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Vietnamese women living in Canada : contextual factors affecting Vietnamese women’s breast cancer and.. Donnelly, Tam Truong 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 v List of Tables x Acknowledgements x Dedication xi Prelude xiiChapter One: Introduction 1 Chapter Two: Literature Review 10 A. Vietnam: A Brief History 1 B. Vietnam: Religion and Culture 3 1. Confucianism 14 2. Mahayana Buddhism 5 3. Taoism 6 4. Christianity 15. Communal Life 7 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 9 2. Social-Cultural Experiences 33 3. Health and Health Care Experiences 5 D. Breast Cancer and Cervical Cancer 7 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 Care3. The Folk Sector of Health Care 7 4. Explanatory Models (Ems) 4B. Postcolonial-Feminist Scholarship: Its Relevance in Addressing Health Care Issues 49 1. Postcoloniaiism 50 2. Understanding Colonisation and Racialisation 51 3. Postcolonial Scholarship 6 4. What is Postcolonial Research? 57 5. Black Feminism 58 Chapter Four: Research Methods 65 A. Research ParticipantsB. Gaining Access and Developing Rapport 66 C. Method of Data Collection 68 D. Research Interviews 9 E. Data Interpretation, Coding, and Analysis 72 F. Representation of The Research Results 5 Chapter Five: Cultural Influences: Knowledge and Values 80 A. Cultural Knowledge and Values about Women's Bodies1. 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) 9 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 4 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 104 B. Ms. Lyn's Story 111 C. ConclusionChapter Seven: Social Support Networks 118 A. Formal Social Support Networks 119 1. General Social Institutional Support2. Formal Health Care Support Networks 124 B. Informal Social Support Networks 26 C. Social Discrimination 132 1. Cross-Ethnic Group Discrimination Experiences 132. Within Ethnic Group Discrimination Experiences 6 D. Conclusion 140 Chapter Eight: Socioeconomic Influence.... I43 A. The Vietnamese Women's Economic Profiles 14B. Women Participants' and Health Care Providers' Perspectives I44 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 166 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 8 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 192. Give Less Emphasis on Western Rationality 4 3. Socially Constructed Position, Race, Gender, and Class Affect Health Care Behaviour 197 C. Implications for Practice 198 1. Developing Collaborative Working Relationships 192. Considering Women's Different Ways Of Knowing 9 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 22Appendix A. Breast Cancer Screening Procedures For Women Over 40 Years of Age 227 Appendix B. Ethics Approval Form 230 Appendix C. Coding System 1 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 2viii 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 12 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 11th century to the 17th 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 14 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. 16 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 30th, 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 49 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 53 (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 54 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 55 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 during our interaction. This awareness provides me with the opportunity to gain a more accurate view of the participants' lives. D. Research Interviews In-depth interviewing is "a data gathering technique used in qualitative research when the goal is to collect detailed, richly textured, person-centered information from one or more individuals" (Kaufman, 1994, p. 123). Elliot Mishler (1986) conceptualises interviewing as a form of discourse.. .that it is discourse shaped and organized by asking and answering questions. An interview is a joint product of what interviewees and interviewers talk about together and how they talk with each other. The record of an interview that we researchers make and then use in our work of analysis and interpretation is a representation of that talk. How we make that representation and the analytic procedures we apply to it reveal our theoretical assumptions and presuppositions about relations between discourse and meaning. (Preface) In conceptualising the interview as a communicative event (i.e., a discourse between speakers), accurate records of the questions asked by the interviewer and the answers given by the interviewee, are necessary. Because interviewing with open-ended questions is often complex in intention and wording, it leaves much room for interpretation by both the interviewer and the participants (Potter, 1994). Ambiguity and complexity are, therefore, present in all interview situations and types of discourse. Shared implicit assumptions and the mutual recognition of contextual factors are important to facilitate mutual understanding ofthe meaning ofthe questions asked and the responses given (Mishler, 1986). If interviewing is a discourse and Foucauldian analysis (Foucault, 1994) contends that power inscribes within discourse, attention to power relations between researchers and their participants is a must. Interviewing involves interactions within an unequal power relationship. I have attempted to minimise this power differential by engaging the participants in a more reciprocal dialectical relationship. Traditionally, researchers often hold more power than their participants and in some situations, "interviewers define the role of interviewees as subordinates; extracting information is more to be valued than yielding it; the convention of interviewer-interviewee hierarchy is a rationalisation of inequality; what is good for interviewers is not necessarily good for interviewees" (Oakley, 1981, p. 40). Furthermore, within the traditional model of sociology, an ideology that validates objectivity and value-free research has made some social researchers view interviews merely as an instrument of data collection (Oakley, 1981). 69 To facilitate the collection of information, a pseudo-conversation is created in which the interviewer asks questions with warmth and clarity, but does not engage in the exchange of information and does not reveal his/her personal beliefs and values. Behaving otherwise would lead to 'bias' and invalid research would result. Thus to ensure the success of the interview, the interviewer has to achieve a balance "between the warmth required to generate 'rapport' and the detachment necessary to see the interviewee as an object" (Oakley, 1981, p. 33). Many feminist researchers assert that these interviewing techniques are unethical. Successful interviewing, they suggest, is achieved when an equal power relationship exists between the interviewer and the interviewee, and when the interviewers are willing to invest their personal identity in the relationship (Finch, 1993; Oakley, 1981). In this study, a non-hierarchical research interviewing approach was used. The women participants and I were willing to invest our personal identities in the relationship through sharing our own stories. This approach to qualitative data gathering helped me to generate detailed, richly textured, and person-centered information from the participants. It has helped me to develop and maintain rapport and trusting relationships with my participants. This is an essential element in the research process because many sensitive topics such as social support, discrimination issues, and political perspectives were addressed. Recognising that political issues exist between the Vietnamese who came from North Vietnam and Vietnamese who came from South Vietnam is an important aspect of this research. Because I came from North Vietnam, which was under control of communism, the participants often want to know about my political perspective, and whether or not I support communism. Thus emphasising that my main purpose for doing this study was to find ways to promote cancer preventive health care practice among Vietnamese Canadian women and that I am a nurse who is mostly interested in health care issues was essential. In addition, by honestly recognising that there is tension between North Vietnamese and South Vietnamese people due to the historical and political nature of our country, I was able to develop trust with my participants. As a result, the participants were quite open in talking about such sensitive topics. The individual in-depth interviews were conducted in the language that was preferred by the participant. Initially, my plan was to interview each woman participant two times, each time for the length of 1 hour to 11/2 hours, whereas each health care provider would be interviewed one time for 30 minutes (which is the time that many busy physicians could give). However, most of the participants wanted to 70 talk, and as a result, our conversations lasted much longer than anticipated. With the participants' permission, all the interviews were audiotape recorded. Interviews with the Vietnamese women yielded information addressing the research objectives: (a) to explore how Vietnamese women participate in breast cancer and cervical screening, what leads Vietnamese women to seek health care and from whom they seek help, and the social support networks that they draw upon to foster their health care practices, (b) to explore whether Vietnamese women find the current preventative cancer services suitable and accessible to them, (c) to explore how 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, (d) to explore differences between Vietnamese women's perspectives and those of health care providers, and how the health care providers' perspectives influence the health care experiences of Vietnamese women, (e) to explore how a postcolonial feminist perspective contributes toward the understanding of Vietnamese women's health care experiences and cancer screening practices. However, some of the interviews with health care providers have also provided much insight into the analysis of these issues. An interview guide with open-ended questions was designed specifically for the study. It was in both the Vietnamese and English languages. The interview guide contains questions regarding Vietnamese-born women's health care knowledge, attitudes, past and current practices about clinical breast examination (CBE), breast self examination (BSE), mammogram, and Pap testing. The questions also inquired into how Vietnamese women practice breast and cervical examination; what prevents or what motivates these women to engage in preventive cancer screening practices; what do they perceive as barriers to accessing health care services and provisions, and who are their health care supporters. In addition, questions assessing socio-demographic information about Vietnamese immigrants gave additional information about Vietnamese women's social support networks (see Appendix G, p. 235 for Initial Interview Questions for Vietnamese Women and Appendix I, p. 239 for the Socio-Demographic Data Form). To identify if there are differences between Vietnamese women's perspectives and those of health care providers, interviews were conducted with health care professionals who provide health care services to Vietnamese women. Interviews with health care professionals focused on exploring what these professionals believe motivates or prevents Vietnamese-born women from engaging in CBE, BSE, mammogram, and Pap testing practices; what they perceive as barriers for Vietnamese women to access 71 these services; what information, health care programs, and services would best benefit Vietnamese Canadian immigrant women; and what they perceive as the best possible strategies to promote breast cancer and cervical cancer screening practices among Vietnamese women (see Appendix K, p. 245 for Initial Interview Questions for Health Care Providers). The data obtained from interviews were transcribed in the primary language of the participants and then back translated into English. Although only sections of interviews that I used to quote were translated into English, a sample of five interviews was randomly selected, translated into English, reviewed, and analysed. The code categories from the English translation were used to compare with the categories from the data in Vietnamese. My coding process was consistent and accurate because the code categories developed in English were similar to the code categories developed in Vietnamese. E. Data Interpretation, Coding, and Analysis Data obtained from interviews and field notes were transcribed as soon as possible. All of the interview data were coded and used as examples to be quoted. My approach in working with the transcribed data also included continuous data analysis and interpretation. Data analysis was an ongoing process that involved thorough reading, marking transcript margins, identifying, refining, adding codes, and categorising themes. In addition, data collecting, filing, and organising theme materials were done so that data could be easily retrieved. The process of data analysis and data collection occurred concurrently. The process of data analysis included specific steps. Step 1: As data were obtained, they were transcribed in the language that was used by the participants (which was mostly Vietnamese). To ensure accuracy, the transcripts were rechecked against audiotape tapes, corrected, then a hard copy was obtained for preliminary data analysis. Step 2: In the early stages of analysis, transcripts were coded to identify preliminary themes from the data and to formulate a list of code categories for organising incoming data. These code categories were refined as subsequent data were gathered. Step 3: Data coded in one category was examined for its relevance to other categories. The final outcome of this analysis is a statement about a set of complicated interrelated concepts and themes. This process of analysis involved a systematic and rigorous development of code categories and subcategories, which were flexible and evolving and used for the coding of subsequent transcripts. During this step, I meet with my supervisors and research 72 committee members to review, and to share reflections on the process of conducting the interview, personal feelings, and analytic descriptions. Step 4: Themes and concepts were used to compare within and across transcripts in the data set and across cases. From this, a higher level of data conceptualisation and broader theoretical formulations were generated. This step also included returning the preliminary results to the participant along with my analytic interpretations in the second interview. Returning the preliminary results to the participants was done with six participants (two Vietnamese women and four health care providers, which included three physicians and a community health nurse). This process enabled me to clarify, expand, and discuss with the participants the emergent themes, ideas, and concepts. It also helped me to develop a deeper understanding of the data and gain more insight into Vietnamese women's breast cancer and cervical cancer screening practices, and the social processes and structures that organise these experiences. Because categories were developed based partially on the meanings that participants attribute to their experiences (Carspecken, 1996), I paid particular attention to the ways in which meaning is reconstructed. Meaning reconstruction involves the way in which I mentally noted the possible underlying meanings and/or messages that the data conveyed. Meaning was understood and contextualised by reflection into the everyday life of the participant. To begin the initial meaning reconstruction, I read through the interview data and field notes, and mentally noted possible meanings. After several careful readings, I was able to identify common patterns as well as unusual elements or events that may have been important to my analysis. I then performed a line-by-line data analysis and preliminary coding was employed at that point. After reading through the data and beginning the preliminary coding process, segments that seem to be representative of action and thought patterns (regular pattern and/or anomalies in the pattern) were selected. This process was done in order to make explicit the underlying norms and possible meanings of these actions and thoughts, and to make the voices of my participants visible. Selected segments were then read line by line and my comments on discursive articulations of meaning, which I believed may underlie the interaction, were recorded. As pointed out by Carspecken (1996), the articulation of possible meaning involves researchers' inference of the meanings they think their participants might infer, either overtly or implicitly. Because I could not know for certain that my articulation of the participants' intended meanings is in fact so, I could only specify possibilities of what my participants might mean. Because there is no guarantee that my reconstruction of meaning is, in fact, experienced by the participants, there is always an element of 73 uncertainty and ambiguity in what I interpret as participant's intended meaning. Thus, it begs the question, how would I validate my reconstruction of meanings? Carspecken (1996) recommended several ways that researchers can support their articulation of meanings. First, the more familiar researchers are with the culture of their participants, the closer their articulated meanings would be to that of the participants. Having gone through an experience of a Vietnamese refugee helped me to understand some of the issues these Vietnamese women were facing. Furthermore, as a health care provider, I was able to understand the social constrains which the physicians and the community health nurses were coping with. Second, the use of member checks plus dialogical data generation helped refine my articulated meanings. Member checks were done by sharing the results of my preliminary data analysis with the people who participated in these first interviews. These were participants whom I believed could give me the most feedback based on their level of articulation. In this study, the women and the health care providers agreed with my constructed meanings, themes, and insights. Member checking was also done with my supervisory committee members through meetings that included presentation of what I conceptualised and by individual consultation with each member, especially with my two supervisors. Another form of member checking was done through the process of generating dialogical data, which is data generated through dialogue between the participants and myself. In this study, an open-ended mode of inquiry helped my interacting with participants and interpretating participants' perspective in a hermeneutic dialectic mode. Guba (1990) emphases that the hermeneutic approach focuses on data interpretation and the refinement of individual constructions; whereas the dialectical focuses on comparing and contrasting dialogue between the researcher and the participants. To bring my interpretations and the participants' interpretations into consensus, active interactions between the participants and myself were employed. During each interview, the participants and I discussed, negotiated, and decided on what I understood as the meanings of the data. On several occasions, further exploration and clarification of my interpretations with the participants lead to greater understanding of participants' experiences. These activities provided ways for further "member checking." Trustworthiness and validity have been identified as important issues in research. To ensure rigor and credibility of this study, beside "member checks," "critical self-awareness," and "self-decentralizing" (Lather, 1991) were employed in this study by recognizing that my own social position and perspective influenced the research process. Validity, to Carspecken (1996), refers to "the soundness of arguments 74 rather than to the truth of statements''^. 55). Validity is, thus, "inhering in the structures of communication...[and] how well it meets validity criteria derived from the communication itself (Carspecken, 1996, p. 57). In this study, for my claims to be considered as "valid," my interpretation was agreed upon (or achieved consensus) by the women and health care provider participants. Besides making sense ofthe data, paying attention to the politics of creating meaning, exercising self-reflexivity and self critique, and ensuring rigor and credibility of the study, there are ethical issues that need to be attended to. Pamela Cotterill (1992) also reminds us that "when the researcher leaves the field and begins to work on the final account, the responsibility for how the data are analysed and interpreted is entirely her own. From now on the [participants] are vulnerable. Their active role in the research process is over and whatever way it is produced is beyond their control" (p. 604). Defining and presenting the participants' realities, in Cotterill's view, is the power that the researchers hold. Sharing the same ethical and moral concerns, Janet Finch (1993) notes that although interviewing is a great technique in creating social knowledge, it also leaves women open to exploitation of various kinds. F. Representation of The Research Results In representing the research findings, researchers are "engaging in the act of representing other's needs, goals, situation, and in fact, who they are; presenting them... [and] participating in the construction of their subject-positions" (Alcoff, 1991, p. 9). Researchers who use qualitative methodology are often faced with an enormous amount of data. It is difficult to decide what relevant information to comment on, issues to address, and what to include in the presentation of the result. Research approaches to organising data and to focusing attention on relevant information have been identified as one of the crucial dimensions in the research process. It has also been recognized that ideology and discourse influence researchers' interpretation of the meaning of their research data. Michael Stubbs (1982) has warned researchers that stereotyped ideology can pose much danger to the way they approach their data. A danger of stereotyped ideology is that "[it] can be a barrier to analysis, and can prevent us from seeing what is really going on" (p. 43). Gubrium and Holstein (1997) emphasise that the interpretation and the presentation of qualitative research should be concerned with not only what research is presented, but also how the research is presented. Cultural sensitivity and 75 reflexivity to the spoken and written texts and the nature of discourse are important issues in this production and reproduction of social forms. Therefore, in the construction and representation of the participants' lived experiences, I paid close attention to my language of analysis and what it means to represent. Michel Foucault (1978) poses a question regarding silence in "History of Sexuality" -silence itself - the things one declines to say, or is forbidden to name, the discretion that is required between different speakers - is less the absolute limit of discourse.. ..There is no binary division to be made between what one says and what one does not say; we must try to determine the different ways of not saying such things, how those who can and those who cannot speak of them are distributed, which type of discourse is authorised, or which form of discretion is required in either case. There is not one but many silences, and they are an integral part of the strategies that underlie and permeate discourses, (p. 27) Thus, I paid attention to what was spoken, what was implied, and what was not spoken about. My analysis included those who can and cannot speak and why certain issues are not spoken about. I was also aware that often it is not a plain and simple imposition of silence. Rather, it [is] a new regime of discourse. Not any less [is] said about it...But things [are] said in a different way; it [is] different people who say them, from different points of view, and in order to obtain different results" (Foucault, 1978, p. 27). Foucault (1978) pointed out that there is a whole network of diverse discourses produced by many mechanisms from different institutions that can act as either stimulating or constraining discursive social practices. From these multiple discourses many distinct discursive formations arise from different disciplines such as medicine, psychology, nursing, ethics, and political science. Thus, multiple discourses, which often involve conflicting perspectives, influence interpretation and thus the presentation of data. Interpretation is a difficult issue in feminist research. As feminist researchers, we are committed to certain ideologies and discourses. Because feminist researchers' goals are to obliterate the oppression and domination of women, and to empower women (Borland, 1991; Farganis, 1986), by providing vehicles that give voice to women who are "socially and politically silent" (Cotterill, 1992), their works might involve contradictions (Borland, 1991). In her own work with oral narrative research, Borland (1991) reminds us that feminist researchers seek to empower the women whom they work with by interpreting the women's perspectives and the ways they live their lives. She cautious us that feminist researchers "hold an explicitly political vision of the structural conditions that lead to a particular social behaviour, a vision that our [participants]... may not recognize as valid" (p. 64). Therefore, conflicting interpretations 76 can arise between the researchers and the participants who do not share the same political perspectives that shape those interpretations (Borland, 1991; Cotterill, 1992). Thus, to adequately present the participant's perspectives, while adhering to their research goals, feminist researchers need to be reflective and sensitive, not only to what kind of information they present and how they will present their work, but also to what kind of ideologies and discourses that they and their participants produce and reproduce. Cotterill (1992) concurs with Borland (1991) by saying that she accepts the validity of the participants, while recognising that the responsibility for presenting their realities and the power that goes with it remains that of the researcher. As such, feminist researchers should be as honest as they can and also "not to undercut, discredit or write-off women's consciousness [that are] different from [their] own" (Cotterill, 1992, p. 604). Last but not least, they should try to create "a sociology which articulates women's experiences of their lives - rather than merely creating data for oneself as researcher" (Finch, 1993, p. 178). From my own involvement with several qualitative research projects, I have found that there are many dominant societal ideologies influencing the stories told to me by participants and that also influence the ways in which they interpret their experiences. As a researcher, my own experiences, cultural background, position as a health care professional, theoretical framework, professional ideologies and discourses, all influence how I interpret the meanings of data. As such, there are instances when my interpretations are not the same as that of the participant. Although it is not possible to always come to a mutual understanding, it took reflexivity and sensitivity from both myself and the participant to understand each other's perspectives. As Bakhtin (1986) explained, to have a special kind of utterance (speech production) is to "enter into a special kind of semantic relationship that we call dialogic" (p. 118). For the researchers to enter this dialogic relationship, elements of language within the language system or within the "text" need to be transformed into a "world view," a "viewpoint," or a "social voice" that extends beyond the boundaries of linguistics" (Bakhtin, 1986). For me, a dialogic relationship and the extension of voices beyond the boundaries of linguistics include the recognition that my voice and the voices that I seek are only a few among many other voices. In the writing of this dissertation, I was constantly reminded of a question that Patricia Collins (2000) once asked of herself: "How can I as one person speak for such a large and complex group as African-American women?" Although I am fully aware that as one researcher I cannot and should not speak for others, Linda Alcoff s (1991) criticism of the position that refrains researchers from speaking for 77 others also comes to mind. Acknowledging that although there are problems involved with issues of speaking for others and about others, Alcoff insists that adopting the position that one can only speak for oneself is sometimes problematic. To Alcoff, "the attempt to avoid the [problem] of speaking for [others] by retreating into an individualist realm is based on an illusion, well-supported in the individualist ideology of the West, that a self is not constituted by multiple intersecting discourses but consists in a unified whole capable of autonomy from others" (p. 21). The question I put forth, then, is how can I as the producer of this dissertation speak and present in such a way that illuminates not one voice but the dialogue between people who have been silenced? Recognising that my social position as a Vietnamese woman, an academic, and a health care provider influence the way I produce this text, I have tried to the best of my ability not to produce and reproduce the unequal social position of my participants. The "rituals of speaking," a term coined by Foucault, refers to "discursive practices of speaking or writing that involves not only the text or utterance but [people's] positions within a social space, including the persons involved in, acting upon, and/or affected by the words" (Alcoff, 1991, p. 12). In the "rituals of speaking," the position or the location of the speakers is an important element. The position or the location of the speaker affects not only the meaning of spoken words and meanings of the event, but also the value and the significance of any claim made (Alcoff, 1991). In the area of knowledge production, whether the knowledge is taken as "true," valid, and legitimate depends on who says it, which, in turn, affects the style and language in which it is presented. An important analysis arose from the conception of the positionality of the speakers; what is taken as truth and whether claims can be upheld as knowledge depends upon the researchers who speak for and about others. It holds researchers accountable and responsible to the ways in which they interpret and present their data. Thus, sensitivity and reflexivity to the location of oneself and others must be critically and consciously exercised in the representation of the text (Wolf, 1996). As a feminist researcher, Patricia Collins (2000) has found that her social position as an African-American/woman/mother/ working-class person/academic scholar has helped her to speak in a voice that is "both individual and collective, personal and political, one reflecting the intersection of [her] unique biography with the larger meaning of [her] historical times" (p, vi). Similarly to Patricia Collins, my social position as a Vietnamese Canadian/woman/mother/refugee/health care provider has enable me to write this text in a way that is reflective of both the participants' collective and my personal experiences. Not only do researchers' social positions influence their worldview and their methodological framework, but also political and cultural ideologies, and discourses. Raymond Williams (1981) states that 78 cultural institutions are essential parts ofthe general social structure and the basic components of selected tradition and ideologies by the people of the dominant culture. These dominant ideologies and selected traditions are taught in schools, expressed in the media, and are important dimensions of the social, political, and economic organisations. These organisations represent and reflect a society's dominant relations and ideologies, which then become a norm against which other forms of social relations, behaviours, and productions are interpreted and judged. In her discussion throughout "Girl Talk," Dawn Currie (1999) warns researchers that they "can not read 'the social' off cultural artifacts, such as commercial magazines" (p. 308). Not only should these commercial texts be viewed as simply cultural or textual representations, but they should also be viewed as "a textual form of social power that mediates everyday practices of meaning-making and the 'doing' of gender" (p. 308). As researcher, we need to move beyond the immediacy of the text and to consider that presentation of qualitative research findings should be concerned with not only what research is presented, but also how the research is presented. Cultural sensitivity and reflexivity to the spoken and written texts and the nature of discourses are important issues in the production and reproduction of social forms (Gubrium & Holstein, 1997). Therefore, in my construction and representation of the participants' lived experiences, effort was made to pay close and systematic attention to the diverse and complex relations between my language of analysis and what they are meant to represent. Analysis of the women participants and health care providers' narratives revealed four themes. These four themes include the influence of cultural knowledge and values, gender roles and expectations, the social support networks, and socioeconomic status on the women's health care practice, in particular, breast cancer and cervical cancer screenings. The next four chapters are report of these findings. 79 Chapter Five: Cultural Influences: Knowledge and Values Vietnamese's social values are different from the general Western population and this divergence contributed to some extent to how Vietnamese women participate in breast and cervical cancer screening programs (McPhee et al., 1997). However, Jenkins, Le, McPhee, Stewart, and Ha (1996) found that their data do not support the notion that traditional beliefs or cultural practices pose barriers to preventive health care services. In the present study, in-depth interviews with Vietnamese Canadian women and their health care providers revealed that cultural conceptualisations of health and illness, social ideologies and values shaped Vietnamese Canadian women's health care practices and health-seeking behaviour to some extent. Furthermore, the results from my study showed that many of their health care practices and knowledge are, in fact, quite congruent with Westerners health care practices. Thus, it begs the question: Why are Vietnamese women considered a hard to reach population? What other factors prevent these women from seeking help from health care providers? These questions force us to ask how health care providers and policy makers provide health care. Based on the data of my study, this chapter illuminates the process by which cultural knowledge and values about women's bodies, social relationships, and knowledge about health and illness influence Vietnamese women's decision to engage in certain health care practices, in particular 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 The women's narratives revealed that conceptualisation of the body as private greatly influences the ways in which they seek and receive health care, especially breast and cervical cancer examination. Because the breast and cervix are considered as the most private body parts of a woman, the women participants' discourse regarding the privacy of the body often link to discourses of embarrassment, hesitation, and sexual morality. For some of these women, Confucianism and Buddhism influence how they view their body which, in turn, influence the ways in which they practice health care and participate in breast and cervical examinations. 80 Many women participants believe, nobody should touch the woman's body except her husband. These women reflected the Confucianism teaching that "Nam nu tho tho bat than" (a woman and a man should never touch or be close to each other. They have to avoid each other). Women's bodies are for themselves and their husbands only, nobody else. The cultural emphasis on women's body as private makes both women and male physicians uncomfortable with clinical breast examination. One male physician stated that he would verbally teach the women how to do breast-self examination but he thinks that clinical breast examination is not culturally sensitive or appropriate for Vietnamese women. Women participants' narratives also reflected the Buddhist teaching that avoiding desire (quyen ru) and modesty toward the display of flesh is important. There is a common assumption held by some women that sins are caused by "Ai" which is love and "Due" which is sex and sexual impulses. Buddhism also teaches that "Ai" and "Due" will lead a person to darkness (vo minh), doing wrong things, and committing sins. This will, in turn, lead that person to a very unhappy and unfortunate life. Below are tables that summarized women participants' experience with breast and cervical examinations. Table 5.1 Papanicolaou Smears: Women Participants' Examination Pattern Frequency Women participants (/V=15) % Women who met screening criteria Women who did not meet screening criteria Regularly once a year 5 33.3% 4 (26.6%) 1(6.6%) Had it done once 3 20% 3 (20%) -Had it done twice 2 13.3% 2(13.3%) -Never go for Pap test 5 33.3% 2(13.3%) 3 (20%) Of the 15 women I interviewd, 11 met both breast and cervical cancer screening criteria at the time of the interview. They reported on both their past and current screening practices. My data show that there are three women who have never gone for Pap testing, did not meet the present screening criteria and one woman who was not eligible for testing at the time of the interview, but had participated in screening. The reason that these three women did not meet the criteria for Pap testing at the time of our interviews was because of their age range (two women 73 year old, one woman 78 year old). However, all three women have been in Canada for many years. During these years of living in Canada, they had met the screening 81 criteria, yet they had never had Pap smear done. Thus their views on cervical examination remain relevant for this study. Table 5.2 Mammography: Women Participants' Examination Pattern Frequency Women Participants (A/=15) % Regularly every 2 years 7 47% Had it done once 1 6.6% Had it done twice 1 6.6% Never 5 33.3% Did not mention 1 6.6% Table 5.3 Clinical Breast Examination: Women participants' Examination Pattern Frequency Women Participants (A/=15) % Regularly once a year 3 20% Never 4 27% Did not mention 8 53% Table 5.4 Breast-self Examination: Women participants' Examination Pattern Frequency Women participants (A/=15) % Regularly once a month 1 6.6% Once in a while 1 6.6% Did not mention 13 86.6% Most of the women participants say that they are very embarrassed when it comes to having Pap smear or breast examination by either male or female physicians. Mrs. Hai: For women, it is very uncomfortable when you let the doctor examine 'it'. Very uncomfortable, very different. It doesn't matter a woman or a man doctor, I don't like it. I don't like any body touch those 'things'...[breast examination] is not as bad as down there. But it is till too uneasy. (Translated and edited from W-Hai-3-A-1) Many Vietnamese women participants say they are very hesitant to go for any kind of women's health care issues such as birth control, clinical breast examination, or Pap test (especially if their doctors are male doctors). For some women, especially older women, removing their clothes during an examination is an uncomfortable task. Even just talking about it creates embarrassment. For example, a group of women who work at the Vietnamese radio show which airs every Sunday from 8 to 10 AM were talking about breast cancer. They were trying to avoid using the word "vu" which means, "breast" in English. So they were talking about "ung thu nguc" which translated into English would be "cancer of the chest." When 82 they realised that it was not appropriate to call breast cancer "the cancer of the chest," they then called it "ung thu nhu hoa" which translated into English as "cancer of the two flowers." After much consideration, they finally called the disease "ung thu vu," which is "breast cancer." Ms. Lyn is 68 years old and has lived in Canada for 13 years. For her, anything to do with "woman's things" is considered private. One should not display those "woman's things" but treat it with discretion. I don't know why I feel that way. I live with my grand daughter but I would wait until she gone to work to take my bath. I wash my underwear but I never let anybody see it. When I was young, no one in my house knew that I was having my period, even my family members... I just feel that men should not see these "women activities." Researcher: What would happen if men see it? Ms. Lyn: Nothing would happen. It's just that I feel very uncomfortable about it. (Translated and edited from W-Lyn-10-B-1) Although she had six children, letting the doctor examine her breasts and the cervix when there is "nothing wrong" is very uncomfortable. Ms. Lyn: I am very embarrassed about it. Just show my breasts when nothing is wrong. Very embarrass (laugh). I would be very embarrassed. Even though I am old, I am still very embarrassed. (Translated and edited from W-Lyn-10-B-1) The thought that she has to tell her son or daughter to take her to the doctor for a breast and cervical examination generates as much anxiety as the examination itself. "What would I say to my children? Ah, I need you to take me to the doctor to have my breast and my cervix exam. No, that is very uncomfortable, very embarrass" (W-Lyn-10-B-1). Similarly, Mrs. Mai says: It is because of the embarrassment that make a woman not wanting to have these examinations. Pardon me but if you have nothing wrong and yet you take off your pants and fay on the table with the legs up like that... I think that is very embarrassed. I think that women would not like that. It is not the same as if you get your teeth check. So if you can have a Vietnamese female person to examine you then it would be better. (Translated and edited by W-Mai-9-A-1) Contrary to other studies (Cheek et al.,1999; Lesjak et al., 1999; Yi, 1994), this study found that the degree of acculturation (good command of English language, more familiar with Western ways of living) and the length of time which Vietnamese women participants live in the host countries do not influence how they participate in breast and cervical cancer screening. The majority of the women participants have been living longer in Canada. For some, it is more than 20 years, and still they are quite uncomfortable with these examinations. For some women, 83 Yes, language is very important. But it is not just the language. Our culture doesn't permit us talking, sharing with others about such taboo problems. Talking about the woman's body cannot be publicly. For example, my friends, they know English very well. They studied here for a long time. They told me "I talk to the doctor about the problem and I was so uncomfortable." These women are not comfortable to talk about it. So I think, language limitation may prevent women who just came here. But also these are not easy topics to discuss. (Translated and edited from W-PN-2-A-1) Mrs. Phi has been living in Canada for 26 years. Not only does she speak English and French fluently, but she has also been very successfully adapting to the Canadian way of living. This is what she said: I am embarrassed even to touch my own breasts, let alone other people. They (health care providers) need to understand that. Talking about the cervical, well, it is even more taboo (tham kin), more embarrassed. So they just don't go, and if they go, they would go to the female doctor. If there is a serious problem, they have to go [to the male doctors]. That's what I mean by understanding Vietnamese culture. Even though we are here, because we were always like that, still, we are remained the same. If there are no female doctors, we would hesitate to go for these kind of check up. (Translated and edited from W-Phi-2-A) She further explained: People here do not live in Vietnam, so they don't know that Vietnamese people, especially, the Vietnamese women, don't like going to the doctors. It is worst if there are no female doctors. Breasts and cervix are places that are most private to the woman. Except the husband, nobody else should touch them. That you must understand. Therefore, when you are trying to motivate them to go to the doctors for these examinations, the first thing they might say is "Oh God, I am too embarrass," some thing like that to see a male doctor! .... They (health care providers) need to understand this. So that they wouldn't be surprised of the fact that Vietnamese women don't used to the maximum this kind of health care services. The major thing is that they are embarrassed. So you see, also for that reason, they (the women) preferred to go to the traditional healers who would only examine their pulses, tell them whether their blood is good or bad, or cold blood, hot blood, etc. then give them the medication. Researcher: They do not touch your body. Mrs. Phi: They do not touch. (Translated and edited from W-Phi-2-A-1) When asked why Vietnamese women feel so embarrassed about breast and cervical examinations, Mrs. Mai attributed it to the ways in which women have been taught from generation to generation. Her narrative also shifted toward what she thinks as sexually appropriate for women and her disapproval of the younger generation's behaviour. Vietnamese women are different. Our traditional behaviour is better. Now a day I see young Vietnamese girls here and back in Vietnam too they act very badly. Their dresses are so short, it shows everything. They would sit on the men's laps in public... Back then we were never like that. We act properly (ne nep). We had to wear long formal dress (ao dai) as soon as we stepped out of the house. Just ask your mother, she'll tell you what it was like...You just would not show your bump like that....Before, when the parents say something, the children would listen, not all mixed up like here... I tell her to wear a longer dress but she like to wear it up to here. (Translated and edited by W-Mai-9-A-1) 84 Physicians also recognized Vietnamese women's hesitancy to address issue related to breasts or cervix. However, one physician, while fully recognising that women are quite embarrassed and hesitant about letting male physicians examine their breasts, stressed the importance of clinical breast examination. Dr. Tien: I think [clinical] breast examination is very important because the patients might not know about the symptoms of breast cancer. It is not simply that they could detect a lump. It's not just that, many times, there is no lump or the lump is just too small to be detected by touching. There are other external symptoms such as changes of the skin, the shape of the breasts, the axillary lumps, indent of the skin, etc. These things, the patients would not know about it. They think that they have cancer only when they have a lump. So clinical breast examination is important. Even though it is not as accurate as mammography or echo-graphy, it is very important. (Translated and edited from H-Tien-17-C-1) Doctor Dau has been providing health care to the Vietnamese in Canada for more than 18 years. He states that even he, a General Practitioner who also practices as an Obstetrician, meets obstacles when it comes to encouraging women to talk about breast and cervical examinations. In his experience, Vietnamese women are very hesitant (ngai ngung) about these things. These are considered very private (tham kin) parts of the women. So they are very hesitated to have these parts examined. That is one of traditional Vietnamese thinking.... Very hesitant. There was a woman who had a lump in her breast and she was still wondering if she should have the doctor examining it or not. When suddenly one day, she told me about it. I was so worried.(Translated and edited from H-Dau-13-C-1) When asked about how he as a Vietnamese male physician feels about talking to the women about these issues, he does not see talking to the women is a problem. However, in practice, he does take precautions. Researcher: When you talk to these women, do you feel uncomfortable? Dr. Dau: No, I am not uncomfortable. But usually I would have other person with me. Usually the woman would have her husband, mother, or friend with her. I have to avoid the, well, the situation. Actually it is not to avoid. I do talk to them. Often there are lots of opportunities to talk to them about it. It is not too bad. I often tell them to have Pap smear done once a year and tell them that it is to their benefit to have it done. (Translated and edited from H-Dau-13-C-1) Although physicians have said that they have no problem with telling the women to go for mammograms, they indicated that providing health care and information about these issues is not easy. Discussion about birth control or sexual relationship problems are often very difficult for the women, even for those whom they have been providing health care for quite some time. There were patients who have sexual relationship problems but did not seek help from physicians until four or five years later because they were too embarrassed to talk about these problems. This might be one of the reasons why some women participants in the present study did not know that they should have breast and cervical examinations regularly. Acknowledging that women's hesitation does pose a barrier to the women's 85 participation in breast examination and Pap smear, physicians, however, think that it could be overcome if health care providers provide adequate information to women. Dr. Dau: But I do think that we can help them to understand. I don't think that it is too difficult. There are many women who have made an effort to get these things done.... Yes, it is important. But this problem could be overcome if we explain these things to the women. However, the problem, as I see it, is that not many people would sit down to explain to them, to encourage them. (Translated and edited from H-Dau-13-C-1) Another Vietnamese speaking male physician, Dr. Thinh, agrees that the Vietnamese traditional view towards the female body as private might influence Vietnamese women's participation in breast and cervical examinations. However, he thinks that it was more of a barrier 10 to 20 years ago, but is no longer an issue. He says: Dr. Thinh: Definitely, it is because of the Vietnamese traditional thinking which emphasise female body as private (kind dao, te nhi) that made women hesitant (ngan ngai). That is our custom. But that was only 10 or 20 years ago. Now a day, it is not an issue anymore. Women are used to it now. They know about it. Now they would go for these checkup and not thinking about being embarrassment anymore. Furthermore, there are female doctors. People who are embarrassed can just go to see the female doctors.... For women who do not want to be examine by a male then I would refer them to other female doctors. (Translated and edited from H-Thinh-16-C-1) Doctor Tien, who trained in a Canadian medical school, asserts that Vietnamese women and Asian women in general do not pay adequate attention to breast and cervical health. He thinks there is a lack of information reaching Vietnamese women, as well as a "cultural mentality" which makes them hesitate (ngai) to discuss these issues. Clearly expressing his disappointment, he talked about the difficulties he encounters in his practice: Dr. Tien: Number one is that there is a lack of information from the government organisations and the physicians. Secondly, it is because of the mentality of Vietnamese women. They don't want doctors examining their breasts and cervixes. The majority of these women are very embarrassed about these things. The majority of the Vietnamese women are feeling that way. Researcher: Do you see that very clearly? Dr. Tien: Oh yes, very clearly, very clearly. That is why I am quite disappointed sometime, very disappointed indeed. When I was in the medical school, they taught us to take care of the women. At a certain age, we should advise them to do this and that. But when I talk to the women about breast examination, although I have all the drawing and the instruction about it, I feel that Vietnamese women, from young to old, are not interested (phot qua) in these issues. They would say something like, "oh, it's no problem".... The mentality of the Vietnamese women is that. They don't even want to have these kinds of examinations with the Vietnamese female physician ... They don't want to be touched or to have these parts examined. Researcher: So. You know that they are quite hesitant, do you still ask them to have these examinations done or are you hesitant yourself? Dr. Tien: I still explain everything, like the risk factors, the consequences, everything. But I think that although they listened to me, sometime, they even agreed to make an appointment for breast examination, they just didn't show up for it. So what can I do? However, as the physician, I still have the responsibility to talk to them about it. I do know that the women don't like to talk about it, 86 but because of my responsibility, I still talk to them. I have to record on my file when they don't show up for these checkups. (Translated and edited from H-Tien-17-C-1) 2. The Body Is an Experiencing Agent: The Embodiment Experience For many people, bodily sensation governs many of their life's activities. Human beings often act and think through their bodies. Thus, human bodies are considered the subject of life's actions (Schutz, 1970). In the present study, women participants often put emphasis on their embodiment experience as the direction for their health care. The body is not treated as separate entity, but as an essential part of the self. How their bodies feel or react to illness and treatment determine their health care actions. How illness is experienced determine from whom they seek help and when they seek help. Several participants do not think they have a problem unless they are experiencing discomfort. Furthermore, the effectiveness of either Easter or Western treatments is evaluated according to the ways in which the body responds to the treatment. Treatments that do not alleviate symptoms would be considered ineffective, and alternative treatment would then be considered. For Mrs. Mai seeking treatment for her arthritis is a process of trying out several treatment modalities. Although she preferred traditional Chinese treatments such as acupuncture, she evaluates the effectiveness of the treatment based on her embodiment experience. After several acupuncture sessions, still having pain in her legs and arms, Mrs. Mai started to use Western medication because she found that it had helped to reduce the pain. Mrs. Mai: For a while, every day my husband took me to the place just few blocks from here for acupuncture. I had it all over my two arms, but it did not work. It did not cure me at all...So I went back to my family doctor. He gave me this medicine. I took this medicine and within two days I felt better. Only two days and I felt better. (Translated and edited from W-Mai-9-A-1) On the contrary, Ms. Lyn has been having problems with her stomach and had been taking Zantac as prescribed by her family doctor for few years. However, in the past few months, she changed the management of her problem based on what her body was telling her. Instead of taking the medication, Ms. Lyn pays very close attention to how her stomach responds to food. Noticing that the pain would subside if she eats small meals every four hours, Ms. Lyn is making sure that she eats before her body has the chance to react. Ms. Lyn: According to my experience, if I eat right away when I feel that the pain is coming, then the pain would stop. So now I am not taking the medication. The medication would just do the same thing. For example, when I have pain, I take the medication, the pain would go away. But then when I am hungry, I would have pain a gain. If I have pain, I eat and I can feel the pain stops. So you see, I just give myself treatment that way and I do not have to go to the doctor for two months now. It is because they [the doctors] gave me Zantac. A dollar for one tablet and 87 when I take it, it has the same effect. If I stop taking the medication, I would have pain just the same. (Translated and edited from W-Lyn-10-B-1) In addition, she has been doing a lot of walking because going for a walk every morning has made her feel healthy and energetic. For Ms. Lyn, motivation for keeping her active life style comes from her body's positive response. Health promotion, disease prevention, and the implementation of a healthier life style are not based on the advice of Ms. Lyn's physician, but are directly related to the ways in which her body is experiencing and responding to her actions. To several participants, the embodiment of health is defined at least in part as the absence of diseases and illnesses. One is having good health if one feels healthy enough to work and if there is no physical symptoms that indicate the presence of diseases. Mrs. Phan: We are healthy if we can go to work as normal. We would go to the doctor only when we have diseases or some evidences to show that we are sick ... Normally, we know that we are healthy if we can work. If we feel that we are sick, have something wrong, or tired and pain then we go to the doctor. That's it. (Translated and edited from W-Phan-11-A-1) Mrs. Chau works every day making Vietnamese sweets to sell to local Vietnamese stores. Her daily routine is to get up in the morning at 6 or 7 o'clock and she works until 8 or 9 o'clock at night. Although Mrs. Chau has been diagnosed as having heart enlargement, hypertension, and has had a stroke in the past, she considers herself very healthy because not only does she have no symptoms, but also she is still able to work every day. Mrs. Chau: I have seen several old women. Every one of them has some health problems. But me, I only go to the doctor twice a year. I seldom go to the doctor.... If I were not healthy, I would die long ago. I would not live this long with those diseases.... So you see, I am very healthy. I work very hard. Even young women would not be able to work like I do. (Translated and edited from W-Chau-7-B-1) B. Cultural Conceptualisation of Health and Illness As Kleinman had suggested, Vietnamese women participants' social reality which includes their beliefs about health and sickness, their expectations toward Western and Eastern treatments influenced how women react to sickness and choose among health care options. But more importantly, women participants in this study placed great emphasis on what health and illness mean to both themselves and their families when they thought about and participated in health care activities such as breast and cervical cancer screenings. 88 1. "Health is Gold" (Sue khoe la vang) Vietnamese's proverb "health is gold" (sue khoe la vang) is emphasised by participants. Women participants explicitly stated that they consider health as the most important thing. Mrs. Mai: Health is a number one important. For example, I'll alway ask you "how are you?" I would never phone you and ask, "How much money do you have?"... When we see each other, the first thing we ask is "How are you?" (Chi co khoe khong?). And I would be very glad if you say that you are fine. But if you say that you are sick with this and that then I would be very sad for you ... Very soon few of my friends will call and they would ask me "How are you in the last few days?"...they would not ask "How many thousands dollars do you have?" or "How much money do you have now?" Nobody is going to ask you that. (Translated and edited from W-Mai-9-A-1) Being healthy is important to Vietnamese women because without health one cannot accomplish much, nor could one take care of one's family. Mrs. Ha insists that "health is gold" because a woman needs to be healthy to take care of her children. Mrs. Ha: If she is not healthy then she cannot work. If she is not healthy then even if she wants to, she cannot do anything. How would she be able to take care of her children if she can't get out of bed. If I want to take care of my children then I have to be healthy. If I want to go somewhere, if I want to ask for help from someone, I would have to go to that person or be able to talk to that person. So you see, health is gold (Translated and edited from W-Ha-12-A-1). For others such as Mrs. Mai, having good health is important because financial stability and family welfare depend upon it. Mrs. Mai: We have to be healthy so that we can go to work to make money because if we don't then how are we going to pay rent and all the other bills....You see, we have to be healthy so that we can handle all those things. Take care of our family, go to work to make money. We have to have money to pay for our bills. We would be very stuck if we don't have money.... If we are not healthy, we would not be able to do our best, to take care of our children. (Translated and edited from W-Mai-9-A-1) This view is shared by one of the physicians, however, what he sees is that although Vietnamese value health as gold, metaphorically speaking, this kind of gold is not properly invested. In his words: Dr. Dau: They [the Vietnamese women] still value it [health]. There is gold that is for keeping in the locked cupboards [laughing]. They still value this gold. You see, in Vietnam, there was much gold that were saved. Not in the bank, but in the houses' locked cupboards...It's just that they don't know how to invest, to use it, to use what they have. (Translated and edited from H-Dau-13-C-1) Because health is viewed as important and health care activities are considered a necessity of life, several participants, even though they do not think that having breast examinations and Pap smears are important for themselves, think that younger Vietnamese women would benefit from having these examinations done. Mrs. Chau, a 73-year-old woman who has never had any kind of breast examination or Pap smear since she came to Canada in 1979 thinks that encouraging women to go for these tests is a good thing, especially when going for these tests does not cost any money. 89 Mrs. Chau: It is very good if you can encourage the women to go for these examinations. No harm done. Don't have to pay. Here they let us go to the doctor. We need to go for these checkups. I see some younger women, husbands and wives have diseases. Younger women need to go...they are ones who have serious diseases. If they leave it for too long, it cannot be cured....These examinations are good for them. (Translated and edited from W-Chau-7-B-1) Vietnamese women's conceptualisation of health also reflects the ideology of the body and mind connection. Absence of physical symptoms might not mean that one is totally healthy. To some women, feeling healthy is performing one's roles and duties well. Thus health is not seen as something that is only connected to the individual's body, but rather, it is being seen as an important dimension of women's daily lives (Aptheker, 1989). That is, health is viewed within the context of the women's daily life, interconnected with other factors. In particular, health is closely connected to women's ability to look after children, to perform family activities, and to survive economically. Thus, health is not seen as a major dimension in and of itself. It is seen in relation to all other life activities. This conceptualisation of health is in contrast to Western culture-bound notion which emphasise the individuation of self. In the present study, understanding of self and health is connected to social relations within the particular culture context. For some Vietnamese, a person is understood as acting agent within the context of a family relationship. Confucianism, Taoism, and Buddhism are internalised within many ofthe Vietnamese. None of these traditions encourages the development of a highly individualised self. The development of self is closely connected with family kinship networks, social position, social obligations, and through the responses of others. An act that denies self s interest is not considered a sign of personal weakness but rather as inner strength. For Dr. Dau, a Vietnamese speaking physician who has worked with the community for more than 18 years, seeing the women's life within their social and family context is not an option but a must. Family problems affect individual's health profoundly. Dr. Dau: if they [the women] are able to help their families back home, they are happier, and as the result, they are healthier. Those things influence their health directly. Imaging, each night or each month they get phone calls telling them that people at home need this and that, their mother, their children, their brother and sister were sick and all that. If they cannot help their loved ones back home, they would go crazy themselves (Dien nguoi len). That would affect their health. So, health means everything. You have to look at everything. You just can't look at medication only. Health is not just that ... Asian's view is very good. That is the physical body and the mind is one. If the physical body or the mind is not good, it affects the whole body's health. In health care, we have to recognize that many things affect health. We have to understand that getting mammogram done or having Pap test done, or having checkup is not enough. Getting these things done is only partially adequate. (Translated and edited from H-Dau-13-C-1) 90 The ways in which Vietnamese women practice health care and keep themselves healthy depends upon how important health is to them. To many women participants, health is considered very important and keeping themselves healthy is the number one priority. The difference, however, is that to some women, health is important in and of itself, while others talk about the importance of having good health within the broader social context of their lives. Good health is seen as the absence of not only physical symptoms, but also psychological symptoms. Most of the participants verbalised that going for checkups, mammograms, and Pap smears are important health care activities for keeping oneself healthy. For example, Mrs. An, a 70-year-old woman, recognises that breast cancer and cervical cancer are diseases that can be present in the body without any symptoms. She stresses the psychological impact of having mammography. Mrs. An: I think it [mammography] is good because, firstly, we could be feeling fine, but inside, we don't know. Secondly, we have to trust the modern machine here. It is better that we know. If we know about it then we would be able to do something about it. If we know about it, we would not be too worry. When we listen to this person and that person talks about it [breast and cervical cancer] we tend to get worry. So if we had the machine check it out for us then we would not worry anymore.... It is necessary and it makes us feel more at peace. (Translated and edited from W-An-14-A-1) 2. Vietnamese Women's Conceptualisation of the Causes of Disease and Illness Reflected in the Vietnamese women's narratives of what cause disease and illness are three major concepts: (a) Disease and illness are caused by an imbalance of the body; (b) Disease and illness are caused by the invasion of bacteria; and (c) Disease and illness are predetermined by a higher power. An ideology of intact harmonious mind-body is often underlined in the ways in which the women participants' conceptualised what makes a healthy body and what causes disease and illness. Because a healthy body is achieved through balancing several forces such as Am (yin) and Duong (yang), or Dark and Light, or Female and Male and the equilibrium of "hot" and "cold," disease and illness will result if there is something that throws the whole body out of balance. Diet, activity, emotion, and environmental conditions are common factors that can cause imbalance of the body. The women's narratives about what cause disease and illness, more specifically, what cause cervical cancer also refers to bacteria's invasion, a belief more in line with contemporary biomedicine. The most frequently mentioned factors are individual hygienic health care practices and environmental conditions. More culturally specific to the women's thinking of what causes ill health is that disease and illness are predetermined by a higher power. Disease and Illness are Caused by the Imbalance of The Body The conception of a healthy body as a body that functions in harmony and balance is pervasive within the Vietnamese participants' discourse. Disease and illness will result if there is abuse or violation, which pushes one's body out of balance. It is interesting to note that Western biomedicine ideologies weave like a thread throughout the women's narratives. Although diet, activity level, emotional state, and unfavourable weather are factors that women think push the body off balance and cause ill health, how one should cope with these is reflective of Western cultural assumptions of a healthy life style. Several women participants talked about how paying inadequate attention to one's diet can cause disease and illness. To them, a diet that causes health problems is a diet that is inadequate in either the quality and/or the quantity of food that is eaten. Mrs. Chi: We get sick and diseases because of the ways in which we eat, because of our diet. First, not eating right. May be because we eat something that is difficult to digest. Second, we get sick because we don't exercise. Third, because we don't eat enough fruit. Fruit is very important. It helps your bowel move regularly. For example, if you don't eat fruit, you'll be constipated. Especially, when you are old. Constipation will lead to many problems. So if you eat about 3 to 4 fruit a day, you will have no health problem. Eat a lot of fruit and swimming a lot.... don't eat fat, eat only lean meat. Buy fresh fruit and vegetable. (Translated and edited from W-Chi-4-A-1) Many women's narratives reflect western medicine's strictures on reducing the intake of fat and maintaining a healthy body weight. The women, like many Canadians, pay a great deal of attention to what they must do to control their weight and cholesterol level. At the age of 72, after having lived in Canada for more than 10 years, Mrs. Mai recognises that life in Canada is different than life back in Vietnam, thus she needs to change the ways in which she eats in order to stay healthy. Mrs. Mai: To keep ourselves healthy, we need to eat properly...don't eat too much or too little. Here, we are worried about fat in the blood. So don't eat too much fat.... Here, fat is the worst. It makes the belly very fat then it needs surgery to get the fat out...Here is different. Back in Vietnam the more food we ate the better for us, but here it is not good to eat too much. Food is plenty here but I would not eat a lot. Only eat moderately. Control your eating. (Translated and edited from W-Mai-9-A-1) Although the women's dietary practices have been influenced by Westerner's ways of viewing diet, Vietnamese women's understanding of food and eating habits is something that is also quite culturally specific. These practices are often passed down from mother to daughter, and sometimes, from generation to generation. Mrs. Le talks at length about how she learned to look after her children from her mother. 92 Mrs. Le: In my family, eating is very important. For example, I would not feed my children fish sauce until they are two years old. Under two years old, I didn't give them because it would make a very bad odor. Fish sauce would goes through the body into the sweat. Fish sauce is very good. It has a lot of protein but I think that it is too strong for a young child. Usually I used salt and soya sauce and I always made sure that there was enough nutritious food .... My mother raised us the same way. (Translated and edited from W-Le-8-A-1) For other Vietnamese participants, eating foods that are considered "doc" (poison) can cause health problems. Ms. Ngoc: We have to be careful with what we eat. I used to eat lots of dry bambo shoots (mang kho). But then people told me that bambo shoots are poisonous (doc). When I was eating it a lot, I had so much pain in my bone and my knees. So I think that they are right, bambo shoots are poisonous. It is not good to eat it. (Translated and edited from W-Ngoc-19-A-1) Similarly, other women also believe that certain foods can hinder the body's healing process. Mrs. Phi: Diet is directly connected to medication. For example, if you take cough medication, you should not eat chicken. If you had an operation, you should not eat beef. It is quite true. If you don't follow that, your disease will take longer to cure. I do belief those things. If you have an operation and you are eating just anything and not abstain from these foods, then your wound will take longer to heal ... you'll have a big scar (theo Ion). Here, they would explain that the reason for a big scar is because the doctors sew it too tight. But I think that it is partially due to what we eat. (Translated and edited from W-Phi-2-A-1) The women's discourse about what causes disease and illness parallels contemporary biomedical discourse. Because disease and sickness can happen if one does not eat well, sleep well and exercise regularly, to keep oneself healthy, one needs to eat wisely and moderately, exercise, get enough sleep, and keep clean. Mrs. Mai: To avoid being sick, I think we need to eat properly. Get enough sleep and exercise regularly. Exercise for half an hour or one hour every morning. Control your eating, don't eat too much or too little. Here, many people have fat in the blood so don't eat too much fat.. ..For women, keep the "women part" clean so it doesn't get infection. In general, that is one should do. (Translated and edited from W-Mai-9-A-1) Mrs. Lyn had a very difficult life when she lived in North Vietnam. In order to make money to look after her family, she had to knit sweaters for an exporting company. She often stayed up and worked until 1 or 2 o'clock in the morning. Mrs. Lyn associates her liver problem to her lack of sleep. Mrs. Lyn: They said that you would have problem with your liver if you lack sleeping. It is because sleeping affects the liver. When you are sleeping, your liver sleeps too. So if you stay up too much, your liver would not be able to sleep either. After a while, it becomes sick. It is just like if you don't go to sleep for a long time, you would get headache. The liver is the same way. They said sleeping is in the liver. So if you stay awake for too long a time, the liver will get sick. (Translated and edited from W-Lyn-10-B-1) Some women participants attribute the cause of cancer to one's life style. For example, Mrs. Chi attributed the cause for her friend's cancer of the liver to that woman's inactive life style, which she see as 93 directly related to the fact that "she just sit and play mahjong all day." Therefore, to keep herself healthy, this is what she does: Here, we eat too well; the body gets fat very easy. Because we get fat so easy, we need to go for walk or swim or exercise at the centers where there are organised classes. I have to do all those things because here I gain weight... I feel very heavy. So I go for walk, swim, and sometime I go on treadmill. I also try to eat less. When I was in Vietnam, I ate meat, I ate the fat too. I didn't said, "oh this has more fat I should eat less of it," but now I have to be careful. I eat very little fat. I eat more fruit and vegetable. In general that's what I do. (Translated and edited from W-Chi-4-A-1) Some women's conceptualisation of what causes cancer is directly related to the imbalance of ones' emotional psychological state, thus reflecting the body-emotion control model. Mrs. Chau has been living in Canada for 21 years. When asked what she thinks cause breast cancer, she says: People get cancer because they are worried and angry too much.... I think there are hereditary diseases, but people who would get the disease if they angry too much. About that disease (breast cancer), I don't think that disease is hereditary. (Translated and edited from W-Chau-7-B-1) Prevention and treatment for cancer, then, is directly related to what she thinks are its causes. Mrs. Chau: Don't get angry, worry or feeling bitter then you will feel much healthier. Number one is to try not to get angry. If you are angry, don't keep it all inside. In the past, I would get angry, but not now. If I were angry with someone, I would forgive him or her. I would not keep it inside so that I would hate that person or think about revenge.... I heard the doctors say that we get diseases because we get angry and bitter too much. (Translated and edited from W-Chau-7-B-1) Disease prevention, for Mrs. Chau has everything to do with psychological health. Thus, to prevent breast cancer and cervical cancer, one should take care of one's psychology and social relationships, especially, emotional control which is seen as an important determining factor. Similarly, Mrs. Phi states: If we were not strong psychologically, we would get sicker. If you are sick but you think the doctors and the nurses are very good. You would then feel that your sickness is not as bad. But if you keep worry about your pain and that nobody around you, your condition will get worst. And it will be difficult to treat you, especially with cancer. I think that if you are strong, and if you are brave, then you might overcome the disease. I read books that tell the story of women who don't pay attention to their sickness. For these women, it was easier to treat the disease. If you just sit there, being depressed and grief over your life, then your disease will get worst. (Translated and edited from W-Phi-2-A-1) Disease and Illness are Caused by the Invasion of Bacteria The women participants' explanations for the cause of diseases, especially, cervical cancer are directly connected to the bacterial invasion theory of contemporary biomedicine. From the women's perspective, bacterial invasion ofthe body is through either individual hygienic health care practice and/or environmental conditions. Thus, to keep oneself healthy, one needs to pay attention to one's hygiene and the environmental conditions in which one lives. Here we see the integration of all three sectors of health care. These sectors, as Kleinman identified are the popular sector, the professional sector, and the folk 94 sector of health care. Women participants beliefs and values about disease and illness in each sector, although has its own distinct explanatory model, are often overlaping. Mrs. Minh is 61 years old. Before coming to Canada, she lived in North Vietnam with 6 children. To keep herself and her children healthy, she has always paid attention to bodily hygiene. Mrs. Minh: In Vietnam, we have many children, so we didn't pay a lot of attention to the food we ate and the clothes we wore. For us, keeping ourselves clean was very important. For example, Vietnam's weather was very warm, and the land was very dirty. So for my family, we kept ourselves clean every day. Many people I knew, for many years they don't even know what soap is. But us, we bathed and cleaned our clothes with soap. Even in the winter when it was very cold, my children still bath two, three times a week. That is how we kept ourselves clean every day. We washed ourselves before going to bed and in the morning. It was necessary for our body. Our health is depended upon our hygiene. (Translated and edited from W-Minh-5-B-1) Mrs. An is 70 years old and used to live in South Vietnam. As a mother of 5 children, she talked of how she always put great effort into making sure the food is handled and cooked properly. To her, one has to pay attention not only to the kind of food one eats, but how the food is prepared. Hygiene is a factor of utmost importance. Her eating practices go back to her life in Vietnam. To ensure that her children stayed healthy and did not get sick by eating contaminated food, she did not allow her children to buy food on the street at the open stalls, but fed them at home instead. Drawing from her own experiences of seeing many people around her suffering with gastrointestinal problems, Mrs. An was very mindful of proper food handling. Mrs. An: I think that the ways we handle the food we eat is very important. We have to have clean hands. That is very important to keeping ourselves healthy. Number one is that we have to be choosing about the food we eat. Number two is to keep our hands clean. We use our hand to put food in our mouth. (Translated and edited from W-An-14-A-1) Bacterial invasion which cause cervical cancer, to some women participants, is also linked to the environment they live in. Exposure to public sources of contamination is another way for bacteria to enter the body. Mrs. An: The third reason is that the women go to public swim. Although there is chemical to clean the water, I don't know how well. There are people who have the disease who going there but we don't know. So we would be with them. Disease such as AIDS, that disease is obvious. (Translated and edited from W-An-14-A-1) Among the women participants, another very common belief regarding the cause of cervical cancer is that a woman would often get the disease via their relationship with their partners. The women's explanation for the cause of cervical cancer is the invasion of bacteria into the woman's body if they are not clean "down there" or by having sexual intercourse with an "unclean man." 95 Mrs. An: I think women get cervical cancer because they are not clean. You grow up with your cervix inside you, nothing would happen to it. You get the disease when the bacteria from the out side get inside you.... For example, women can get the bacteria from their unclean husbands. There are men who are dirty. They don't pay attention to their hygiene and then they sleep with their wives. Those wives would then get the bacteria into their cervix.... Another way a woman would get the disease is if she is not clean when she has her period.... Bacteria would also go inside you if your own hands were not clean. (Translated and edited from W-An-14-A-1) Because bacteria is viewed as the main cause for cervical problems and is thought to be the result of poor hygiene or a sexual relationship with a partner who has poor hygiene, prevention is focused on cleanliness. Thus, Mrs. Chi: Yes, hygiene is important. Also when they are having sex (an o voi chong) with their husbands too. After having sex, they should clean themselves. That thing [the vagina] should be kept cleaner than the mouth even. You clean your mouth how many times a day, you clean that "thing" just as many times. You should never ignore its hygiene. If you don't clean that "thing." It will get diseases.... Also, you have to keep an eye on your husband. Don't let him do wrong thing. If he does the wrong thing, it doesn't mater how clean you are, you'll get the disease. (Translated and quoted from W-Chi-4-A-1) Women's discourse around the cause of cervical cancer and other sexually transmitted diseases, especially AIDS is often alluded to sexual relationship. The new Vietnamese policy that encourages people who have left Vietnam to come back to the country for visits has created a trend of Vietnamese Canadian making trips back to Vietnam. Many men had gone back to seek wives and some have gone back just for a visit. Several women participants have expressed concern saying that many men who had been back to Vietnam got the "disease." Researcher: What do you mean by doing the "wrong thing"? Mrs. Chi: Well doing the "wrong thing" means, I don't know about the Caucasian men, but Vietnamese men, especially the younger ones, when they come back to Vietnam, all of them have got the disease. (Translated and edited from W-Chi-4-A-1) Because cervical cancer is viewed as the diseases of "young people," who are sexually active, older women think that they are not at risk for getting these diseases. Mrs. Chau does not see that it could happen to her. "These cancers, it is not going to happen to me. I am too old for that" (W-Chau-7-B-1). One of the reasons Mrs. Chau has never gone for a breast examination or Pap smear is her perception that an old woman is not at risk for getting these diseases. She thinks only younger women who are sexually active are at risk for getting the disease. As I have shown, Vietnamese women's conceptualisation about what cause diseases and cancer is quite diverse. Although many women express their firm belief in modern medical technology, some women remain skeptical about its ability to diagnose and treat contemporary diseases. For Mrs. An, cancer is a name that is given to diseases that cannot be cured by biomedicine. Mrs. An: I think that whatever the diseases that they cannot cure, they called it cancer. If they try many different treatments but they can't cure that disease then they call it cancer.. ..I think that diseases which they cannot cure, they call it cancer and diseases that take too long to treat they call it allergy. That is what I think. About cancer that is inside the body, I don't know. It just stays inside, when it becomes noticeable, it cannot be cured, then it is a cancer....They don't know what it is so they call it cancer. (Translated and edited from W-An- 14-A-1) This belief might be one of the reasons why some women would not seek help or treatment for cancer. To these women, if cancer cannot be cured then seeking treatment for it may be seen as a waste of time and family resources. Disease and Illness are Predetermined by a Higher Power Several women participants have very strong beliefs in their religious teaching, whether it is Buddhism or Christianity. According to Buddhism, everything that happens is under the influence of "nhan duyen" and "dinh menh" (destiny). Under this universal law, a person does not have much control over his/her life, and what ever is destined to happen, will happen. It is up to God (mac troi). Because of that belief, a woman may not seek treatment, believing that a cure is up to God. Sickness, we cannot do anything about it, whatever happen, will happen. Mrs. An, a 70-year-old woman illuminates how this belief influenced her daughter's decision on how to deal with breast cancer. Mrs. An: She told me, "Mom, I am not going to the doctor." I don't exactly know what she thinks but she decided not to go to the doctor. The doctor tried to talk to her many times. He told her "you are still very young. I don't want to see you died." She said, "doctor, I have God. My destiny is in God's hand. I do not want to have the operation." (Translated and edited from W-An-14-A-1) Mrs. An's daughter, who was only 40 years old, discovered a small lump under her arm while watching TV with her sister. Despite the doctor's entreaties, she refused a mastectomy and lived for seven years without treatment of any kind. Only in her final stage, in the hospital bed, did she consent to chemotherapy treatment. According to Mrs. An, one of the reasons her daughter refused to have the operation is her faith in God. Although Mrs. An acknowledged that she is sad that her daughter is gone, she firmly believes they will be united again. Born and raised in a strong Protestant family, Mrs. An and her husband, who is a Pastor, are among the most active members of their Church. Their lives are organised around Church activities and their trust in God is unshakable. Mrs. An thinks that her daughter's seven years of living with breast cancer without pain was a miracle, a gift from God. Women who are members of a particular religion often talked about their firm belief and trust in God to cure their diseases. Mrs. Ly is 78 years old. She contributes her ability to walk again to God's doing, 97 Mrs Ly: I am very grateful to God. God must of see that I am a good person because what ever I pray God for, God gives me. I am so grateful to God. When I was sick. I had pain in my legs. I had to use a cane for walking.... I couldn't even move my legs ... because I kept praying to God a lot, I now could walk without the cane ... God told me not to use the cane. So I didn't use the cane. Do you know what? When I first came to live here (Vancouver), in 1994 or 1995,1 have been living here for several years now. In the morning, I could not get up. I had to work at it, sometime, not until 12 o'clock when I could get up to eat lunch. Can you imagine that? I could not move both of my legs. But God makes my legs strong now. That is miracle. (Translated and edited from W-Ly-6-B-1) Similarly, Mrs. Chau talked about her miracle recovery from what she called "a big heart disease." For her, the reason that she is alive today is because of God's help. Mrs. Chau: I had a big heart disease. A very serious one. I saw many doctors in Sai Gon, Hong Duong. They told me just go home to eat and die....That day, I thought I was going to die. The Pastor came to pray for me. I couldn't even lay still. I had pain in every joints of my body. I couldn't breath...That night I thought I was going to die. The doctor left and the Pastor came. He prayed for me. About five minutes after he prayed for me I felt much better. I was able to lay still and go to sleep. I hadn't slept for several days. I couldn't even recognise my children. But after he prayed for me, I went to sleep.... I was well from then on...I didn't even have to go to the doctor for checkup. Even though the doctor told me that my heart is still as big as the two men's heart, I didn't have to go to the doctor. I am not sick anymore. Praying to God had cured me...God gave me my health. (Translated and ed