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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  iv  List of Tables  ix  Acknowledgements  x  Dedication  xi  Prelude Chapter One: Introduction  xiii 1  Chapter Two: Literature Review  10  A. Vietnam: A Brief History  11  B. Vietnam: Religion and Culture  13  1. Confucianism  14  2. Mahayana Buddhism  15  3. Taoism  16  4. Christianity  16  5. Communal Life  17  6. Vietnamese Family Practices and The Changing Status of Vietnamese Women  19  7. Conceptualisation of the Female Body: Body as an Experiencing Illness Agent  24  C. Vietnamese Living in Canada  28  1. Economic Experiences  29  2. Social-Cultural Experiences  33  3. Health and Health Care Experiences  35  D. Breast Cancer and Cervical Cancer  37  1. Mortality and Incidence Rates  38  2. Vietnamese Canadian Women's Health Care and Cancer Screening Practices  39  E. Research Questions Chapter Three: Theoretical Questions A. Kleinman's Explanatory Model: Medical System as Cultural System  42 43 44 iv  1. The Popular Sector of Health Care  46  2. The Professional Sector of Health Care  46  3. The Folk Sector of Health Care  47  4. Explanatory Models (Ems)  47  B. Postcolonial-Feminist Scholarship: Its Relevance in Addressing Health Care Issues  49  1. Postcoloniaiism  50  2. Understanding Colonisation and Racialisation  51  3. Postcolonial Scholarship  56  4. What is Postcolonial Research?  57  5. Black Feminism  58  Chapter Four: Research Methods  65  A. Research Participants  65  B. Gaining Access and Developing Rapport  6  C. Method of Data Collection  68  D. Research Interviews  69  6  E. Data Interpretation, Coding, and Analysis  7  2  F. Representation of The Research Results  7  5  Chapter Five: Cultural Influences: Knowledge and Values A. Cultural Knowledge and Values about Women's Bodies  80 80  1. The Private Body: Embarrassment, Hesitation, and Sexual Morality Discourses  80  2. The Body Is an Experiencing Agent: The Embodiment Experience  87  B. Cultural Conceptualisation of Health and Illness  88  1. "Health is Gold" (Sue khoe la vang)  89  2. Vietnamese Women's Conceptualisation of the Causes of Disease and Illness  91  Disease and Illness are Caused by the Imbalance of The Body  92  Disease and Illness are Caused by the Invasion of Bacteria  94  Disease and Illness are Predetermined by a Higher Power  97  C. Beliefs and Values about The Health Care Provider and Patient Relationship D. Conclusion Chapter Six: Gendered Roles and Expectations  98 101 104 v  A. Vietnamese Social Relationships  1  0  B. Ms. Lyn's Story  1  1  C. Conclusion  1  1  Chapter Seven: Social Support Networks A. Formal Social Support Networks  4  1  4  1 1  1 8  1  9  1. General Social Institutional Support  11  2. Formal Health Care Support Networks  1  2 4  B. Informal Social Support Networks  1  2 6  C. Social Discrimination  132  9  1. Cross-Ethnic Group Discrimination Experiences  132  2. Within Ethnic Group Discrimination Experiences  136  D. Conclusion Chapter Eight: Socioeconomic Influence.... A. The Vietnamese Women's Economic Profiles B. Women Participants' and Health Care Providers' Perspectives C. Socioeconomic Status Influences on Health and Health Care Behaviour  1  4 0  I 1  43  4 3  I  44  147  1. Low Socioeconomic Status and Health  150  2. Low Socioeconomic Status and Health Care Behaviour  152  D. Conclusion Chapter Nine: Health Care Responsibility and Accessibility A. The Canadian Health Care System  155 161 162  1. Foundational Values Underlying the Canadian Health Care System  162  2. Restructuring of The Canadian Health Care System  163  B. Shared Responsibility  1  6 6  1. Health Care Responsibility: The Women's Perspectives  167  2. Health Care Responsibility: The Health Care Providers' Perspectives  170  3. Inaccessibility of Health Care Services to Immigrant Women  173  Chapter Ten: Discussions, Recommendations, and Conclusion A. Vietnamese Canadian Women: Health Care Decision Making Process 1. Recognition Stage  179 180 181 vi  2. Negotiation Stage  182  3. Integration/Resistance Stage  184  4. What Leads Women to Seek Health Care  187  5. Why Women Cannot Seek Health Care  188  6. From Whom do They Seek Help?  190  7. Women Participant's Experience on Breast Cancer and Cervical Screening  192  B. Promotion Strategies for Breast and Cervical Cancer Screening  193  1. Women Are Active Participants Of Health Care  193  2. Give Less Emphasis on Western Rationality  194  3. Socially Constructed Position, Race, Gender, and Class Affect Health Care Behaviour  197  C. Implications for Practice  198  1. Developing Collaborative Working Relationships  198  2. Considering Women's Different Ways Of Knowing  199  3. Increase Funding To Support Programs That Provide Services To Immigrant Women  202  D. Recommendations for Future Research  207  E. Conclusion  208  References  214  Appendices  228  Appendix A.  Breast Cancer Screening Procedures For Women Over 40 Years of Age  227  Appendix B.  Ethics Approval Form  230  Appendix C.  Coding System  231  Appendix D.  Women Participants' Socio-demographic Data  232  Appendix E.  Vietnamese Woman's Consent Letter  234  Appendix F.  Vietnamese Women's Consent Letter in Vietnamese  234  Appendix G. Initial Interview Questions for Vietnamese Women  235  Appendix H.  Initial Interview Questions For Vietnamese Women in Vietnamese  238  Appendix I.  Socio-Demographic Data Form  240  Appendix J.  Socio-Demographic Data Form in Vietnamese  244  Appendix K.  Initial Interview Questions For Health Care Providers  246  vii  Appendix L.  Health Care Provider's Consent Letter  Appendix M.  Community Agency Project Information Letter For Recruitment Of Vietnamese  Canadian Women's Participants Appendix N.  24  Community Agency Project Information Letter For Recruitment Of Vietnamese  Canadian Women's Participants in Vietnamese Appendix O.  24  25  Community Agency Project Information Letter for Recruitment of Health Care  Provider's Participants  25  viii  List of Tables  Table 1.1. 2001 Canada, British Columbia, and Vancouver Population Profile  7  Table 2.1. 1991 Canadian-Born and Vietnamese-Bom's Occupational Distribution  31  Table 2.2.1996 and 2001 Vietnamese Women's Occupational Distribution  32  Table 2.3. 1996 and 2001 Vietnamese Female's Income  33  Table 4.1. Health Care Provider Participants' Profile  65  Table 5.1. Papanicolaou Smears: Women Participants' Examination Pattern  81  Table 5.2. Mammography: Women Participants' Examination Pattern  82  Table 5.3. Clinical Breast Examination: Women Participants' Examination Pattern  82  Table 5.4. Breast-self Examination: Women Participants' Examination Pattern  82  Table 7.1. 2001 Vietnamese's Self-Employment Data  123  List of Figures Figure 10.1. Vietnamese Women's Health Care Decision Making Process  181  ix  Acknowledgments  This study was a collaborative effort including many people beside myself. Foremost are the women and men who participated in the study, giving their time, opening their hearts, shedding their tears, and sharing their worlds. To them, I offer my humble gratitude and hope that this dissertation, in some small way, repays them for their insights and trust. Several noble friends and mentors traveled with me on my journey, to whom I now bow in deepest gratitude. My heartfelt appreciation to Dr. Joan Anderson, my research supervisor and my most persistent intellectual power source. Dr. Anderson's vision and courage have inspired me to get to where I am today. Thank you for showing me the path, for sharing your wisdom, for caring, and for letting me know how theory could be linked to research and practice. I also offer my deepest appreciation to Dr. William McKellin, also my research supervisor - my most persistent source of encouragement. Dr. McKellin's endless prodding, pulling, and caring helped me to see the end of my journey. Thank you for keeping me together in mind and in text, and for lighting my path. My special thanks go to Dr. Bonnie Long, Dr. Gregory Hislop, and Dr. Nancy Waxier-Morrison my research supervisory committee members. Thank you for your insights, for staying with me all the way, for cheering, and for seeing in me more than I could. For institutional support, I am grateful to the National Cancer Institute of Canada for the PhD Research Studentship Award, which provided me with funding from the Canadian Cancer Society. Above all, my deepest thanks to my children, Delmar, Jasmine, and Nakisa for enduring, encouraging, and reminding that what I was doing was good and significant, and for reassuring me that I am a good mother even when my work became stressful.  In dedication to..  my parents - Tran Thi Ngoc Ann and Truong Cao Thanh for their courage, wisdom, and phuc due; my beloved late husband - Robert Lee Donnelly for his love and courage; my children - Delmar, Jasmine, and Nakisa for their hope and encouragement; Mehran Zabihiyan for his love and support; Shirley and Robert Donnelly for their affection and trust; my brother - Truong Cao Thien for his creativity and imaginations.  xi  Prelude  It's beginning with my last gaze Upon the land I once called "home" Sadness Gladness Fear But my new home will be filled with laughter, warmth, and security. I envisioned. Look at me! Can you see a silent smile? Yes, I laugh but my laughter has no sound Yes, I am warm...within these walls Secure...if my loved ones around Please! Sir, which way do I go? Left?... Right? Back or forth? Back and forth Back and forth. Loss.... in this strange world. I cannot tell you how I feel my anguishes, my joys, my wishes For words piled up inside Cannot come out! cannot come out! cannot come out! I am locked up inside. Talk to me in any language...yours, mine, ours. I will only smile and nod. But the sound of your voice means that your are present and that you care. It fills this empty space that keeps me locked up inside. For without voices... You Me We are all locked up inside.  Tarn Truong Donnelly  xii  Chapter One: Introduction  An increase in the number of immigrants to Canada has changed Canadian social structure and approaches to health service delivery. Ensuring that immigrants from different ethnocultural backgrounds have equal access to appropriate health care services is an important issue for both the government and health care disciplines (British Columbia Ministry of Health and Ministry Responsible for Seniors, 1997). Between 1979 and 1985, approximately 85,000 South East Asian refugees arrived in Canada, most of them Vietnamese. "Refugees" as defined by the Citizenship and Immigration Canada (CIC), are people in or outside Canada who fear returning to their country of nationality or habitual residence. These are persons needing protection. Canada, through its refugee protection system, provides safe haven to those with a well-founded fear of persecution, or are at risk of torture or cruel and unusual treatment or punishment (Citizenship and Immigration Canada, 2004). By contrast, the term "immigrants" refers to persons who seek lawful admission to Canada to live as permanent residents (Citizenship and Immigration, 2004). Most ofthe Vietnamese who came to Canada between 1975 and 1985 were refugees. It is important to note that in this dissertation, I use the term "immigrant" to cover persons who are admitted to Canada in either the refugee or the immigrant category. I have given much thought to the use of this term. While I fully realized that the experience of a refugee versus an immigrant might be different due to the legal differences for immigration, I decided to use this term to cover Vietnamese refugees and immigrants because as my data show, Vietnamese who came to Canada as refugees and Vietnamese who came to Canada as immigrants (the majority of them came under family class category) face similar cultural, language, and economic challenges. Furthermore, even though Vietnamese who arrived as refugees received more support from the government than those who arrived as immigrants who received support from family members, this kind of support only lasted for a short time. Thus, there are very few differences in the eligibility for services and other institutional support by both groups. Although the term immigrant can generate negative stereotypical assumptions, using the term "immigrant" enabled me to avoid the term "refugee," a word which often implies that a refugee is usually a "survivor of oppression, plunged into poverty, purified by their suffering, and boundlessly grateful for safe haven" (Beiser, 1999, p. 170). The problems arise when there is evidence to show that the refugees are not "pure" or not "grateful" to the host society. There is a growing public ambivalence towards refugees. 1  Despite the fact that many Vietnamese refugees have successfully integrated into Canadian society and are good citizens, public misinformation about Vietnamese gang-related problems casts shadows on their image (Beiser, 1999). Sympathy turns to negativity and doubt. Not only are Vietnamese now viewed as trouble makers by some Canadians, but they are also viewed as a burden. A national survey by the Gallup organization of Canada in 1994 revealed that 39% of Canadians believe that "refugees were using up more than their share of the country's health and social services" (Beiser, 1999, p. 168-169) and 43% feel that the presence of Southeast Asian refugees in Canada costs the Canadian taxpayers too much money (Beiser, 1999). Furthermore, one-quarter of the Gallup poll respondents do not believe that "Southeast Asian refugees are interested in giving something back to Canada" (Beiser, 1999, p. 169). By 2001, the estimated number of Vietnamese immigrants living in Canada was 151,410 and 25,675 of these immigrants made their home in British Columbia (Statistics Canada, 2001 Census). Before coming to Canada, the majority of these immigrants suffered from poor health, disadvantaged economic situations, limited education, and lack of adequate medical care. Data from the U.S. and Australia show that breast cancer and cervical cancer are major contributors to cancer morbidity and mortality among Vietnamese women, especially cervical cancer. Studies have also suggested that Vietnamese women are at risk due to their low participation rate in cancer preventative screening programs. The new Health Goals for British Columbia were developed in 1997 as the result of an extensive public consultation process. The Ministry of Health's mission is "to maintain and improve the health of British Columbians by enhancing quality of life and minimising inequalities in health status" (British Columbia Ministry of Health and Ministry Responsible for Seniors, 1997, p. 5). Equality is a basic social value underlying the Canadian health care system. Equality in health care means that, in principle, all citizens should be given equal access to health care regardless of wealth, race, gender, or ethnic origin (Storch, 1996). However, according to the 1991 BC Royal Commission on Health Care and Cost, there is evidence that immigrants living in British Columbia do not have equal access to health care services. Many health care providers have recognised that immigrants often encounter difficulty accessing health care services and provision. Barriers to access the health care delivery system include limited language skills, different cultural health beliefs and practices, lack of cultural acceptance and appropriate health care services, and lack of social resources (Anderson, 1998; Hirota, 1999; Stephenson, 1995).  Furthermore, ethnic inequality, unequal health care provider-client power relations, restructuring of the health care system with its emphasis on lowering health care costs have been identified as barriers to providing health care services for Asian immigrants. Despite the fact that BC's health care system has changed its services to some extent to accommodate the health care needs of the different ethno-cultural background clients, the BC Provincial Health Officer's 1996 Annual Report of 1995 revealed that "the health care needs of adults and children living in...ethnic neighbourhoods are not being well-served by the current system" (p. 1). Anderson and her colleagues (1993) argue that a significant number of immigrant women had difficulty in their encounters with health care professionals. The women, especially nonEnglish 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 British Columbia  Canada Total population Immigrant population  Vancouver  29,639,035  3,868,875  1,986,965  5,448,480  1,009,820  38,289  18%  26%  38%  151,410  25,675  22,140  0.5%  2.5%  3%  Share of total population Vietnamese population Share of total population  Source: Statistics Canada, Census of Population and Housing BC Stats www.bcstats.gov.bc.ca  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 11 century to the 17 century, the need for more rice-growing th  th  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