. 7). C. Vietnamese Living in Canada Vietnam began its new era with the march of the North Vietnamese troops to Saigon (now called Ho Chi Minh City) on April 30 th, 1975. The downfall of the South Vietnamese government and withdrawal of the American troops from Vietnam marked a new period of Vietnamese history. Taking control of an entire country that was almost totally destroyed by war, the Vietnamese government was faced with enormous social, political, and economic problems. To deal with these problems, drastic measures were used. The new government, with its triumphant military force, enforced many extreme economic, political, and social changes. These changes created an influx of Vietnamese refugees seeking political and economic asylum in the Western world. According to the 1991 Government of Canada's profile of immigrants from Vietnam, there were two large influxes of immigrants to Canada. The first wave of these immigrants entered Canada between 1975 and 1980, the second wave between 1984 and 1985. Before 1978, several hundred Vietnamese lived in Canada. Most of them were students or highly trained professionals living in Montreal (Chan & Indra, 1987). Between 1979 and 1984, the Canadian government and private sponsors took in approximately 60,000 Vietnamese immigrants. By 1991,113,595 Vietnamese had made Canada their new country, with the hope of building a better life for themselves and for their families - including family members left behind in Vietnam. Most of these immigrants left Vietnam for political and/or economic reasons. A large portion of these immigrants came without their immediate and extended family. Many of them had suffered hardship, extreme violence, and cruelty prior to leaving their homeland and during their flight. Many Vietnamese immigrant women suffered from exposure to direct combat, and were victims of rape and other forms of sexual assault and violence. As estimated by the United Nations, at least 39% of the women who fled Vietnam by boat were abducted or raped by sea pirates (Compton & Chechile, 1999, p. 191). Despite horrific past experiences, Vietnamese immigrants generally integrated fairly well into the Canadian society and way of life (Johnson, 1999). As Johnson points out, Vietnamese Canadian 28 immigrants integrated into Canadian culture in a way that enabled them to embrace aspects of both cultures -Vietnam's and Canada's. Rather than giving up their ethnic origin and cultural identity in order to assimilate into the new society, Vietnamese immigrants retained aspects of their cultural values and beliefs, while interacting with and adopting certain aspects of mainstream society. Although there is evidence to show that adaptation to a new life and the resettlement process have been relatively successful for the majority of Vietnamese, social, cultural, and economic changes are inevitable. The impact of these changes is both positive and negative. To gain insight into the living and health care experiences of the Vietnamese immigrant women, this section seeks to understand how certain economic, social, and political issues affect their settlement and adaptation processes, which will, in turn, affect their health care experience and practice of cancer prevention. 1. Economic Experiences The economic adaptation of immigrants has been considered an important indicator of how well immigrants have adjusted to their new lives (Deschamps, 1987). Research into this area has been encouraged because the establishment of a stable economic status is often a shared aim of the government and the immigrants. As such, the immigrants' ability to enter the work force and to generate income are viewed as one of the best indicators for the success or failure of the integration process (Deschamps, 1987). Samuel (1987) asserts that there are two important factors leading to successful economic adaptation. One factor is the ability to find employment in the occupation for which the immigrants have been trained, and the second is proficiency in either English or French. Vietnamese immigrants have problems in both of these areas. Downward occupational mobility is a common phenomenon for Vietnamese (Beiser, 1999; Chan & Indra, 1987; Gold, 1992; Johnson, 1988, Kibria, 1993; Samuel, 1987). Chan and Indra's study of 25 Vietnamese men and women living in Montreal, Quebec, showed that regardless ofthe respondents' educational background and previous occupation in Vietnam, the majority of their respondents were employed in lower echelon jobs at a minimum wage. They were often employed as garment factory workers, janitors, dishwashers, and factory labourers. Similarly, Johnson's (1988) study of Vietnamese living in Vancouver, BC revealed that 57% of the 772 Vietnamese respondents were working in low paying jobs such as labourers, dishwashers, kitchen helpers, cleaners, janitors, fruit and vegetable pickers, and sewing machine operators. Furthermore, the Government of 29 Canada's profile of Vietnamese immigrants disclosed that 36% of men and 32% of Vietnamese women work in manufacturing, and Vietnamese immigrants are more likely than other immigrants and Canadians to work in manufacturing (Government of Canada, Statistics Canada, 1996). Although by 1991, the majority of Vietnamese immigrants could speak at least one official language, with 85% conducting a conversation in either English and/or French (Government of Canada, Statistics Canada, 1996), limited proficiency in one of Canada's official languages has been considered a negative factor affecting the Indochinese immigrants' employment opportunities (Samuel, 1987). There is evidence to show that the unemployment rate of immigrants who had poor or no knowledge of English is four points higher than those who have fluent knowledge of the language (Samuel, 1987). However, another study has shown that insufficiency in English does not affect the employment rate, but rather the wages and the opportunities for occupational advancement (Johnson, 1988). Johnson (1988) found that an ethnic community, such as Chinatown, with Asian-owned business has helped immigrants with limited language skills to find employment within the Asian community. The disadvantages of such opportunities are lower wages, long hours of work, and no opportunity for advancement. Thus, the establishment of the Asian community with its labour force has helped to increase the immigrants' employment, although not necessarily with high paid and/or desirable employment. A group of researchers in British Columbia conducted a 10 year longitudinal study of socioeconomic conditions of Vietnamese immigrants, their employment patterns, savings practices, and the impact of unemployment. The study reveals that self-employment is "one of many avenues taken to provide for the family's economic situation" (Johnson, 2000, p. 9). According to the Government of Canada's profile of Vietnamese immigrants, they have limited language skills (only 66% could carry on a conversation in English) and the majority have a lower level of education (only 8% had a university degree, and 21 % had less than a grade 9 education). Furthermore, their professional training is not marketable. These barriers, coupled with the experience of being discriminated against in the labour force have made the idea of self-employment desirable (Johnson, 2000). Johnson (2000) revealed that the majority of their respondents rated self-employment as more satisfying, helping them to achieve greater financial success, more prestigious, and offering more flexibility at work. The literature on self-employment suggests that self-employment is desirable for immigrants because (a) it provides income and helps immigrants to avoid the problem of being unemployed, and (b) it helps immigrants achieve a sense of independence, autonomy, and opportunity to accomplish their political and personal and family goals (Gold, 1992). Thus, self-employment is valued highly by the Vietnamese and considered a more desirable mode of employment (Johnson, 2000). Although Vietnamese immigrants living in Canada experience both positive and negative impacts of the changes in their economic status, they generally adjust fairly well economically. Many have successfully achieved economic independence. However, a large portion still have incomes below Statistics Canada Low-income Cut-offs and Vietnamese immigrants' income level is still lower than people who are born in Canada (Government of Canada, Statistics Canada, 1996). By 1991, there were 113,595 Vietnamese living in Canada. Most of them live in populous provinces such as Ontario (45%), Quebec (18%), Alberta (17%) and British Columbia (13%). Only about 6% of the Vietnamese made other provinces their home (Government of Canada, Statistics Canada, 1996). The 1991 Canadian Census also revealed that, in general, Vietnamese are less likely to be employed as compared to the other immigrants and people born in Canada. Of the Vietnamese people aged 15-64, 66% of the men and only 54% of the women were employed and many of these people were working in manufacturing. At the time of the Census in 1991, 36% of the Vietnamese men and 32% of the Vietnamese women were working in these areas versus only 15% of men and 4% of women born in Canada. Also, while 33% of Canadian-born women held professional or management positions, only 15% of Vietnamese-born women held such positions (Government of Canada Statistics, 1996). Table 2.1 1991 Canadian-Born and Vietnamese-Bom's Occupational Distribution Occupational Canadian-born men Vietnamese-born men Canadian-born women Vietnamese-born women Employed fulltime/fullyear 58.7% 54.9% 45.2% 45.4% Manufacturing 15% 36% 4% 32% Professional/ Management 27% 17% 33% 15% Average income $29,837 $20,358 $17,457 $14,276 Source: Statistics Canada, Citizenship and Immigration Canada: Profiles Vietnam, 1991 The 1991 National socioeconomic profile of Vietnamese in Canada shows that many Vietnamese women are among the low socioeconomic status groups (Government of Canada Statistics, 1996). 31 Evidence also shows that the income level among Vietnamese living in Canada, especially women, is lower than the general population. In 1990, an annual average income of the Vietnamese was $17,600 ($23,700 for the general population) with the women's average income being $14,300. The situation is even worse for Vietnamese aged 65 and more. Their income averages $7,700 per year. As such, a large number of Vietnamese women live in poverty, below Statistics Canada Low-income-Cuts-off (Government of Canada Statistics, 1996). The more recent data from the 1996 Canadian Census shows an increase in the Vietnamese population in Canada to 136,325 with about half of the population (68,175) being female. The data also showed that among 49,425 Vietnamese females who are 15 years and over, only 21,845 of them are employed. The census also reveals that most of these women who are employed work at services industries which include: manufacturing industries (8,050); whole sale and retail trades industries (3,850); accommodation, food, and beverage service industries (3,365); other service industries (2,460); health and social service industries (2,045); and business service industries (1,110). Table 2.2 1996 and 2001 Vietnamese Women's Occupational Distribution Occupation Vietnamese population in private households by census family status Vietnamese female population Employed Vietnamese female Manufacturing industries Whole sale and retail trades industries Accommodation, food, and beverage service industries Other service industries Health and social service industries Business service industries Total Other occupations 1996 136,325 68,175 21,845(100%) 8,050 (36.8%) 3,850(17.6%) 3,365(15.4%) 2,460(11.3) 2,045 (9.4%) 1,110(5.1%) 20,880 (95.6%) 965 (4.4%) 2001 151,205 76,485 32,045(100%) 10,655 (33.2%) 4,650(14.5%) 4,315(13.5%) 3,000 (9.4%) 3,175 (9.9%) 3,000 (9.4%) 3250(10.1%) 28,795 (89.9%) Source: Statistics Canada (1996, 2001). Ethnocultural Portrait of Canada: Topic Based Tabulations VEL=2&FREE=0 32 Although in 2001, the average income among Vietnamese working women has increased to $28,269, the average income for all Vietnamese female is $18,560 (which is an increase from $14,300 in 1991 Canada Census). However, the data reveal that almost one fourth of all Vietnamese female living in Canada (18,095) are surviving with the income less than $9,999 per year. Table 2.3 1996 and 2001 Vietnamese Female's Income 1996 2001 Vietnamese women's average employment income $16,207 $28,269 Vietnamese female's average income $14,054 $18,560 Vietnamese female with income less than $ 5,000 per year 10,635 10,210 Vietnamese female with income between $5,000-$9,999 per year 7,425 7,885 Source: Statistics Canada (1996, 2001). Ethnocultural Portrait of Canada: Topic Based Tabulations VEL=2&FREE=0 In contrast, the Vietnamese immigrants' economic status is much more encouraging in the United States. The United States' Office of Refugee Resettlement (ORR) revealed that Vietnamese immigrants have twice as high a rate of participation in the labour force as compared to the other South East Asian refugees (Robinson, 1998). By 1994, only 4% of the Vietnamese were unemployed and the number of Vietnamese who received cash assistance and non-cash assistance (such as Medicaid, Food Stamps, public housing, etc,) was substantially lower than other Indochinese refugee groups (Robinson, 1998). 2. Social-Cultural Experiences In the traditional Vietnamese family, it is expected that the husband is the main breadwinner; the woman's economic contribution is viewed as secondary to that of the husband. During the Vietnam war, the situation changed with many Vietnamese women becoming the main providers for the family. In Vietnam, submerged in the social ideology and culture conceptualisation that supports the domination of men over women, Vietnamese women's status remains one that is conformist to the authority of their husband and their parents. In Canada, there is evidence to show that Vietnamese immigrant's family structure and relationships have changed dramatically (Gold, 1992). These changes have not only affected their family dynamics, functions, and roles, but also their psychological and social relations. As 33 with many Western families, to make ends meet, both husband and wife need to enter the labour force. According to Gold (1992), because ofthe employment situation coupled with the influence of Western values and ideologies, Vietnamese women's role as breadwinner took on a different meaning in Western society - one that comes with a change of status and more power for women. This role reversal and changing status have created hostility between husbands and wives in some Vietnamese families. Marital conflict, emotional, and psychosomatic problems for both men and women have occurred, especially for men, who were habituated to their dominant role. As a result, wife and child abuse, alcoholism, self- destructive behaviours, and depression have occurred in some families (Gold, 1992). It has been observed that the traditional Vietnamese family, as an intact harmonious and extended patriarchal family, might have ceased to exist when Vietnamese people came to live in Australia (Coughlin, Walsh, & Cook, 1996). Based on the data obtained from personal observations spanning two decades, Coughlin et al. call into question the general assumption of the Vietnamese family in which the elderly are well respected and children are well behaved and studious. The fact that 5,000 elderly Vietnamese-Australians are either homeless or abandoned by their children, and about the same number of Vietnamese youth run away from home indicates that the Vietnamese family is becoming dysfunctional. It has been argued that social disruption, Western ideologies and values, and the effect of urbanisation have changed the nature of the Vietnamese family structure. Coughlin et al. argue that Vietnamese families are now largely comprised of a two-generation nuclear-family which consists of parents and children, and that the number of single-Vietnamese parents is increasing. Not only is the traditional close relationship with the extended family becoming more distant, but also the parent-child relationship is deteriorating. Following these perspectives, one can assume that many changes within the Vietnamese family in the Western world are negative. Integration into the Western way of life with its cultural beliefs and values has been a challenge to many Vietnamese. Role reversal has been documented as one of the most cited problems between husband and wife, between parents and children (Gold, 1992; Kibria, 1993). The traditional hierarchical Confucian family system in which the elderly and the man of the family hold a respected position with power over women and children, has changed under the influences of the struggle for economic survival, and of Western values and ideologies. An important virtue that is instilled within every Vietnamese is that one should always put family and group interests before one's self-interest. The pursuit of individual goals is not only frowned upon as 34 selfish, but also seen as an act of disrespect for others. Thus, individuals who exhibit self-negation, self- sacrifice, and modesty are considered to be individuals with good character. These cultural values and expectations have led Vietnamese women to conform to their role as care givers and to view additional responsibilities and hardships as "the way things are" (Maltby, 1998). These women's behaviours are reinforced within the Vietnamese community by the high regard that is given to these women as "good mothers," "good daughters," and "good women." Contrary to Vietnamese culture, values, and expectations, Western society values individual independence, autonomy, and the pursuit of one's own success. Failure to do so is viewed as a personal weakness. The integration of these values has, to a certain degree, created conflict within some Vietnamese families. In sum, although Vietnamese still retain their cultural values and beliefs, adaptation to the new way of life and integration process into Canadian society have changed their social roles and relationships. Economic adaptation necessitated changes within the family function, leading to changes in the roles of men, women and children. These changes have directly and indirectly influenced how Vietnamese women practice health care. An understanding of Vietnamese cultural beliefs, values, their past and present social, political, economic, and historical processes will assist health care professional in understanding Vietnamese Canadian's adaptation. This understanding will also help in identifying health care strategies that could be applied to the development of an effective and culturally appropriate health promotion and disease prevention program for Vietnamese living in Canada. 3. Health and Health Care Experiences It is documented that Vietnamese immigrants have suffered from several physical, emotional and psychological problems (Beiser, 1999; Nelson, Bui, & Samet, 1997). Coming from a country where health-related concerns are secondary to fighting for survival, doubled with the very unhygienic conditions in the refugee camps, a large portion of immigrants have contracted or have come into contact with infectious diseases such as cholera, typhoid fever and communicable diseases such as tuberculosis and hepatitis B. A study done in the U.S. which screened 99 recent Vietnamese immigrants who lived in the country for less than six months has shown that 51% of the Vietnamese suffered parasite problems (63% of these people required treatment), 70% tested positive for tuberculin skin tests (39% of them required treatment), 83% had been exposed to hepatitis B, and 17% were depressed (Nelson et al., 1997). However, mental health problems have been identified as the most prevalent among the Vietnamese 35 immigrants. Studies from the U.S. and Canada revealed that depression and anxiety are the most common mental health problems among immigrants (Beiser, 1988,1999; Berry & Blondel 1982; Tracy & Mattar, 1999) - especially for Vietnamese whose pre-migration lives and flight were marked with much suffering (Beiser, 1999). It has been reported that as many as 19% of Vietnamese living in Canada suffered a depression disorder (Beiser, 1999). Beiser (1999), a Canadian psychiatrist, believes that although Indochina immigrants are exceptionally resilient people because they have managed to survive extraordinary adversity in their home countries, the horror of escape, and the crushing environment of the refugee camps, "pre- and post-migration stresses place [immigrants'] mental health and adaptation in jeopardy" (p. 61). Thus, from Beiser's point of view, the host society should concentrate on alleviating stresses that are experienced by the immigrants due to unemployment, underemployment, and discrimination. He also insists that the presence of the family, and the support of both the ethnic community and the host society, influence immigrants' mental health directly and indirectly. Because family provides emotional as well as economic support, immigrants who are married and who live with their family will have better mental health than single immigrants (Beiser, 1999). As such, to facilitate immigrants' well-being and successful adaptation, support for immigrants should be given from the family, the ethnic community, and society at large. With the migration process, many Vietnamese immigrants came to Canada alone. Their dream is that someday they would be able to sponsor their loved ones to join them in Canada. However, working at low paying jobs has made meeting the government's requirement criteria for sponsorship a difficult task. Thus, many have seen their dreams of family reunion delayed. This has resulted in high incidence of depression among the Vietnamese (Beiser, 1988; Berry & Blondel, 1982). Many health care providers have recognised that immigrants often encounter difficulties accessing health care services. Barriers to access a health care delivery system include language difficulties, different cultural health beliefs and practices, lack of cultural acceptance and appropriate health care services, and lack of social resources (Anderson, 1998; Hirota, 1999; Stephenson, 1995). It has been shown that an individual's cultural conceptualisation of health, illness, fate, and acceptable ways to deal with life events affects how one views stress and shapes coping responses and outcomes (Aldwin, 1994; Kleinman, 1980; Lazarus & Folkman, 1984; Slavin, Rainer, McCreary, & Gowda, 1991). For example, many people who live in North America view that health is important and stress causes many illnesses. Thus, how to avoid stress has been a popular topic in both lay and professional 36 discourses. Individuals are told that they can deal with stress and stay healthy by changing their life style and learning to use methods developed to reduce stress (Donnelly & Long, 2003). Many techniques such as relaxation exercise, meditation therapy, and counseling have been developed to help people deal with daily pressure. Similarly, to many Vietnamese, health is viewed as gold. However, illness is viewed as an inevitable part of life - an event predetermined by destiny (Maltby, 1998; Nguyen, 1985, Donnelly, 2002). Thus, the acceptance of these beliefs has helped the Vietnamese to view changes in life, illness, and sometimes even death not as a source of stress, but as part of the Buddha's teaching: "to be born, grow old, fall ill and die" (Nguyen, 1985, p. 410). In this context, individuals' cultural backgrounds shape their explanatory models of illness and disease, and their expectations toward treatments, which in turn, determine how they make decisions regarding coping with illness and health care practices (Good, 1994; Kleinman, 1980). Maltby (1998), in a combined qualitative and quantitative study, compared the cultural beliefs and values that underlie the health behaviour of Vietnamese women living in Australia with mainstream cultural groups. Malby's study indicated that Vietnamese women's health care practices reflected their cultural conceptualisation of health and illness. Although there is little research focused specifically on the health status of Vietnamese immigrant women living in Canada, a few studies from Canada and other countries such as the United States and Australia have revealed that Vietnamese immigrant women suffer from a number of major health problems. Among them, infectious diseases, communicable diseases, and mental illnesses ranked high (Beiser, 1999; Nelson, Bui, & Samet, 1997). Mental illnesses such as depression, anxiety, and somatisation have been identified as the most common psychological problems experienced by Vietnamese women. Recent studies have also revealed that Vietnamese women suffer high mortality rates for cervical cancer and breast cancer due to delays in seeking help for these diseases (Cheek, Fuller, Gilchrist, Maddock, & Ballantyne, 1999; Lesjak, Hua, & Ward, 1999). D. Breast Cancer and Cervical Cancer Cervical cancer is among the most common cancers for women in the countries where Papanicolaou smears are not routinely performed (BC Cancer Agency, 2000), and Vietnamese-born women have a significantly higher incidence of cervical cancer (Cheek, Fuller, Gilchrist, Maddock, & Ballantyne, 1999; Lesjak, Hua, & Ward, 1999). Even though breast cancer is less common among Vietnamese women, they are more likely to be diagnosed at the late stages than women in the general population (Pham & McPhee, 1992). Screening reduces the incidence and mortality of both cervical cancer and breast cancer (BC Cancer Agency, 1999, 2004). However, the data from the U.S. and Australia suggest that Vietnamese women do not fully utilise these cancer screening services (Cheek, Fuller, Gilchrist, Maddock, & Ballantyne, 1999; Jenkins, Le, McPhee, Stewart, & Ha, 1996; Lesjak, Hua, & Ward, 1999; Yi, 1994). Because both breast cancer and cervical cancer involve body sites that are considered very private, and taboo, investigating these two problems together and how Vietnamese women use both breast cancer and cervical cancer screening services will explain why there are differences in mortality and late stages diagnosis for these diseases. 1. Mortality and Incidence Rates According to the Canadian Cancer Statistics 2003, the Age-Standardised Incidence Rate of breast cancer rose from approximately 88.3/100,000 in 1974 to an estimated rate of 107.3/100,000 in 2003. The breast cancer mortality rate slightly decreased from 31.1/100,000 in 1974 to 25.4/100,000 in 2003. It was estimated that in 2003 approximately 21,100 women would develop breast cancer and 5,300 women would die of this disease (Canadian Cancer Statistics, 2003). Each year, in British Columbia alone, 2,800 women develop breast cancer and about 600 women die of this disease (BC Cancer Agency, 2004). Although incidences of cervical cancer and mortality rates have decreased greatly in Canada, in 2003 there were approximately 1,400 new cases of cervical cancer, and 420 Canadian women died of this disease (Canadian Cancer Statistics, 2003). As indicated by Lee et al. (1998), immigrant women who are older and/or with a lower socioeconomic status have a higher risk of cervical cancer. The U.S. data suggest that although the breast cancer incident rate is low for Asian women, their mortality rate is high due to late stage diagnosis of the disease. There is evidence to show that more Asian women (79%) were diagnosed with breast cancer's tumors larger than 1 cm than U.S. white women (70%) (Hedeen, White, & Taylor, 1999), and more Vietnamese-American women were diagnosed at advanced stages of breast cancer than Caucasian women (Pham & McPhee, 1992). Furthermore, the mortality rate for cervical cancer is higher for Asian women than for American women (Perkins, Morris, Wright, 1996 cited in Wismer, 1999). Data from the U.S. National Cancer Institute for the years 1988 38 through 1992 show that Vietnamese women's average annual age-adjusted breast cancer incidence rate was 37.5/100,000 while white women's breast cancer incidence rate was 111.8/100,000; by contrast the cervical cancer incidence rate for Vietnamese women was 43.0/100,000 as compared to white women's cervical cancer incidence rate of 8.7/100,000. In addition, data from the Northern California Cancer Center in the U.S. revealed that among Vietnamese women, there was an annual age-adjusted incidence rate of 47.7/100.000 for breast cancer and 38.1/100.000 for cervical cancer from 1988 through 1993 (McPhee, Stewart, Brock, Bird, Jenkins, & Pham, 1997). More recent data also revealing that, according to U.S. National Cancer Institute's Surveillance, Epidemiology, and End Result (SEER), Vietnamese women have the highest incidence rate for cervical cancer, which is 43 per 100,000, while White women's cervical cancer incidence rate is only 7.3 per 100,000 (Lawson, Henson, Bobo, & Kaeser, 2000). This high incidence of cervical cancer might be the result of low Pap testing among the Vietnamese women, hence the precursor lesions are not detected and treated before progression to cancer. Furthermore, in Australia, Vietnamese-born women have a significantly higher incidence of cervical cancer as compared to other groups of immigrants and Australian born women (Cheek, Fuller, Gilchrist, Maddock, & Ballantyne, 1999; Lesjak, Hua, & Ward, 1999). 2. Vietnamese Canadian Women's Health Care and Cancer Screening Practices In relation to health care practices, not only do cultural beliefs, values, and practices influence an individual's appraisal of illness and their coping choices and options, but also their social positions within a particular society. These, in turn, will shape an individual's health care behaviour. Anderson (1991, 1993, 1998), Dyck (1989), Kearns and Dyck (1995), Papps and Ramsden (1996), Stephenson (1995), and Stingl (1996) have examined barriers to access health care by members of different ethno-cultural background groups. They have identified obstacles to accessing health care that are not only related to cultural beliefs and values, but also ethnic inequality, in terms of political power and social economic status. Thus, other determinants of health such as social, political, economic, and historical factors should become important issues of analysis. A review of the literature reveals that cultural attitude, beliefs about health, and beliefs about the sources of illness influence how the Vietnamese practice health care and that differences in cultural conceptualisations of health and illness can pose barriers to seeking treatment from Western health care (Stephenson, 1995; Uba, 1992). Stephenson's study (1995) revealed that Vietnamese underutilised the 39 existent health care services, although not specifically related to breast and cervical cancer screening practices, further suggests that Vietnamese Canadian women might be less likely to have cancer screening compared to women in the general Canadian population. A quantitative survey conducted by a group of health care providers in California showed that although not strongly correlated, Vietnamese's social values contributed to some extent to how Vietnamese women practice breast and cervical cancer screening (McPhee et al., 1997). The results of Yi's (1994) telephone survey of 141 Vietnamese women and McPhee et al.'s telephone survey of 933 Vietnamese women in the U.S. suggested that barriers to Vietnamese women's cancer screening behaviour are low socioeconomic status, lack of health care insurance, low level of education, poverty, and never being married. In addition, while McPhee et al. (1997) found that having a Vietnamese physician contributed to the lower participation rate of these women's cancer screening practices, Lesjak et al. (1999) and Cheek et al. (1999) found the length of residence in the adopted country affects participation in cervix screening with recent immigrants being less likely to be screened. It has been pointed out that an individual's responses to illness, which differ from the physician's assumed rational point of view, are not just because of lack of information, but rather because they are grounded in a culture and a system of beliefs and practices that might be different from those of biomedicine (Good, 1994, p. 38). Barriers to practice biomedicine by people of different ethnocultural backgrounds may be the result of different understanding of health, illness, and diseases. While caring for clients of different cultures, different personal beliefs and values might lead to discrepancies in the perception and expectation of care between health care providers and clients. Anderson (1987) pointed out that culturally appropriate care cannot be achieved unless health care professionals recognise and take into account the different cultural perspectives on health and illness held by the clients. They should be able to elicit these discrepancies by negotiation with the clients to come up with a plan of care that is mutually acceptable to both the health care providers and the client. Cecil Helman (1990) concurs with this notion by saying that it is important to maintain open communication between medical professionals and the clients because their views of health, illness, and diseases may be very different. Therefore, "the clinician's diagnosis and treatment must make sense to the patient, in terms of their lay view of ill-health, [clinicians] should acknowledge and respect the patient's experience and interpretation of his or her own condition" (Helman, p. 125). Working within biomedical model, which has its knowledge and practices closely connected to the biological sphere (Good, 1994), physicians and many other health-care professionals have often viewed disease and illnesses as particular parts of a complicated human body that is malfunctioning, and that these parts can be "fixed" with specific solutions (Capra, 1982; Good & Good, 1993). Health-care critics contend that this perspective neglects the wholeness of the patient and pays inadequate attention to the social and environmental contexts of illness and disease (Capra, 1982; Good, 1994). As observed by Byron Good (1994), contemporary biomedicine and medical behavioural science do not adequately address social and psychological issues by focusing on the modification of individuals' "irrational" behaviour to reduce risk factors and increasing the compliance with medical regimens. In health care practice, health care professional cannot assume that knowledge will lead to "rational" behaviours, which in turn, leading to appropriate illness preventing and health-seeking behaviours. Not only do individuals often ignore their risks (Gifford, 1986), but health-seeking and/or illness preventing behaviours should be seen as a situated product, largely shaped by the immediate circumstances and affected by contextual factors ofthe situation (Bloor, Barnard, Finlay, & McKeganey, 1993). In summary, an overview of the literature reveals that Vietnamese women are at significant risk of having advanced breast cancer and cervical cancer due to their low participation in these cancer screening programs. To date, I have not been able to locate other studies examining how Vietnamese Canadian women participate in breast and cervical cancer screening practices. However, present data indicate that Vietnamese women's health care practices are influenced by their cultural backgrounds, understanding of health and illness, social values, and degree of acculturation. Sparse data from the U.S. and Australia also indicated that Vietnamese women's low participation rate in breast cancer and cervical cancer screening programs is the result of different cultural beliefs and values, low level of education, poverty, never being married, recently migrated, and having a Vietnamese physician. There is very limited information on (a) how Vietnamese Canadian women use the available breast cancer and cervical cancer screening services, the quality, suitability, and accessibility of these services, (b) what leads Vietnamese Canadian women to seek health care, from whom they seek help, and the social support networks that women draw upon to foster their health care practices. Furthermore, there is very little research that analyses the role of cultural conceptualisations, social ideologies, and socioeconomic status, which are shaped by race, gender, and class, as important factors in determining Vietnamese Canadian women's breast cancer and cervical cancer preventive health care practices and health-seeking behaviour. 41 E. Research Questions In this study, I address the following research questions from both the Vietnamese women and the health care providers' perspectives: 1) How do Vietnamese-Canadian women participate in breast and cervical cancer screening practices? 2) What is the process by which the decision to engage in regular breast cancer and cervical cancer screening is reached? What are the key factors that influence this decision-making process? 3) How do contextual factors such as social, cultural, political, historical, and economic at the intersection of race, gender, and class affect Vietnamese-Canadian women's breast cancer and cervical cancer screening practices? 42 Chapter Three: Theoretical Questions I hold that individuals' health care behaviours are influenced not only by their cultural beliefs, values, and practices, but also by their social positions within a particular society. Race, class, and gender shape individuals' social position. Thus, addressing Vietnamese Canadian women's breast cancer and cervical cancer screening practices should be viewed and assessed using theoretical perspectives that emphasise the effect of culture, race, class, and gender on individuals' social, cultural, historical and economic background. Social and cultural processes shape the ways in which people think, act, and use health care services (Kleinman, 1980). Examining how culture conceptualisations influence Vietnamese women's view of health, disease, illness, and social relationships will provide insight into the ways in which they make decisions to engage in breast and cervical cancer screening programs. The ways in which people use health care services is influenced by how they conceptualise health and illness. Kleinman (1980) asserts that "[people's] beliefs about sickness... including their treatment expectations .... affect the way individuals think about and react to sickness and choose among and evaluate the effectiveness of the health care practices available to them" (p. 38). Furthermore, "beliefs about symptoms, diseases, and health have a strong influence on how individuals make sense of their vulnerability and respond to illness" (Johnson, Bottorff, Balneaves, Grewal, Bhagat, Hilton, & Clarke, 1999. p. 251). For this study, Weinman's explanatory model of health and health care has directed me toward the examination of (a) Vietnamese women's conceptualisation of health and illness, and their explanation of what causes breast and cervical cancer; (b) whether or not Vietnamese women's health care behaviour is influenced by their cultural knowledge and values, (c) to what extend cultural knowledge and values influence Vietnamese women's health care decision making and health care relationships; and (d) what elements of culture can be identified as facilitators and/or barriers to health care practice. I hold that social antagonism and inequalities, the effects of poverty and political domination, which are present in the institutions such as work places, schools systems, government offices, and health care services, influence Vietnamese women's lives and health care. Adopting postcolonialism and Black feminism will help with the investigation of how the micropolitics of power and the macrodynamics 43 of social and institutional structure (Kirkham & Anderson, 2002) shape individuals' social position within a society, which in turn, influence how they experience reality and practice health care. Postcolonialism and Black feminism will "shed light on the complex issues at the intersection of gender, race, class relations and culture, and further our understanding of how material existence, shaped by history, influences health and well-being for those who... have 'suffered the sentence of history...[of] diaspora, [and] displacement'" (Anderson, 2002, p. 11). In health care, postcolonialism and Black feminism offer an alternative approach to the examination of issues such as equity in health and accessibility in health care services at the time when global migration and health care reform are happening in many Western countries (Anderson, 2002). Postcolonialism and Black feminism provide a theoretical framework that recognise Vietnamese women's marginalised voices as legitimate, as a direction for health care actions that are responsive to Vietnamese women's specific social locations within Canadian society. This chapter illuminates how Kleinman's Explanatory Model (1978, 1980), postcolonialism, and feminism —in particular Black feminism— have provided theoretical perspectives and conceptual frameworks that guided the way in which I chose to address Vietnamese Canadian women's breast cancer and cervical cancer screening practices and answered my research questions. In the first section, I present an overview of Kleinman's explanatory model. In the second section, I articulate the theoretical framework that underlies my research - postcolonialism and feminism. A. Kleinman's Explanatory Model: Medical System as Cultural System Arthur Kleinman (1980) asserts that health and illness beliefs and behaviour, and health care activities are governed by the same set of socially legitimated rules. The way people think, act, and use health care services shape health care systems. To study changes in health care behaviour, one must also examine changes in the health care system. The medical system is viewed as a cultural system because the health care system's origin, structure, and function, Kleinman theorises, is socially and culturally constructed. Culture, Kleinman (1978) defines, is "a system of symbolic meanings that shapes [individual's] social reality and personal experience" (p. 86). Culture mediates between the 'external' (social, political, economic, historical, epidemiological and technological) and 'internal' (psychological, behavioural and communicative) parameters of medical systems, thus culture is a major determinant of 44 the medical system content, effect, and functions. How people of a particular society conceptualise health and illness, their cultural beliefs, values, behaviours, and expectations toward treatments shape their health care system. To understand how a particular health care system functions and operates within a given society, we have to analyse it within the social and cultural contexts of that society. Therefore, to understand Vietnamese women's health care behaviour, we need to understand their conceptualisation of health, illness, and disease, and how their cultural knowledge and values shape their expectations toward medical treatment within Canadian context. According to Kleinman (1980), social reality and clinical reality are two important dimensions of the health care system. Social reality symbolises human interactions which consist of meanings, norms, social structures, and behaviour expected in a society. Kleinman suggests that, "beliefs about sickness, the behaviours exhibited by sick persons, including their treatment expectations, and the ways in which sick persons are responded to by family and practitioners are all aspects of social reality" (p. 38). Thus, the ways in which Vietnamese women think about and make decisions about breast cancer and cervical cancer screening will be affected by their social reality which consists of their beliefs about sickness, their treatment expectations, and the ways in which they are responded to by family and health care practitioners. Clinical reality is a health-related aspect of social reality. It is defined as " the beliefs, expectations, norms, behaviours, and communicative transactions associated with sickness, health care seeking, practitioner-patient relationships, therapeutic activities, and evaluation of outcomes" (Kleinman, 1980, p. 42). Both social reality and clinical reality are "cultural constructions, shaped distinctly in different societies and in different social structural settings within those societies" (Kleinman, p. 38). Thus, to understand how Vietnamese women think about and attend to their health, we need to have insight not only into their beliefs and expectations, but also into what they consider to be social norms in regard to communication, health care seeking, and their relationship with important others and health care providers. The inner structure of every health care system, Kleinman (1980) proposes, is composed of three overlapping domains: the popular (e.g., family, community, social network), the professional (e.g., nursing, medicine, and other health care professions), and the folk sector (e.g., non-professional). Although there are some beliefs and values shared by the three domains, each of the three domains has its own distinct explanatory model of health and illness. 45 1. The Popular Sector of Health Care According to Kleinman (1980), the popular sector of health care is the largest part of any health care system. It is within this sphere of health care that illness is first defined, treatment initiated, and progress evaluated. Within this sector, the family plays a crucial role in deciding what to do and how to engage in what type of health care activities. These decisions are influenced by the popular culture's beliefs and values about health and illness. For instance, if a Vietnamese child is sick with the flu, it is his parents who first notice that the child is sick. The parents then draw from their past experiences and cultural knowledge about this type of illness, what they believe regarding health (a balance between two basic components: am or breath, and duong or blood) and illness (caused by bad wind, rotten food, or bad spirits). The family will then decide whether to administer herbal therapy or to seek outside help by taking the child to a medical facility, or both. 2. The Professional Sector of Health Care The professional sector of health care is comprised ofthe organised healing professions. It is often referred to as modern scientific medicine. In many societies, the modern medical profession has become a source of social power and has successfully dominated the health care system by using legal and political means. The modern medical profession has forced other healing traditions to disperse and to submit to its power (Kleinman, 1980). An increase in professional power creates changes within the system of knowledge, medical technology, and health care institutional structure. In some societies, these changes have resulted in culture-repatterning and Westernisation ofthe health care systems. Kleinman criticises the ideology held by many modern medical professionals that many health-related activities undertaken as the result of beliefs held by the popular or folk sector are irrational and unscientific. This ideology, he points out, has led to an insensitivity towards patient expectations and beliefs of health, illness, and health care. Thus, Kleinman (1980) calls for a broader cross-cultural perspective that would include the views of clinical reality held by other healers and by patients themselves. He also instructs health care professionals to be skeptical about the value judgments enforced by the socially constructed biomedical professional ideology. More importantly, health care professionals should be able to elicit and recognise "patients beliefs and values with respect to their illnesses and treatments and to negotiate with (or 46 translate between) these differing perspectives in the same way an advisor gives expert advice to an advisee, who retains the right to accept, alter, or reject that advice" (Kleinman, 1980. p. 58). 3 . The Folk Sector of Health Care Kleinman (1980) categorises this sector of health care as a mixture of many different components, some related to the professional sector, but most related to the popular sector. There are two distinct sides to this sector of health care, sacred and secular, but they often overlap. Sacred healing usually emerges from studies of folk religion and includes ritual curing. Secular forms of healing comprise "herbalist, traditional surgical and manipulative treatments, special systems of exercise and symbolic non- sacred healing" (Kleinman, 1980. p. 59). Many health care professionals question the efficiency and effectiveness of folk healing medicine because there is no system in place to evaluate the patient's condition before and after treatment. However, there are many forms of folk healing linked to the popular culture and traditional healing in Western societies and in developing countries, indicating the important function of this health care sector. Kleinman (1980) observes that there are no clear-cut boundaries between these three components ofthe health care system. All three sectors interact because the patients pass between them. It is important to note that boundary lines only serve as points of entry and exist for patients who follow their health care plan. For example, a Vietnamese woman may enter the professional sector of health care for treatment of a certain illness, but in the process of evaluating the effectiveness of the treatment will also draw from her knowledge acquired from having contact with all three sectors of the health care system. 4. Explanatory Models (EMs) Individuals' EMs provide explanation for sickness etiology, symptoms, pathology, course of illness, and treatment. EMs derive from individuals' knowledge and values, which are specific to their different social sectors and subsectors ofthe health care system. Studying and comparing clients, family, and health care practitioners' EMs can contribute to understanding health care relationships. Conflicting EMs coupled with cultural insensitivity will lead to relationship and communication breakdown between client and health care provider. These, in Kleinman's view, are major deterrents of client compliance, satisfaction, and appropriate use of health care services. Client-health care provider communication 47 problems are often the result of differences between lay (popular culture) EMs that construe sickness as illness while professional medical (biomedical) EMs construct sickness as disease. One of Kleinman's important contributions was the distinction between disease and illness. Disease "denotes a malfunctioning in or maladaptation of biological and or psychological processes .... Disease is most commonly associated with the EMs of professional practitioners (modern or indigenous), where it relates to special theories of disease causation and nosology that are stated in an abstract, highly technical, usually impersonal idiom .... Illness, on the other hand, signifies the experience of disease (or perceived disease) and the societal reaction to disease. Illness is the way the sick person, his family, and his social network perceive, label, explain, valuate, and respond to disease" (Kleinman, 1978, p. 88). Illness is often associated with the EMs of the lay (or popular culture) whereas sickness is dealt with in a more personal, less technical manner and where life problems arise as a result of sickness are manifested. The illness EM is directly influenced by the individual's culture, knowledge, values, and experiences. Kleinman further points out that health care activities mitigate between both the disease and the illness models of sickness. Problems will arise if health care professionals only see and treat sickness as disease whereas clients seek both symptom relief and meaningful explanations to which they could psychologically, socially, and culturally relate. The important point here is that to provide effective health care, and to ensure clients' cooperation, health care professionals need to treat both disease and illness in a way that the client can relate to culturally, socially, and individually. Within these perspectives, Kleinman's approach to patient care is most holistic because it incorporates the social and cultural aspects of the patient's life. Another relevant feature of Klienman's approach is its recognition of the separate conceptualisations of health, illness, and different personal beliefs and values that both health care professionals and clients bring to health care situations (Anderson, 1990). Kleinman's explanatory model has been examined by many scholars (Anderson, 1985,1987, 1990,1993; Dyck, 1989; Good, 1977; Helman, 1990; Lynam, 1992). Although his conceptual framework addresses health care at a professional-client level and not at the structural and health care institutions level, Kleinman's theoretical model of medicine as a cultural system provides a systematic method for the analysis of the impact of culture on individual's sickness and healing. Kleinman's conceptualisation of the medical system as a cultural system and his explanatory model of health, disease, and illness have also provided me with a framework by which to examine the 48 interactions between Vietnamese women, their families and health care practitioners, which reveals how cultural knowledge and values influence Vietnamese women's breast cancer and cervical cancer screening behaviour. However, Kleinman's framework does not illuminate how power relations, race, class, and gender influence individuals' health care experiences. Incorporating postcolonialism and Black feminism as theoretical perspectives for this study will enable me to examine how Vietnamese women's health care practice is shaped by other contextual factors, namely, social, political, historical, and economic factors at the intersection of race, gender, and class. B. Postcolonial-Feminist Scholarship: Its Relevance in Addressing Health Care Issues Both postcolonialism and feminism provide a theoretical lens through which issues of equity and social justice are examined and incorporated into the analysis of this research. Postcolonialism "provides a theoretical perspective from which to contest the historical construction of the racialised and cultural 'other' through the processes of colonisation" (Anderson, 2002, p. 18). Because Canada is a nation founded on colonisation and immigration, and my research is with Vietnamese women who come from a colonised society, postcolonial perspectives, with its conceptual framework, issues, and debate provide valuable insights that guide the way I address and incorporate the effect of racialisation processes into the analysis of Vietnamese Canadian women's health care experience and practice. As Anderson (2002) points out, "[f]rom a post-colonial vantage point, we might come to understand that the difficulties people face in accessing and utilising health care may be due not to their 'culture', but instead, to historical processes that have produced systemic inequities and oppression" (p. 15). Postcolonialism can be used to examine social issues in any place that has had an experience of colonialism. In Western societies, many social and cultural issues do bear comparison with situations in postcolonial societies —issues such as the sociocultural conditions that are affecting both majority and minority populations (Quayson, 2000). According to Alto Quayson, "[fjactors like multiculturalism, ethnicity, diaspora and transnationalism as they apply in the West can only be fully understood if seen in tandem with the realities of struggles in real postcolonial societies, precisely because some of these factors are actually the effects of global population and cultural flows after colonialism" (p. 11). Black feminism provides a conceptual framework from which to examine social phenomena from the women's perspectives. It pushes us to use the everyday experiences of women as the sources for 4 9 research. Most importantly, "black feminism pushes [researchers] to analyse gender, 'race' and class relations as simultaneous forces, and to examine knowledge production from different social and political locations" (Anderson, 2002, p. 18). These above theoretical perspectives have directed me towards the exploration of how the social, cultural, political, historical, and economic, which are shaped by the conceptualisation of race, gender, and class, influence Vietnamese women's breast cancer and cervical cancer screening practices. Moreover, postcolonialism and Black feminism have led me to a research methodology that has the following characteristics: (a) there is a shift in thinking that science is socially constructed; (b) the researcher treats women as subject and not as object of the study; (c) the researcher is committed to fostering social and political equality for women; and (d) the research is used for the promotion of social justice and equality. With postcolonialism and black feminism combined, this research methodology "[lays] the groundwork for the analysis of gender, 'race' and class relations as simultaneous, contextualised and historicised" (Anderson, 2002. p. 19). To illuminate how post colonialism and feminism provide lens through which Vietnamese women health care experiences can be examined, I discuss postcolonialism and Black feminism. 1. Postcolonialism Quayson (2000) asserts that the term "postcolonialism" often invokes the implicit idea of chronological supersession because of its prefix 'post' —which suggests that the colonial stage has been surpassed. However, the term should be viewed as "a process of coming-into-being and of struggle against colonialism and its after-effects" (p. 9). In viewing postcolonialism as process we are avoiding the misleading conception that views postcolonialism merely as a chronological marker, connecting the postcolonial phenomenon with any precise dating. Anderson (2002), drawing on Quayson, suggests that there is no single definition of postcolonialism. Although the understanding of postcolonial scholarship is diverse, scholars critically address the experience of colonialism whether it is in the past, present, or future and how these experiences have been constructed under the influence of race, racialisation process, and culture within particular historical, colonial, and neo-colonial contexts. In a broad sense, [P]ostcolonialism refers to theoretical and empirical work that centralises the issues stemming from colonial relations and their aftermath. Its concern extends to the experiences of people 50 descended from the inhabitants of these territories and their experiences within the 'first-world' colonial powers .... Overall, the project of postcolonialism today centers on theorizing the nature of colonised subjectivity and the various forms of cultural and political resistance. (Kirkham & Anderson, 2002, p. 3) Quayson (2000) conceptualises postcolonialism as a process, an epistemological path which addresses social issues that are related to: (a) the global politics and the formation of a global order after empire; (b) the re-evaluation of the exclusionary forms of Western knowledge and their roles in imperial expansion and the formation of colonialist rules; and (c) the challenges to dominant discourses (Quayson, 2000, p. 3). Moreover, these concerns extend beyond the formerly colonised lands to include the relationship of dependency between the West and its Others. He writes: Postcolonialism has to be seen as a viable way not just of interpreting events and phenomena that pertain directly to the 'postcolonial' parts of the world, but, more extensively, as a means by which to understand a world thoroughly shaped at various interconnecting levels by what...we might describe as 'the inheritance of the colonial aftermath'. The process of postcolonializing, then, would mean the critical process by which to relate modern-day phenomena to their explicit, implicit or even potential relations to this fraught heritage. (Quayson, 2000, p. 11) Postcolonialism allows for a wide rage of applications because it often involves the discussion of various experiences such as migration, suppression, resistance, differences, race, as well as racial discrimination and minority issues in the West. Although postcolonialists address very diversified issues, in Quayson's (2000) view, what has served to unite these different methodologies is the desire to draw on an understanding of the process of colonialism for understanding the formation of the contemporary world with its social, political, and cultural issues. To further my discussion on the possibility and challenges of postcolonialism, I offer background information on the process of colonisation and colonial issues. 2. Understanding Colonisation and Racialisation The process of colonisation involved the invasion and the acquisition of territories by European nations in the late nineteenth century by means of economic and military forms of power, as well as the desire to protect these territories from other competing nations (Williams & Chrisman, 1994). Colonialism is also viewed by Williams and Chrisman (1994) as "a particular phase in the history of imperialism, it is now manifested as the globalisation of the capitalist mode of production, its penetration of previously non- capitalist regions of the world, and the destruction of its social organisation" (p. 2). In this context, imperialism and colonisation are complex processes. Both are supported and impelled by the ideologies 51 that certain territories and its people are inferior, subordinate, and dependent; and thus, require authority and domination, and the knowledge that is associated with domination (Fanon, 1994; Said, 1993). Because colonisation aimed to seek new markets, sources of raw material, and labour, its ultimate result was economic exploitation of the indigenous people. Colonisation also involves systematic domination that maintains the dominant group's power relation with others and produces an organisational system with institutions that perpetuate these relationships (Williams & Chrisman, 1994). Aime Cesaire (1994) vividly narrates how colonisation works when he writes, Colonisation dehumanised even the most civilised man...I see force, brutality, cruelty, sadism, conflict..There is room for only forced labour, intimidation, pressure... contempt, mistrust.... domination and submission which turn the colonizing man into a classroom monitor, an army sergeant, a prison guard, a slave driver, and the indigenous man into an instrument of human production, (p. 177) Colonisers brought with them not only a series of assumptions that the indigenous people were interested in the coloniser's social system construction, religious, legal, and health care systems, but also the diseases, conflicts, and technology which seriously altered the indigenous people's lives (Ramsden, 1990). The environment and land were exploited and divided for trading value and commercial use. The destruction of cultural beliefs and values, and the economic and spiritual deprivation have consequences to this day. Alienation, poverty, and a lack of cultural dignity, which result from long-term suppression, lead to grief and anger within indigenous populations (Papps & Ramsden, 1996). This trouble is often manifested in high mortality and morbidity rates, much lower life-expectancy compared to the country's average life-expectancy, high incidence of mental illness, escalating high risk behaviour, and inflated suicide rates (Ramsden, 1990). Edward Said (1993) examines culture in relation to imperialism and colonisation. He sees imperialism as "the practice, the theory and the attitudes of a dominating metropolitan center ruling a distant territory" (p. 9), and colonialism, a consequence of imperialism, is "the implanting of settlements on distant territory" (p. 9). Imperialism and colonialism, Said theorises, are acts of accumulation and acquisition of certain dominant ideologies within a society. The ideologies in which certain people are deemed "less advanced" or "subordinate" or even "inferior" have allowed the processes of domination to occur, creating tensions, inequalities, injustice, and racism in many societies. Said insists that this process of domination has been extended and embedded in all cultural affairs. Although there now exists a greater awareness of cultural differences, and more effort is being put towards the elimination of racism, 52 the consequences of these imperial ideologies, the discrimination of one culture by another, the tendency to dominate other cultures, and an inequality of power and wealth still exists in many societies (Said, 1993). Racism is "a doctrine that unjustifiably asserts the superiority of one group over another on the basis of arbitrarily selected characteristics pertaining to appearance, intelligence, or temperament" (Elliott & Fleras, 1992, p. 52). Connell (1989) has identified three levels of racism: (a) Personal racism occurs when an individual or a group of people see itself as superior and has the power to enforce this superiority upon other groups which it views as inferior. This level of racism is detrimental to people because it destroys their sense of self-worth and denies them access to resources and opportunities in society, (b) Institutional racism occurs when institutions and agencies enforce policies which put certain racial groups at a disadvantage, (c) Cultural racism is less obvious, but it is embedded in people's way of life. The most destructive aspect of cultural racism is, again, the underlying ideology of superiority. Although "it is not openly expressed ... it is constantly implied" (Connell, 1989, p. 17). Furthermore, cultural racism is often associated with the differential access to power in the determination of control over the means of social production and distribution of social resources. Many immigrants suffer all three levels of racism. Racial oppression implies, "an unequal relationship... [in which] the dominant group has the power to oppress and the subordinate group has fewer resources to resist the oppression" (Bolaria & Li, 1985, p. 22). Racial oppression results in a loss of cultural identity, the destruction of human relationships, inferior education, housing segregation, and poverty. Racial oppression also results in economic exploitation and social system domination, all of which contribute to inequity and injustice within a society (Bolaria & Li, 1985), poor health and other psychological problems (Connell, 1989; Fanon, 1994; Hall, 1994; Li, 1988; Papps & Ramsden, 1996; Ramsden, 1990; Said, 1993). The question put forth is that how do racial discrimination and oppression contribute to immigrants' health care problems? Racial discrimination and class assumptions can affect immigrants at both the individual and institutional level of care. At the individual level, racism refers to the negative attitudes and behaviour exhibited towards clients of different ethno-cultural backgrounds, which can potentially interfere with a health care professional's willingness to care for clients who are perceived to be different (Kearns & Dyck, 1996). The health care provider's negative attitudes and behaviour towards clients can create barriers for immigrants who feel that they are powerless or discriminated against 5 3 (Anderson, 1985; Donnelly, 1998; Dyck & Kearns, 1995; Kearns & Dyck, 1996; Lynam, 1992; Papps & Ramsden, 1996; Ramsden, 1990). This situation contributes and reinforces the problems of immigrants' access to equity in health care services. Thus, at the individual level, health care providers must be aware of their own capacity for racial discrimination, and of their own cultural beliefs, values, and attitudes that they bring to their work. This view is consistent with Kleinman's (1980) assertion of the importance of health care provider-client relationships. However, problems with health care relationships are the result not only of conflicting explanatory models between clients and clinicians, but also of health care providers' negative attitude and behaviour toward clients. It is important to acknowledge that clients' negative attitude and behaviour toward health care providers will also result in relationship problems. However, in health care relationships, health care providers often hold more power which, when misused, can potentially cause harm to clients. Health care providers have the power in decision-making regarding client care and distribution of health care resources. This is well demonstrated in the way health care providers make care plans and health care policy. It is the health care providers who identify the client's needs, decide on the solutions to meet these needs and decide which health care programs should be funded. Thus, it is essential for health care providers to recognise that "each health care relationship between a professional and a consumer is unique, power-laden and culturally dyadic. From this perspective, whenever two people meet in health care interactions, it inevitably involves the convergence of two cultures. This bicultural component involves not only unequal power and different statuses but often also two cultures with differing colonial histories, ethnicities or levels of material advantage" (Kearns & Dyck, 1996, p. 373). At the institutional level, unequal access to health care resources and unequal power relations between social groups affect how individuals receive health care and cope with illness. Anderson, Blue, Holbrook, and Ng (1993) found that non-English-speaking immigrant women were unable to obtain health care services that they needed because of the position and condition in which these women worked and lived, and also because the existing health care system is set up to serve mainstream society. Thus, it is imperative to examine the effect of racism at the institutional level because this is where the policies are made and reinforced. It is at this level that the dominant group has the power, and the capacity to excise that power to situate certain racial groups at a disadvantaged social position and to place them in low 5 4 socioeconomic status groups. Examining ethnic inequality in relation to social class, education, and economic opportunities, can illuminate immigrants' inequality and their inadequate access to health care. Examining ethnicity and race as products of unequal relationships which are socially constructed and maintained by differential power relations between a dominant and a subordinate group, Li (1988) found that ethnicity makes a difference in the education and economic opportunities of Canadians. Moreover, ethnic inequality has become a systematic and institutionalised feature of Canadian society. Li (1988) asserts that structured social inequality is responsible for the disadvantaged positions of many ethnic groups. These disadvantages include unequal access to educational opportunities, class positions, and earnings. Barriers within a school system for certain ethnic groups to achieve higher education will affect earning potential. Earning disparity contributes to the unequal distribution of wealth, privileges, and power among classes in Canadian society. These dimensions of inequality combined with low earnings contribute to poor health status of immigrants, poor quality of life, and loss of control over life situations. Canada's immigration process, its history, law, and policy not only systematically structure and reinforce sexism and racism against women, but also put immigrant women at a disadvantaged status and create barriers that prevent them from accessing certain social supports and resources (Ng, 1988; Thobani, 1999). Historically, Canadian immigration policy has always been racist in the sense that White English-speaking immigrants are preferred over non-white immigrants in the selection process (Ng, 1988). Thobani (1999) has pointed out that at its inception, Canada's nation building process was developed to strictly control and prevent the entry of women from the third world by designating them "non-preferred races." Third world women were viewed as a threat due to their present racial "inferiority" and their potential to produce "non-preferred races" (Thobani, 1999). Although the 1976 Immigration Act had helped to remove racist and sexist discrimination to some extent, women from third world countries still faced discrimination (Thobani, 1999) due to the fact that under this Act, the husband, in most cases, is the one who will be granted the "independent" immigrant status and he is considered to be the head of the family. The wife and the children are considered "family class" immigrants, which means that they are allowed to enter Canada only if a husband or an immediate family member who is either an independent immigrant or a Canadian citizen sponsors them. This process has not only systematically structured gender inequality within a family, but has also made women totally dependent on their sponsors with a series of disadvantageous consequences. For example, family class immigrant women and children are not eligible to obtain family benefits, welfare, employment training, health care programs, and other forms 5 5 of provincial assistance during the five-year sponsorship period, unless there is a break in the sponsorship contract (Ng, 1988). Over the years, many new Immigration Laws and Acts have been added and changed, yet immigrant women remain unequally treated and discriminated against. As summarised by the Canadian Research Institute for the Advancement of Women (CRIAW), the timeline between women and immigration has several important features: 1976-78: A new Immigration Act was passed in 1976. This document governed Canadian immigration for 25 years. More regulations were passed in 1978 dealing with the sponsorship of "dependents". This is the basis for the regulations that still have a negative effect on the lives of immigrant women. 1981: The Foreign Domestic Movement Program came into effect. It allowed women to immigrate to Canada if they could first find employment as a domestic worker. These women were not granted citizenship and were forced to follow strict rules regarding their living and employment arrangements. 1992: The Live-In Caregiver Program replaced the Foreign Domestic Movement Program. This increased the training requirements needed to apply, and retained all regulations that had been affecting women negatively since 1981. 2002: The Immigration and Refugee Protection Act was passed. This replaced the Immigration Act and governs all immigration to Canada. Unfortunately it was influenced by the fear of terrorism after Sept. 11, 2001. The Act makes it harder for immigrant women to gain access to Canada. However, the Act requires that a yearly report be presented to Parliament on the gender impact of this law. (CRIAW, 2004, Thus "institutional discrimination against immigrant women is built into the statutory services for immigrants" (Ng, 1988, p. 188). 3. Postcolonial Scholarship Recognising the complexity of contemporary experiences, postcolonialists, on the one hand, place an emphasis on illuminating how hegemonic discourses construct and define domination and subjugation in social relations in society. On the other hand, they pay close attention to the ways in which material, social, political, and economic factors produce and reproduce any discourses. In other words, "a central underline assumption is that a focus on the discourse and ideology of colonialism is as important as one on the material effects of subjugation under colonialism and after" (Quayson, 2000, p. 2). Thus postcolonialists are critical of colonial discourses, which represent "Others" in ways that re/produce unequal social relations (Bhabha, 1994; Hall, 1997; Mohanty, 1991; Quayson, 2000; Said, 1994; Spivak 1988; Trinh, 1989). 56 Homi Bhabha (1994) theorised that an important feature of colonial discourse is the ideological construction of racial, cultural, and historical otherness through representation. Conceptualising colonial discourse as "an apparatus of power"(p. 70), as a form of "governmentality" that appropriates, directs, and dominates the colonised society's various spheres of activity, he said: [Colonial discourse] is an apparatus that turns on the recognition and disavowal of racial/cultural/historical differences... It seek authorisation for its strategies by the production of knowledges of coloniser and colonised which are stereotypical but antithetically evaluated. The objective of colonial discourse is to construe the colonised as a population of degenerate types on the basis of racial origin, in order to justify conquest and to establish systems of administration and instruction. (Bhabha, 1994, p. 70) In contrast, "post-colonial discourse [provides] the grounds for interrupting ahistorical, generalising, essentialising, culturalist and racialising discourses, which have categorised people according to racial categories and hierarchies" (Anderson, 2002, p. 13). Thus, researchers who engage in postcolonial scholarship are critical about the language they use in the production of knowledge. They pay attention to the process by which dominant hegemonic discourses and ideologies create a sense of otherness, unequal social relations, imbalance and injustice within society. Following these perspectives, I recognize that dominant social and cultural ideologies and discourses through language and social practices have, to a certain extent, contributed to the racialisation process that place and maintain Vietnamese women within the socially disadvantaged "Others" category, which in turn, impact how health care is provided to these women. 4. What is Postcolonial Research? According to Quayson (2000), the central tenet of any postcolonialist project is the ability (a) to critically examine the social phenomenon in such a way as to disclose the complex interrelationships between postcolonialism and other domains of contemporary experience, (b) a postcolonial project will address the imbalances and injustices that are present in both East and West societies - whether it is about racism, minority rights, labour division between the sexes, or environmental issues. In other words, the postcolonial project has to do with the correction of imbalances in the society wherever these imbalances and injustices may be found - not merely for the oppressed in and from formerly colonised societies, but also for the "intersubjective relations that arise out of responses to crime from both crime fighters and racial minority victims" (p. 12), (c) although far from unified in their views, many postcolonial projects are concerned with issues pertaining to the social construction of race and the process of racialisation, as well as the re-conceptualisation of culture as a concept that operates with/in the construction of race and carries with it social, political, and historical meanings (Anderson et al., 2003). Race is no longer viewed as a biological entity that categorises people according to their physical attributes, but it is viewed as a socially constructed ideology that has often been used to define and organise social relations between society's social groups. Racialisation is "an [ideological] process of delineation of group boundaries and of allocation of persons within those boundaries by primary reference to (supposedly) inherent and/or biological (usually phenotypic) characteristics" (Miles, 1989, p. 74). Thus, the term "racialisation" "draw[s] attention to the social processes whereby groups are singled out for unequal treatments on the basis of real or imagined phenotypical characteristics" (Li, 1990), and (d) the representation of Other which re/produces a sense of otherness. 5. Black Feminism The central tenet of Black feminism, Anderson (2002) points out, is that it views women's experiences as diverse, historicised, and contextualised. Recognising that women's struggles are the product of historical reasoning, racialising processes, and class relations, the researchers' aim is to expose these sources of oppression. Thus, there is a commitment to listen to and value the voices of marginalised women - voices that come from the margins. Following these perspectives, I have used Vietnamese women's everyday life situations as resources for investigating their health issues. Because I hold that there are gender differences in the lives of men and women, women's lives are used as sources for defining their social and health problems and to create scientific evidence and knowledge, and women's health research begins in women's everyday lived experiences. Starting from the Vietnamese women's perspectives enables me to understand the processes through which social life and social relations have organised these women's lives and have shaped labour division between the sexes, which in turn, have influenced how they practice health care. By women's everyday lives is meant "the patterns women create and the meanings women invent each day and over time as results of their labours and in the context of their subordinated status" (Aptheker, 1989. p. 39). Thus, describing every aspect and the activities of women's lives is not as important as knowing the meanings women give to their labours (Aptheker, 1989). If health care 58 professionals understand how Vietnamese Canadian women create patterns of their daily lives and what this means to them, then they will see women's reality in a different way. Feminism posits that women's experiences are important resources for the organisation of social structure and social life in general. As such, women should have an equal opportunity (to men) to participate in the design of social and institutional structures, administration, rules, and practices (Harding, 1987). Feminism holds that in many patriarchal societies, women have often been looked upon as subordinate, and their experiences have been considered as insignificant or totally ignored. Thus, feminists believe that women, in general, and to a different degree, have been oppressed and mistreated by socially dominant groups. Oppression, as defined by Patricia Hill Collins (2000), "describes any unjust situation where, systematically and over a long period of time, one group denies another group access to the resources of society. Race, class, gender, sexuality, nation, age, and ethnicity among others constitute major forms of oppression" (p. 4). In a society, dominant groups hold power that can exclude women from actively participating in social relations, production, and reproduction. Insisting that inequality and injustice exist between men and women within society, feminists are committed to the elimination of social inequity and injustice (Borland, 1991; Harding, 1987). bell hooks (2000) asserts that feminism encompasses the examination of how women's everyday reality is informed and shaped by politics (which include the personal politics, the politics of society, and global revolutionary politics). Feminism can also become a means by which to analyse and illuminate how social ideologies and institutional structures produce and reproduce the experience of discrimination, exploitation, or oppression. To hooks (2000), when feminism is viewed in that way, it "calls attention to the diversity of women's social and political reality, it centralises the experiences of all women, especially the women whose social conditions have been least written about, studied, or changed by political movements" (p. 27). Scholars such as Anderson (2002), Collins (2000), and hooks (2000) assert that marginalised women's social position, which is the result of historical, racialisation, and classification processes, should be an important element in the analysis of women's struggles and experiences. Regarding Black feminism, it is important to explicate that the term "black" is not used as "a biological category, but as a 'political' category" (Anderson, 2002, p. 15). The term "black" is "used by people of different shades of skin colour in a show of solidarity and coalition to resist labels such as 'visible minority' which, unwittingly, designate people as marginal with minority status and, therefore, inferior" (Anderson, 2002, p. 15). Black women, in the view of bell hooks (2000), "are in an unusual position in this society, for not only are [they] collectively at the bottom of the occupational ladder, but [their] overall social status is lower than that of any other group. Occupying such a position, [they] bear the brunt of sexist, racist, and classist oppression" (p. 16). Thus, Black feminists have a world view that closely reflects the lived experiences of marginalised women in a patriarchal society. With the understanding of how marginalised women live, Black feminists are in an advantageous position to generate knowledge that fosters women's empowerment and social justice (Collins, 2000; hooks, 2000). An important question is what would a postcolonial feminist research guided by the above perspectives look like? A postcolonial feminist research exhibits several important characteristics. First, researchers who conduct postcolonial feminist research are critical of traditional social science, its ontological and epistemological underpinnings. They argue against the objectivism and value-free epistemology of traditional scientific inquiry (Gandhi, 1998). Thus knowledge generated in this dissertation is socially constructed. Recognising that the researcher's race, gender, class, and culture shape her/his research process, my positionality as a Vietnamese immigrant woman is acknowledged and incorporated into the research analysis. In this research, the limitation of the biomedical model is recognised and the rhetoric of biomedicine that has produced conventional biomedical knowledge is not taken for granted. It is this awareness that has directed me to choose a qualitative research approach with Kleinman's explanatory model and the postcolonial feminist theoretical perspective as foundations of analysis. Adopting postcolonial feminist perspective, Vietnamese women's breast cancer and cervical cancer issues can be identified and addressed from the perspective of women's experiences. Because the postcolonial feminist perspective values women's experiences as a significant indicator of women's lives, solutions to women's problems are derived from women's perspectives which provide women with explanations that they can draw upon to understand themselves and the social world. All of the above helps to validate women's sense of agency - the autonomy, the right, and the freedom to address what women themselves define as important issues and problems (Harding, 1987). Second, a feminist project is a social justice project that places women's experiences and thought at the center of analysis (Anderson, 2002; Collins, 2000). Feminist research is also politically driven in the sense that it challenges the hegemonic forces that shape women's lives and seeks answers to how to neutralise those forces (Harding, 1987). In this study, Vietnamese women's lived experiences were 60 emphasised as the most important component of analysis. My aim is not only to generate a more accurate account of women's health care activities from their everyday experiences, but also to improve the conditions in which women live and practice health care. Third, a postcolonial feminist research is committed to the examination of how race, gender, and class relations influence social, cultural, political, and economic factors, which in turn, shape the lives of marginalised women. One of the important functions of postcolonial feminist research is to illuminate the ways in which unequal social power relations contribute to the unequally distributed health care resources and inaccessibility of health care services for the women of marginalised social groups. In this study, I examined how racialisation, gender roles and expectations, and class hierarchical relations shape Vietnamese Canadian women's health care practice. Instead of viewing individual women as being totally responsible for their health care behaviours - behaviours which are dictated by their cultural beliefs - I have also examined how health care institutions and organisations' infrastructure and policy affect these women's health and health care. Fourth, postcolonial feminist research pays attention to the connection between knowledge and power relations. Discussion of Foucault's work is of benefit here because his theory which underlie the work of many postcolonial feminist scholars, connects the production of knowledge with power relations, and discourse (Anderson, 2002). Foucault (1994) insists that knowledge cannot be simply reduced to language, meaning, or the investigation of whether or not statements and theories are true, because all knowledge is subject to change (and distortions) under the influence of power relations within social institutions and disciplines. To Foucault, knowledge is connected to social and institutional discursive practices. It is also produced in relation to the disciplinary power structure - the power structure that influences meaning statements, regulates discourse, and produces strategic knowledge. Thus, Foucault's theory about discourse places much emphasis on the relationship between power, knowledge, and truth. One of the most important works of Foucault is his challenge to the many otherwise taken-for- granted assumptions of contemporary health care and medicine (Cheek & Porter, 1997). Through a Foucauldian analysis, health and illness concepts are viewed as not objectively created, but rather produced through the dominant discourse of biomedicine. The dominant discourse of biomedicine has shaped the ways in which disease, illness, and health are conceptualised, which in turn, promotes certain treatments of particular health problems and exclude other conceptualisations of health and disease treatments (Cheek & Porter, 1997). The dominant biomedicine discourses also produce knowledge that 61 values rationality, and influences the discursive nature of health care towards naturalism, individualism, and objectivism (Donnelly & Long, 2003). A limitation of discourse analysis, however, is its totalisation of history's imprint that emphasises that the subject's (women) practices and experiences are constructed (or are determined) by societal macro forces, social discourse, and cultural practices. This might compromise women's ability to resist oppression and domination because it undermines women's sense of agency and ability to reflect on the social discourse and challenge its determinations. It erases any room for maneuver by the individual within a social discourse or set of institutions (Alcoff, 1991). In this study, paying attention to discourse is useful because, "the study of discourse allows an investigation of the social rather than psychic imperatives of behaviour" (Currie, 1999, p. 289). It is important to note that discourse analysis does not simply designate the study of passages of connected writing or speaking through language. It is a study of where meanings come from, and how discourse produces meanings through social and institutional rules and practices that shape and influence social relations, and the production of knowledge in different historical periods (Hall, 1997). The study of health care discourse is then a study about how both popular (or lay) and professional discourses produce and reproduce meanings of health, disease, and illness through social and institutional practices that ultimately shape Vietnamese women's understanding of breast cancer and cervical cancer, and its management. Because discourse provides a medium through which thought, actions, and communication are expressed, articulated, and controlled, the study of health care discourse should emphasise not only how knowledge of health, illness, and its management are constructed and used in social interactions, but also how knowledge influences our consciousness, social values, and in fact, our practices. Because social consciousness and values are produced by people, and are a social product, the analysis of health care discourse should also focus on "issues concerning stake and accountability, and look at the ways in which people manage pervasive issues of blame and responsibility [and]... the way that descriptions are put together to perform actions and manage accountability" (Potter, 1994, p. 129). In conclusion, because I hold that individuals' cultural conceptualisation of health, disease and illness, and socially constructed positions within a society influence/shape their health care behaviour, Kleinman's explanatory model, postcolonialism, and feminism provide the theoretical foundation for this research. Kleinman's conceptual framework has helped me to explore how culture exerts its influences on 62 Vietnamese women's health care behaviour, in particular, breast cancer and cervical cancer screening practices. Postcolonialism and feminism have pushed me to examine critically how individuals' social position which is shaped by race, gender, and class influences Vietnamese women's lives and health care practices. Recognising that cultural and social constraints which are the result of societal inequality and unequal power relationships, effect how immigrant women practice health care, I have drawn on the postcolonial and feminist perspectives to address Vietnamese women's breast cancer and cervical cancer screening issues. Postcolonial feminist researchers assert that traditional research pays inadequate attention to the historical forces that shape the individual's social position and thus their experiences (Anderson, 2002; Kirkham & Anderson, 2002). Inherent in many postcolonial feminist projects is the discussion of the ways in which dominant ideologies and discourses construct the Other's images as "irrational," "backward," and "uncivilised." Postcolonialists such as Edward Said, Stuart Hall, and Homi Bhabha, to name a few, have illuminated how these discourses have contributed to the racialisation process that secures the "different Other" as "inferior Other." The detrimental effect of such a racialisation process is that it naturalises and legitimatises unequal social relations, and creates an unequal distribution of power and social resources in society. If inequality and injustice are seen as inherently present within a society, one is to accept one's own situation. It destroys individuals' agency and silences their voices. For this research, postcolonial feminist scholarship has helped me to put Vietnamese women's marginalised experiences at the focal point of analysis. It has also helped me to analyse the effect of historical forces, together with the present social and political processes, which have shaped Vietnamese women's lives, their health care, and contributed to the remaking of social inequity. These analyses have brought out the awareness that to provide appropriate and effective health care to clients of different ethno-cultural backgrounds and to foster their health care practice, changes in both individual behaviour and social and institutional structural conditions and practices are needed. Drawing on the literature on Vietnamese and women's health care practices, Kleinman's explanatory model, postcolonialism and feminism the following research questions were constructed: (a) How do Vietnamese-Canadian women participate in breast and cervical cancer screening practices? (b) What is the process by which the decision to engage in regular breast cancer and cervical cancer screening is reached? What are the key factors that influence this decision-making process? and, (c) how do contextual factors such as the cultural, social, political, historical, and economic at the intersection of 63 race, gender, and class affect Vietnamese-Canadian women's breast cancer and cervical cancer screening practices? Chapter Four: Research Methods A. Research Participants In this study, a maximum variation purposive sampling was used. Maximum variation purposive sampling is "the process of deliberately selecting a heterogeneous sample and observing commonalties in their experiences" (Morse, 1994, p. 229). Maximum variation purposive sampling can enable the researcher to capture and describe core experiences from the common pattern or themes that emerge from variation within participants (Patton, 1990). The participants consisted of 15 Vietnamese women and 6 health care providers. Fifteen Vietnamese first generation immigrant women with diverse backgrounds, age 50 and over, who speak Vietnamese, come from both North and South Vietnam, and lived in Canada for more than 3 years participated in the study (see Appendix D, p. 231 for their socio-demographic profiles). Justifications for this selection include: (a) the need for the age group to overlap for both breast and cervical cancer screening; (b) the increased aging population; (c) the increased risk for both cancer sites with older age; and (d) the decreasing rate of usage of screening with older ages. The health care providers consisted of four physicians and two community health nurses, who provide health care services to Vietnamese women. The physician's years of working in Canada ranged from 7 to 25 years. One community health nurse had been working with Vietnamese women for 4 years, while the other nurse worked with Vietnamese women for more than 15 years. All health care providers except one community health nurse speak Vietnamese fluently. Table 4.1 Health Care Provider Participants' Profile Years of practice Physicians (A/=4) Community health nurses (A/=2) 4 1 (female) 7 1 (male) 18 1 (male) 1 (female) 21 1 (male) 25 1 (male) 65 Because the cervix and breasts are considered the most private parts of the woman's body, investigating factors that affect how women participate in both cancer screenings would give more information on women's cancer preventive behaviour. Due to the need for the age group to overlap for both breast and cervical cancer screening, women between the age of 18 and 50 were not included. Thus, data on factors that influence Pap testing on Vietnamese women between 18 and 50 years of age are not gathered. The reason for this decision is that younger adults who have been living in Canada since a much younger age, some of them even being born in Canada, are not likely to face the same challenges of accessing Pap testing as older women. Younger Vietnamese adults' cancer screening behaviours might be similar to that of young adults in the general population because they might not have language barriers and the influence of cultural knowledge and values might be minimal. I found that having data on both breast cancer and cervical cancer screening practices does not complicate analysis of the result of this study. Morse (1994) proposed that in qualitative research, adequacy of research sampling is guided by the expertness of the participants and their ability to articulate their experience. In this study, based on the richness and quality of the data collected, a total of 26 interviews were conducted with 21 participants to meet the project's objectives. Each interview conducted with the Vietnamese women lasted between 3 to 4 hours (with the exception of one interview, which lasted for only 2 hours). Interviews with health care providers lasted between 1/2 to 1 hour. Informed consents in both languages, Vietnamese and English, were provided and was obtained from each participant. Each participant was given an explanation of the study. Participant information was kept confidential in a locked cabinet and password protected computer's files. All identifying information from transcripts was removed to preserve participants' anonymity. Pseudonyms and code numbers were used throughout the research process and this report. B. Gaining Access and Developing Rapport Gaining access through Vietnamese community gatekeepers and health care organisations was the main approach of this study. Recruitment of Vietnamese women was made through Vietnamese Community based organisations such as MOSAIC - a multilingual multicultural non-profit organisation, Vietnamese Senior Association, Vietnamese Senior Support Groups, Protestant Church and Women 66 Support group, and by personal referral from the Vietnamese community workers and the women participants. Recruitment of health care professionals was done by referral from community workers, community health nurses, and by personal referral from physicians who also participated in this study. Letters specifying the study's purpose, objectives, research questions, and recruitment criteria were provided to community agencies. Moreover, I made several presentations about the research project to community agencies. Participants and personnel from community agencies were asked to contact potential participants who fit the study criteria, to inform them about the study, and to ask their permission for the researcher to contact them. Once I received permission to make contact, I then talked to potential participants via telephone. During the initial telephone conversation, I explained the study to potential participants and answered any questions before scheduling an interview. At the interview session, I read and explained the informed consent to the participants, answered questions, and reassured them that they had the right to withdraw from the study at anytime (see Appendix E, p. 233, and Appendix F, p. 234 for Women's Informed Consent Letter). Enthusiastic support from community agencies was received. Being a Vietnamese woman who had gone through the experience of being a refugee living in Canada, I have insights into the Vietnamese culture and understanding of Vietnamese women's experiences. I am also aware that the unequal power relation that exists between myself as the researcher and the participants might create discomfort for the participants. Thus, every effort was made to be respectful towards the participants. At the beginning of the interview, often, the participant and I shared our story about our flight to Canada. Many participants have often asked about my own experience in Vietnam and how I got out of the country. My experience of leaving Vietnam by fishing boat via China to Hong Kong helped generate some commonalities between the participants and myself. There were several occasions when knowing that I had grown up in North Vietnam under communism generated discomfort for participants who came from South Vietnam. However, by honestly acknowledging that I was not a communist, and sharing my own family background helped me to create a more comfortable atmosphere and more open communication. There were times when I felt that trust was established between us only after I talked about my family's experiences under communism. 67 C. Method of Data Collection To address my research purposes and questions, a qualitative research approach was used because it provides detailed contextual information, and can capture the complexity, and meanings that Vietnamese women and their health care providers attribute to their thoughts, actions, and health-related behaviours (Stephenson, 1995). In a study where different language and cultural perspectives are prevalent, conducting in-depth interview using the participants' language enables the participants to describe their experiences using their own words (Anderson, 1986). Fluency in Vietnamese gave me the ability not only to conduct interviews in Vietnamese, but it has also enabled me to understand and closely attend to the participants' narratives. It allowed me to engage more directly with participants. The data for this study are constituted of information gathered from in-depth interviews, field notes with Vietnamese immigrant women and health care providers, and direct participation in Vietnamese community events (i.e., Vietnamese women group meetings, church meetings, Vietnamese social gathering events). Demographic data about the women participants were also compiled. In addition, information about the health care structure and policy, social resources, Mammogram Screening programs, and data from BC Cancer Agency and BC Ministry of Health were reviewed and documented. All the above mentioned data were used for data analysis. In-depth interviews were the main method of data gathering and analysis. In this study, the process of in-depth interviews can be described as open but focused (Schwandt, 1994). The participants were able to describe their experiences as openly as possible while still maintaining a research focus because dialogue between the participant and myself was interactive, reflective, and open. Participants were encouraged, respected, and listened to. Using an explanatory conceptual framework developed by Kleinman, postcolonialism, and feminism as theoretical foundations, a semi-structured questionnaire with open-ended probing questions was developed to encourage the participants to discuss their experiences with breast cancer and cervical cancer screenings. Ideology and discourse influence the research process - from formulating the research purpose, refining the research question, developing the interview guide, completing the interviews, data analysis, and the representation of results. Interviewing involves direct interaction between the researcher and the research participants. Thus, I am aware of how ideology and discourse influence the ways in which I ask questions, the type of questions that are generated during the in-depth interview, and the power that exists dur ing our interact ion. This awareness provides m e with the oppor tun i ty to gain a more accura te v iew of the part ic ipants ' l ives. D. Research Interviews In-depth interv iewing is "a da ta gather ing techn ique used in qual i tat ive research w h e n the goal is to col lect detai led, r ichly textured, person-centered in format ion f rom one or more individuals" (Kau fman , 1994, p. 123). Elliot Mishler (1986) conceptua l ises interv iewing as a fo rm of d iscourse. . .that it is d iscourse shaped and organ ized by ask ing and answer ing quest ions. A n interview is a joint product of wha t in terv iewees and interv iewers talk about together and how they talk wi th each other. T h e record of an interview that w e researchers m a k e and then use in our work o f analys is and interpretat ion is a representat ion of that talk. H o w w e m a k e that representat ion and the analyt ic procedures w e apply to it reveal our theoret ical assumpt ions and presupposi t ions about relat ions be tween d iscourse and mean ing . (Preface) In conceptual is ing the interview as a communica t i ve event (i.e., a d iscourse be tween speakers) , accurate records of the quest ions asked by the interv iewer and the answers g iven by the in terv iewee, are necessary. Because interv iewing wi th open-ended quest ions is of ten complex in intent ion and word ing , it leaves m u c h room for interpretat ion by both the interv iewer and the part ic ipants (Potter, 1994). Ambigu i ty and complex i ty are, therefore, present in all interv iew si tuat ions and types of d iscourse. Shared implicit assumpt ions and the mutual recogni t ion of contextual factors are important to faci l i tate mutual unders tand ing o f t h e mean ing o f t h e quest ions asked and the responses g iven (Mishler, 1986) . If in terv iewing is a d iscourse and Foucauld ian analysis (Foucaul t , 1994) con tends that power inscr ibes wi th in d iscourse, at tent ion to power relat ions be tween researchers and their part ic ipants is a must. Interv iewing involves interact ions within an unequa l power relat ionship. I have a t tempted to min imise this power differential by engag ing the part ic ipants in a more reciprocal dialect ical relat ionship. Tradit ional ly, researchers of ten hold more power than their part ic ipants and in s o m e si tuat ions, " interv iewers def ine the role o f in terv iewees as subord inates ; ex t rac t ing in format ion is m o r e to be va lued than yielding it; the convent ion of in terv iewer- in terv iewee h ierarchy is a rat ional isat ion of inequal i ty; wha t is good for interviewers is not necessar i ly good for in terv iewees" (Oakley, 1 9 8 1 , p. 40) . Fur thermore, wi thin the tradit ional model of sociology, an ideology that val idates object ivi ty and value- f ree research has m a d e s o m e social researchers v iew interviews mere ly as an inst rument of da ta col lect ion (Oakley, 1981) . 69 T o facil i tate the col lect ion of informat ion, a pseudo-conversat ion is c reated in w h i c h the interviewer asks quest ions with w a r m t h and clarity, but does not engage in the exchange of informat ion and does not reveal his/her personal bel iefs and va lues. Behav ing otherwise wou ld lead to 'bias' and invalid research wou ld result. Thus to ensure the success of the interview, the interv iewer has to ach ieve a ba lance "be tween the w a r m t h required to genera te 'rapport ' and the de tachment necessary to see the in terv iewee as an object" (Oakley, 1 9 8 1 , p. 33) . M a n y feminist researchers asser t that these in terv iewing techniques are unethical . Successfu l interviewing, they suggest , is ach ieved w h e n an equal power relat ionship exists be tween the interv iewer and the interv iewee, a n d w h e n the interv iewers are wi l l ing to invest their personal identity in the relat ionship (F inch, 1993; Oakley, 1981) . In this study, a non-hierarchical research interv iewing approach w a s used. T h e w o m e n part ic ipants and I were wi l l ing to invest our personal identit ies in the relat ionship th rough shar ing our o w n stories. Th is approach to qual i tat ive data gather ing he lped m e to genera te detai led, richly tex tured, and person-centered informat ion f rom the part ic ipants. It has helped m e to deve lop and mainta in rapport and trust ing re lat ionships wi th m y part ic ipants. Th is is an essent ial e lement in the research process because many sensi t ive topics such as social support , d iscr iminat ion issues, and polit ical perspect ives were addressed . Recogn is ing that polit ical issues exist be tween the V ie tnamese w h o c a m e f rom North V ie tnam and V ie tnamese w h o c a m e f rom South V ie tnam is an important aspect of this research . Because I c a m e f rom North V ie tnam, wh ich w a s under control of c o m m u n i s m , the part ic ipants of ten wan t to k n o w about my polit ical perspect ive, and whether or not I suppor t c o m m u n i s m . T h u s emphas is ing that m y main purpose for do ing this s tudy w a s to f ind w a y s to promote cancer prevent ive heal th care pract ice a m o n g V ie tnamese Canad ian w o m e n and that I a m a nurse w h o is most ly in terested in heal th ca re issues w a s essent ia l . In addi t ion, by honest ly recognis ing that there is tens ion be tween Nor th V ie tnamese and South V ie tnamese people due to the historical and polit ical nature of our country, I w a s able to deve lop trust wi th m y part ic ipants. A s a result, the part ic ipants were quite open in talk ing about such sensi t ive topics. T h e individual in-depth interviews were conduc ted in the language that w a s preferred by the part icipant. Initially, m y plan w a s to interv iew each w o m a n part icipant two t imes, each t ime for the length of 1 hour to 11/2 hours, whereas each health care provider wou ld be interv iewed one t ime for 30 minutes (which is the t ime that m a n y busy physic ians could give). However , most of the part ic ipants w a n t e d to 70 talk, and as a result, our conversat ions lasted m u c h longer than ant ic ipated. W i t h the part ic ipants ' permiss ion, all the interviews were audio tape recorded . Interviews wi th the V ie tnamese w o m e n y ie lded informat ion address ing the research object ives: (a) to explore h o w V ie tnamese w o m e n part ic ipate in breast cancer and cervical screening, wha t leads V ie tnamese w o m e n to seek health care and f rom w h o m they seek help, and the social suppor t ne tworks that they d raw upon to foster their health care pract ices, (b) to explore whe ther V ie tnamese w o m e n f ind the current preventat ive cancer serv ices sui table and accessib le to t h e m , (c) to explore h o w social , cultural , polit ical, historical, and economic wh ich are shaped by the conceptual isat ion of race, gender , and c lass inf luence V ie tnamese w o m e n ' s breast cancer and cervical cancer screen ing pract ices, (d) to explore di f ferences be tween V ie tnamese w o m e n ' s perspect ives and those of heal th care providers, and how the health care providers ' perspect ives inf luence the heal th care exper iences of V ie tnamese w o m e n , (e) to exp lore how a postcolonial feminist perspect ive contr ibutes toward the unders tand ing of V ie tnamese w o m e n ' s health care exper iences and cancer screen ing pract ices. However , s o m e of the interviews wi th health care providers have a lso prov ided m u c h insight into the analys is of these issues. A n interview gu ide wi th open-ended quest ions w a s des igned specif ical ly for the study. It w a s in both the V ie tnamese and Engl ish languages. T h e interv iew gu ide conta ins quest ions regard ing V ie tnamese-born w o m e n ' s health care knowledge, at t i tudes, past and current pract ices about cl inical breast examinat ion (CBE) , breast self examinat ion (BSE) , m a m m o g r a m , and Pap test ing. T h e quest ions also inquired into how V ie tnamese w o m e n pract ice breast and cervical examinat ion ; what prevents or wha t mot ivates these w o m e n to engage in prevent ive cancer screen ing pract ices; wha t do they perceive as barr iers to access ing health care serv ices and provis ions, and w h o are their heal th care suppor ters . In addi t ion, quest ions assess ing soc io -demograph ic in format ion about V ie tnamese immigrants gave addit ional informat ion about V ie tnamese w o m e n ' s social suppor t ne tworks (see Append ix G, p. 235 for Initial In terv iew Quest ions for V ie tnamese W o m e n and Append ix I, p. 2 3 9 for the Soc io -Demograph ic Data Form) . T o identi fy if there are di f ferences b e t w e e n V ie tnamese w o m e n ' s perspect ives a n d those o f health care providers, interviews were conduc ted wi th health care professionals w h o provide health care serv ices to V ie tnamese w o m e n . Interviews wi th heal th care professionals focused o n exp lor ing wha t these professionals bel ieve mot ivates or prevents V ie tnamese-born w o m e n f rom engag ing in C B E , B S E , m a m m o g r a m , a n d P a p test ing pract ices; wha t they perce ive as barr iers for V ie tnamese w o m e n to access 71 these serv ices; wha t informat ion, health care p rograms, and services wou ld best benefi t V ie tnamese Canad ian immigrant w o m e n ; and what they perceive as the best possible st rategies to p romote breast cancer and cervical cancer screening pract ices a m o n g V ie tnamese w o m e n (see Append ix K, p. 245 for Initial Interv iew Quest ions for Heal th Care Providers) . T h e data obta ined f rom interviews w e r e t ranscr ibed in the pr imary language of the part ic ipants and then back t ranslated into Engl ish. A l though on ly sect ions of interv iews that I used to quo te w e r e t ranslated into Engl ish, a sample of f ive interv iews w a s randomly se lected, t ranslated into Engl ish, rev iewed, and ana lysed . The code categor ies f rom the Engl ish t ranslat ion w e r e used to c o m p a r e wi th the categor ies f rom the data in V ie tnamese. My cod ing process w a s consistent and accurate because the code categor ies deve loped in Engl ish were simi lar to the code categor ies deve loped in V ie tnamese . E. Data Interpretation, Coding, and Analysis Data obta ined f rom interviews and field notes were t ranscr ibed as soon as possible. All of the interv iew data w e r e coded and used as examples to be quoted . My approach in work ing wi th the t ranscr ibed data also included cont inuous data analysis and interpretat ion. Data analysis w a s an ongo ing process that involved thorough reading, mark ing transcript marg ins, identi fying, ref ining, add ing codes , and categor is ing themes . In addi t ion, da ta col lect ing, f i l ing, and organis ing t h e m e mater ia ls w e r e done so that data cou ld be easi ly retr ieved. T h e process of data analysis and data col lect ion occur red concurrent ly . T h e process of data analysis inc luded specif ic s teps. Step 1: A s data w e r e obta ined, they were t ranscr ibed in the language that w a s used by the part ic ipants (which w a s most ly V ie tnamese) . T o ensure accuracy, the t ranscr ipts were rechecked against audio tape tapes, cor rec ted, then a hard copy w a s obta ined for prel iminary da ta analysis. Step 2: In the ear ly s tages of analysis, t ranscr ipts were coded to identify pre l iminary t h e m e s f rom the data and to formula te a list of code categor ies for organis ing incoming data. T h e s e code categor ies w e r e ref ined as subsequen t da ta w e r e ga thered. Step 3: Da ta c o d e d in one ca tegory w a s examined for its re levance to other categor ies. T h e final ou tcome of this analysis is a s ta tement about a set of compl ica ted interrelated concepts and themes . This process of analysis involved a sys temat ic and r igorous deve lopmen t of code categor ies and subcategor ies , wh ich w e r e f lexible and evolv ing and used for the cod ing of subsequent t ranscr ipts. Dur ing this step, I meet wi th m y superv isors and research 72 commi t tee m e m b e r s to review, and to share ref lect ions on the process of conduct ing the interview, personal feel ings, and analyt ic descr ipt ions. Step 4: T h e m e s and concepts were used to c o m p a r e within and across t ranscr ipts in the da ta set and across cases. From this, a higher level of data conceptual isat ion and broader theoret ical fo rmula t ions were genera ted . This step also inc luded return ing the prel iminary results to the part ic ipant a long wi th m y analyt ic interpretat ions in the second interview. Return ing the prel iminary results to the part ic ipants was d o n e with six part ic ipants ( two V ie tnamese w o m e n and four health care providers, wh ich inc luded three physic ians and a commun i t y heal th nurse) . This process enabled m e to clarify, expand , and d iscuss wi th the part ic ipants the emergen t themes , ideas, and concepts . It a lso helped m e to deve lop a deeper unders tand ing of the data and gain more insight into V ie tnamese w o m e n ' s breast cancer and cervical cancer sc reen ing pract ices, and the social p rocesses and structures that organise these exper iences. Because categor ies were deve loped based partial ly on the mean ings that part ic ipants attr ibute to their exper iences (Carspecken, 1996), I paid part icular at tent ion to the w a y s in wh ich mean ing is reconst ructed. Mean ing reconstruct ion involves the w a y in wh ich I menta l ly noted the possib le under ly ing mean ings and/or m e s s a g e s that the da ta conveyed . Mean ing w a s unders tood and contextual ised by ref lection into the everyday life of the part icipant. T o begin the initial mean ing reconstruct ion, I read th rough the interview data and f ield notes, and mental ly noted possible mean ings . After several careful readings, I w a s able to identify c o m m o n patterns as wel l as unusual e lements or events that m a y have been impor tant to m y analys is . I then per fo rmed a l ine-by- l ine da ta analysis and pre l iminary cod ing w a s emp loyed at that point. Af ter reading th rough the data and beginn ing the prel iminary cod ing process, segments that s e e m to be representat ive of act ion and thought patterns (regular pat tern and/or anomal ies in the pat tern) were se lected. This process w a s done in order to m a k e explicit the under ly ing no rms and possible mean ings of these act ions and thoughts , and to m a k e the vo ices of my part ic ipants visible. Selected segmen ts were then read line by line and m y c o m m e n t s on discurs ive art iculat ions of mean ing , wh ich I bel ieved m a y underl ie the interact ion, we re recorded. A s pointed out by Carspecken (1996) , the art iculat ion of possible mean ing involves researchers ' inference of the mean ings they think their part ic ipants might infer, ei ther overt ly or implicit ly. Because I could not k n o w for certain that m y art iculat ion of the part ic ipants ' in tended mean ings is in fact so, I could only speci fy possibi l i t ies of what m y part ic ipants might m e a n . Because there is no guaran tee that m y reconstruct ion of mean ing is, in fact, exper ienced by the part ic ipants, there is a lways an e lement of 73 uncer ta inty and ambigu i ty in wha t I interpret as part ic ipant 's in tended mean ing . Thus , it begs the quest ion , how wou ld I val idate my reconstruct ion of mean ings? Carspecken (1996) r e c o m m e n d e d several w a y s that researchers can suppor t their art iculat ion of mean ings . First, the more famil iar researchers are wi th the cul ture of their part ic ipants, the c loser their art iculated mean ings wou ld be to that of the part ic ipants. Hav ing gone th rough an exper ience of a V ie tnamese refugee he lped m e to unders tand s o m e of the issues these V ie tnamese w o m e n were fac ing . Fur thermore , as a heal th care provider, I w a s ab le to unders tand the social const ra ins w h i c h the physic ians and the c o m m u n i t y health nurses w e r e cop ing wi th . Second , the use of m e m b e r checks plus dialogical data generat ion helped ref ine m y art iculated mean ings . M e m b e r checks were done by shar ing the results of my prel iminary da ta analysis wi th the people w h o part ic ipated in these first interviews. T h e s e were part ic ipants w h o m I bel ieved could give m e the mos t feedback based o n their level o f art iculat ion. In this study, the w o m e n and the heal th care prov iders agreed wi th m y const ructed meanings, themes , and insights. M e m b e r check ing w a s also done wi th m y superv isory commi t tee m e m b e r s through meet ings that inc luded presentat ion of wha t I conceptua l ised and by individual consul tat ion wi th each member , especia l ly wi th m y two superv isors . Another fo rm of m e m b e r check ing w a s done th rough the process of generat ing dialogical data , wh ich is da ta genera ted th rough d ia logue be tween the part ic ipants a n d myself . In this s tudy, an o p e n - ended m o d e of inquiry helped m y interact ing wi th part ic ipants and interpretat ing part ic ipants ' perspect ive in a hermeneut ic dialect ic mode . G u b a (1990) e m p h a s e s that the hermeneut ic approach focuses on da ta interpretat ion and the re f inement of individual const ruct ions; whereas the dialect ical focuses on compar ing and contrast ing d ia logue be tween the researcher and the part ic ipants. T o bring m y interpretat ions and the part ic ipants ' interpretat ions into consensus , act ive interact ions be tween the part ic ipants and mysel f we re emp loyed . Dur ing each interview, the part ic ipants and I d iscussed, negot iated, and dec ided on what I unders tood as the mean ings of the data. O n several occas ions, fur ther explorat ion and clari f icat ion of my interpretat ions wi th the part ic ipants lead to greater unders tand ing of part ic ipants ' exper iences. T h e s e activit ies prov ided w a y s for fur ther "member check ing . " Trustwor th iness and val idi ty have been identi f ied as important issues in research . T o ensure rigor and credibi l i ty of this study, beside " m e m b e r checks , " "critical se l f -awareness, " and "sel f -decentra l iz ing" (Lather, 1991) were emp loyed in this s tudy by recogniz ing that m y o w n social posi t ion and perspect ive inf luenced the research process. Validity, to Carspecken (1996) , refers to "the soundness of a rguments 74 rather than to the truth of s t a t e m e n t s ' ' ^ . 55). Val idi ty is, thus, " inher ing in the st ructures of commun ica t ion . . . [and ] how wel l it meets val idi ty cr i teria der ived f rom the communica t ion i t s e l f (Carspecken , 1996, p. 57) . In this study, for m y c la ims to be cons idered as "val id," m y interpretat ion w a s agreed upon (or ach ieved consensus) by the w o m e n and heal th care provider part ic ipants. Besides mak ing sense o f t h e data, pay ing at tent ion to the polit ics of creat ing mean ing , exerc is ing self-ref lexivi ty and self cr i t ique, a n d ensur ing r igor and credibi l i ty of the study, there are ethical issues that need to be a t tended to. Pame la Cotteri l l (1992) also reminds us that "when the researcher leaves the f ield and begins to work on the final account , the responsibi l i ty for h o w the data are ana lysed and interpreted is ent i rely her o w n . From n o w on the [part ic ipants] are vulnerable. Thei r act ive role in the research process is over and whatever w a y it is p roduced is beyond their contro l " (p. 604) . Def in ing and present ing the part ic ipants ' realit ies, in Cotteri l l 's v iew, is the p o w e r that the researchers hold. Shar ing the s a m e ethical and moral concerns, Janet Finch (1993) notes that a l though interv iewing is a great techn ique in creat ing social knowledge, it also leaves w o m e n open to exploi tat ion of var ious k inds. F. Representation of The Research Results In represent ing the research f indings, researchers are "engag ing in the act of represent ing other 's needs, goals, s i tuat ion, and in fact, w h o they are; present ing t h e m . . . [and] part ic ipat ing in the const ruct ion of their subject-posi t ions" (Alcoff, 1 9 9 1 , p. 9). Researchers w h o use qual i tat ive methodo logy are of ten faced wi th an e n o r m o u s amoun t of da ta . It is difficult to dec ide w h a t re levant informat ion to c o m m e n t on , issues to address, and wha t to include in the presentat ion of the result. Research approaches to organis ing da ta and to focus ing at tent ion on re levant in format ion have been identi f ied as one o f the crucia l d imens ions in the research process. It has also been recogn ized that ideology and d iscourse inf luence researchers ' interpretat ion of the mean ing of their research da ta . Michael Stubbs (1982) has warned researchers that s tereotyped ideology can pose m u c h danger to the w a y they approach their da ta . A danger of s tereotyped ideology is that "[it] can be a barr ier to analysis, and can prevent us f rom seeing wha t is real ly go ing o n " (p. 43) . Gubr ium and Holstein (1997) emphas ise that the interpretat ion and the presentat ion of qual i tat ive research should be concerned wi th not on ly wha t research is presented, but a lso h o w the research is presented. Cul tura l sensi t iv i ty and 75 reflexivity to the spoken and wri t ten texts and the nature of d iscourse are important issues in this product ion and reproduct ion of social f o rms . There fo re , in the construct ion and representat ion of the part ic ipants ' l ived exper iences, I paid c lose at tent ion to my language of analysis and wha t it means to represent. Michel Foucaul t (1978) poses a quest ion regard ing s i lence in "History of Sexual i ty" - s i lence itself - the th ings one decl ines to say, or is forb idden to name, the discret ion that is requi red be tween di f ferent speakers - is less the absolu te l imit o f d iscourse. . . .There is no b inary divis ion to be m a d e be tween wha t one says and what one does not say; w e must try to de te rmine the dif ferent w a y s of not say ing such th ings, h o w those w h o can and those w h o cannot speak of t hem are distr ibuted, wh ich type of d iscourse is author ised, or wh ich fo rm of discret ion is required in ei ther case. There is not one but m a n y s i lences, and they are an integral part of the st rategies that under l ie and pe rmea te d iscourses, (p. 27 ) Thus , I paid at tent ion to wha t w a s spoken , wha t w a s impl ied, and what w a s not spoken about . My analysis included those w h o can and cannot speak and w h y certa in issues are not spoken about . I w a s also aware that of ten it is not a plain and s imple imposi t ion of s i lence. Rather, it [is] a new reg ime of d iscourse. Not any less [is] sa id about i t . . .But th ings [are] sa id in a di f ferent w a y ; it [is] d i f ferent peop le w h o say t h e m , f rom different points of v iew, and in order to obta in di f ferent results" (Foucaul t , 1978, p. 27) . Foucaul t (1978) pointed out that there is a who le network of d iverse d iscourses produced by m a n y m e c h a n i s m s f rom different insti tut ions that c a n ac t as ei ther s t imulat ing or const ra in ing d iscurs ive social pract ices. F rom these mult iple d iscourses m a n y dist inct d iscurs ive format ions ar ise f rom dif ferent discipl ines such as medic ine, psychology, nurs ing, ethics, and polit ical sc ience. T h u s , mult iple d iscourses, wh ich of ten involve conf l ict ing perspect ives, inf luence interpretat ion and thus the presentat ion of data . Interpretat ion is a diff icult issue in femin is t research. A s femin is t researchers , w e are commi t ted to certain ideologies and d iscourses. Because femin is t researchers ' goals are to obl i terate the oppress ion and dominat ion of w o m e n , and to e m p o w e r w o m e n (Bor land, 1 9 9 1 ; Farganis, 1986), by provid ing vehic les that give voice to w o m e n w h o are "social ly and polit ically si lent" (Cotteri l l , 1992) , their wo rks might involve contradict ions (Bor land, 1991) . In her o w n work wi th oral narrat ive research, Bor land (1991) reminds us that femin is t researchers seek to e m p o w e r the w o m e n w h o m they work wi th by interpret ing the w o m e n ' s perspect ives and the w a y s they live their l ives. She caut ious us that feminist researchers "hold an explici t ly polit ical v ision of the structural condi t ions that lead to a part icular social behaviour, a vision that our [par t ic ipants] . . . m a y not recognize as va l id" (p. 64) . Therefore , conf l ict ing interpretat ions 76 can ar ise be tween the researchers and the part ic ipants w h o do not share the s a m e polit ical perspect ives that shape those interpretat ions (Bor land, 1 9 9 1 ; Cotteri l l , 1992) . T h u s , to adequate ly present the part ic ipant 's perspect ives, whi le adher ing to their research goals, femin is t researchers need to be ref lect ive and sensi t ive, not on ly to wha t k ind of in format ion they present and h o w they will present their work , but also to wha t kind of ideologies and d iscourses that they and their part ic ipants p roduce a n d reproduce. Cotteri l l (1992) concurs wi th Bor land (1991) by say ing that she accepts the val idi ty of the part ic ipants, whi le recognis ing that the responsibi l i ty for present ing their reali t ies and the power that goes with it remains that of the researcher. A s such , femin is t researchers should be as honest as they can and also "not to undercut , discredit or wri te-off w o m e n ' s consc iousness [that are] di f ferent f rom [their] o w n " (Cotteri l l , 1992, p. 604) . Last but not least, they shou ld try to c reate "a socio logy wh ich art iculates w o m e n ' s exper iences of their l ives - rather than mere ly creat ing data for onesel f as researcher" (F inch, 1993, p. 178). F rom my o w n involvement wi th several qual i tat ive research projects, I have found that there are many dominan t societal ideologies inf luencing the stor ies told to m e by part ic ipants and that also inf luence the w a y s in wh ich they interpret their exper iences. A s a researcher, m y o w n exper iences, cultural background , posi t ion as a health care professional , theoret ical f ramework , professional ideologies and d iscourses, all inf luence h o w I interpret the mean ings of da ta . A s such , there are ins tances w h e n m y interpretat ions are not the s a m e as that of the part icipant. A l though it is not possib le to a lways c o m e to a mutua l unders tand ing , it took reflexivity a n d sensi t iv i ty f rom both myse l f and the part ic ipant to unders tand each other 's perspect ives. A s Bakht in (1986) exp la ined, to have a special kind of u t terance (speech product ion) is to "enter into a special k ind o f semant i c relat ionship that w e cal l d ialogic" (p. 118) . For the researchers to enter this dialogic relat ionship, e lements of language wi th in the language sys tem or wi th in the "text" need to be t rans formed into a "world v iew," a " v iewpo in t , " or a "social vo ice" that ex tends beyond the boundar ies of l inguist ics" (Bakht in , 1986) . For me, a dialogic relat ionship and the ex tens ion of vo ices beyond the boundar ies of l inguist ics include the recogni t ion that m y vo ice and the vo ices that I seek are only a f e w a m o n g m a n y other vo ices. In the wr i t ing of this d issertat ion, I w a s constant ly reminded of a quest ion that Patr icia Col l ins (2000) once asked of herself: "How can I as one person speak for such a large and complex group as Af r ican-Amer ican w o m e n ? " A l though I a m ful ly aware that as one researcher I cannot and shou ld not speak for others, L inda A lco f f s (1991) cr i t ic ism of the posit ion that refrains researchers f rom speak ing for 77 others also c o m e s to mind . Acknowledg ing that a l though there are prob lems involved wi th issues of speak ing for others and about others, Alcof f insists that adopt ing the posit ion that one can only speak for onesel f is somet imes problemat ic. T o Alcoff, " the a t tempt to avoid the [problem] of speak ing for [others] by retreat ing into an individualist rea lm is based on an i l lusion, wel l -suppor ted in the individualist ideology of the Wes t , that a self is not const i tuted by mult iple intersect ing d iscourses but consis ts in a unif ied who le capab le of a u t o n o m y f rom others" (p. 21) . T h e quest ion I put for th, then, is how can I as the producer of this dissertat ion speak and present in such a w a y that i l luminates not one voice but the d ia logue be tween people w h o have been s i lenced? Recognis ing that m y social posi t ion as a V ie tnamese w o m a n , an academic , and a health care provider inf luence the w a y I p roduce this text, I have tr ied to the best of m y abi l i ty not to p roduce and reproduce the unequa l social posi t ion of m y part ic ipants. T h e "rituals of speak ing , " a term co ined by Foucault , refers to "discursive pract ices of speak ing or wr i t ing that involves not only the text or u t terance but [people's] posit ions wi th in a social space, including the persons involved in, ac t ing upon, and/or a f fec ted by the w o r d s " (Alcoff, 1 9 9 1 , p. 12). In the "rituals o f speak ing , " the posit ion or the locat ion of the speakers is an important e lement . T h e posi t ion or the locat ion of the speaker affects not only the mean ing of spoken words and mean ings of the event, but also the va lue and the s igni f icance of any claim m a d e (Alcoff, 1991). In the a rea of knowledge product ion, whether the knowledge is taken as "true," val id, and legi t imate depends on w h o says it, wh ich , in turn, af fects the style and language in wh ich it is p resented. A n important analysis a rose f rom the concept ion of the posit ional i ty of the speakers ; what is taken as truth and whe ther c la ims can be upheld as knowledge depends upon the researchers w h o speak for and about o thers. It holds researchers accountab le and responsib le to the w a y s in wh ich they interpret and present their da ta . T h u s , sensit iv i ty and ref lexivity to the locat ion of onesel f and others mus t be crit ically and consc ious ly exerc ised in the representat ion of the text (Wolf, 1996). A s a feminist researcher, Patr icia Col l ins (2000) has found that her social posit ion as an A f r i can-Amer ican /woman/mother / w o r k i n g - c l a s s person /academic scholar has he lped her to speak in a voice that is "both individual and col lect ive, personal and polit ical, one ref lect ing the intersect ion of [her] unique b iography wi th the larger mean ing of [her] historical t imes" (p, vi). Simi lar ly to Patr ic ia Col l ins, m y social posi t ion as a V ie tnamese Canad ian /woman/mother / re fugee/hea l th care prov ider has enab le m e to wr i te this text in a w a y that is ref lective of both the part ic ipants ' col lect ive and m y personal exper iences. Not on ly do researchers ' social posi t ions inf luence their wor ldv iew and their methodolog ica l f ramework , but also polit ical and cultural ideologies, and d iscourses. R a y m o n d Wi l l iams (1981) states that 78 cultural insti tut ions are essent ia l parts o f t h e genera l social s t ructure and the basic componen ts of selected tradit ion and ideologies by the people of the dominan t cul ture. T h e s e dominan t ideologies and selected tradit ions are taught in schools , expressed in the media , and are important d imens ions of the social , polit ical, and economic organisat ions. T h e s e organisat ions represent and reflect a society 's dominant relat ions and ideologies, wh ich then b e c o m e a no rm against wh ich other fo rms of social relat ions, behaviours , and product ions are interpreted and j u d g e d . In her d iscuss ion th roughout "Girl Talk," D a w n Curr ie (1999) warns researchers that they "can not read 'the social ' of f cul tural art i facts, such as commerc ia l magaz ines" (p. 308). Not on ly shou ld these commerc ia l texts be v iewed as s imply cultural or textual representat ions, but they should also be v iewed as "a textual f o rm of social power that media tes everyday pract ices of mean ing -mak ing and the 'doing ' of gender" (p. 308) . A s researcher, w e need to move beyond the immed iacy of the text and to cons ider that presentat ion of qual i tat ive research f indings should be concerned wi th not only what research is presented, but also how the research is presented. Cultural sensit iv i ty and reflexivity to the spoken and wr i t ten texts and the nature of d iscourses are important issues in the product ion and reproduct ion of social f o rms (Gubr ium & Holstein, 1997) . There fore , in m y const ruct ion and representat ion o f the part ic ipants ' l ived exper iences, effort w a s m a d e to pay c lose and systemat ic at tent ion to the d iverse and complex relat ions be tween m y language of analysis and what they are meant to represent. Analys is of the w o m e n part ic ipants and health care providers ' narrat ives revealed four t hemes . T h e s e four t hemes include the inf luence of cul tural knowledge and va lues, gender roles and expectat ions, the social suppor t networks, and soc ioeconomic status on the w o m e n ' s health care pract ice, in part icular, breast cancer and cervical cancer screenings. T h e next four chapters are report of these f ind ings. 79 Chapter Five: Cultural Influences: Knowledge and Values Vie tnamese 's social va lues are dif ferent f rom the general W e s t e r n populat ion and this d ivergence contr ibuted to s o m e extent to how V ie tnamese w o m e n part ic ipate in breast and cervical cancer sc reen ing p rograms ( M c P h e e et al., 1997). However , Jenk ins , Le, McPhee , Stewart , and Ha (1996) found that their data do not suppor t the not ion that tradit ional bel iefs or cultural pract ices pose barr iers to prevent ive health care serv ices. In the present study, in-depth interviews wi th V ie tnamese Canad ian w o m e n and their health care prov iders revealed that cultural conceptual isat ions of health and i l lness, social ideologies and va lues shaped V ie tnamese Canad ian w o m e n ' s health care pract ices and heal th-seek ing behaviour to s o m e extent. Fur thermore, the results f rom m y s tudy s h o w e d that m a n y of their health care pract ices and knowledge are, in fact, qui te congruent wi th Wes te rne rs health care pract ices. Thus , it begs the quest ion : W h y are V ie tnamese w o m e n cons idered a hard to reach populat ion? W h a t other factors prevent these w o m e n f rom seek ing help f rom health ca re prov iders? T h e s e quest ions fo rce us to ask h o w heal th ca re providers and pol icy makers provide health care. Based on the data of my study, this chapter i l luminates the process by wh ich cultural knowledge and va lues about w o m e n ' s bodies, social re lat ionships, and knowledge about health and i l lness inf luence V ie tnamese w o m e n ' s decis ion to engage in cer ta in heal th care pract ices, in part icular breast cancer and cervical cancer screenings. A. Cultural Knowledge and Values about Women's Bodies 1. The Private Body: Embarrassment, Hesitation, and Sexual Morality Discourses T h e w o m e n ' s narrat ives revealed that conceptual isat ion of the body as private great ly inf luences the w a y s in wh ich they seek and receive heal th care, especia l ly breast and cervical cancer examinat ion . Because the breast and cervix are cons idered as the most private body parts of a w o m a n , the w o m e n part ic ipants ' d iscourse regard ing the pr ivacy of the body of ten link to d iscourses of embar rassment , hesitat ion, and sexual moral i ty. For s o m e of these w o m e n , Confuc ian ism and Buddh ism inf luence h o w they v iew their body wh ich , in turn, inf luence the w a y s in wh ich they pract ice health care and part ic ipate in breast and cervical examinat ions. 80 Many w o m e n part ic ipants bel ieve, nobody shou ld touch the w o m a n ' s body except her husband . T h e s e w o m e n ref lected the Confuc ian ism teach ing that "Nam nu tho tho bat t han" (a w o m a n and a m a n should never touch or be c lose to each other. T h e y have to avoid each other) . W o m e n ' s bodies are for themse lves a n d their husbands only, nobody e lse. T h e cul tural emphas is o n w o m e n ' s body as pr ivate makes both w o m e n and male physic ians uncomfor tab le wi th cl inical breast examinat ion . O n e male physic ian stated that he wou ld verbal ly teach the w o m e n how to do breast-sel f examinat ion but he th inks that cl inical breast examinat ion is not cultural ly sensi t ive or appropr iate for V ie tnamese w o m e n . W o m e n part ic ipants' narrat ives also ref lected the Buddhis t teach ing that avo id ing desire (quyen ru) and modes ty toward the d isplay of f lesh is important. There is a c o m m o n assumpt ion held by s o m e w o m e n that s ins are caused by "A i " wh ich is love and "Due" wh ich is sex and sexual impulses. Buddh ism also teaches that "A i " and "Due" will lead a person to darkness (vo minh), do ing w r o n g th ings, and commi t t ing s ins. This wil l , in turn, lead that person to a very unhappy and unfor tunate life. Be low a re tables that s u m m a r i z e d w o m e n part ic ipants ' exper ience wi th breast a n d cerv ical examinat ions. Tab le 5.1 Papan ico laou S m e a r s : W o m e n Part ic ipants ' Examinat ion Pat tern F requency W o m e n part ic ipants (/V=15) % W o m e n w h o met screen ing criteria W o m e n w h o did not meet screen ing cri teria Regular ly once a year 5 3 3 . 3 % 4 (26 .6%) 1(6 .6%) Had it done once 3 2 0 % 3 (20%) - Had it done twice 2 13 .3% 2 ( 1 3 . 3 % ) - Never go for Pap test 5 3 3 . 3 % 2 ( 1 3 . 3 % ) 3 (20%) Of the 15 w o m e n I interv iewd, 11 met both breast and cervical cancer screen ing cri teria at the t ime of the interview. T h e y repor ted on both their past and current screening pract ices. My data s h o w that there are three w o m e n w h o have never gone for Pap test ing, did not meet the present sc reen ing cr i ter ia and one w o m a n w h o w a s not el igible for test ing at the t ime of the interview, but had part ic ipated in screen ing. T h e reason that these three w o m e n did not meet the cr i ter ia for Pap test ing at the t ime of our interv iews w a s because of their age range (two w o m e n 73 year o ld, one w o m a n 78 year old). However , all three w o m e n have been in C a n a d a for many years. Dur ing these years of l iving in C a n a d a , they had met the screen ing 81 criteria, yet they had never had Pap smear done. Thus their v iews on cervical examinat ion remain relevant for this study. Tab le 5.2 M a m m o g r a p h y : W o m e n Part ic ipants ' Examinat ion Pat tern Frequency W o m e n Part ic ipants (A/=15) % Regular ly every 2 years 7 4 7 % Had it done once 1 6 .6% Had it done twice 1 6 .6% Never 5 3 3 . 3 % Did not ment ion 1 6 .6% Tab le 5.3 Clinical Breast Examinat ion: W o m e n part ic ipants' Examinat ion Pattern Frequency W o m e n Part ic ipants (A/=15) % Regular ly once a year 3 2 0 % Never 4 2 7 % Did not ment ion 8 5 3 % Tab le 5.4 Breast-sel f Examinat ion: W o m e n part ic ipants' Examinat ion Pat tern Frequency W o m e n part ic ipants (A/=15)