‘I do want to ask, but I can’t speak’: a qualitative study of ethnic minority women’s experiences of communicating with primary health care professionals in remote, rural Vietnam

This study utilises a qualitative design, and takes a pragmatist theoretical stance [36]. Specifically, this study is a focused ethnography. As in traditional ethnographic research, the focused ethnographic approach allowed us to centre culture while containing our focus to specific research objectives. In focused ethnography, the field of investigation is determined by pre-existing research questions, which are generally problem-focused and context specific [37, 38]. Data collection is not reliant on long-term participant observation, as in traditional ethnography, with an emphasis on “time intensivity” over “time extensivity,” whereby a large amount of data is produced in a shorter amount of time, followed by an intensive data analysis process [39].

We conducted the study in October 2015 in Tuan Giao District, DBP. Tuan Giao district was chosen in collaboration with provincial and district health officials as being a representative rural district at significant distance from the provincial capital (approximately 80 km). The district is divided into 19 communes, with a total population of approximately 82,000 (Son LD, personal communication, Oct 12, 2017). The basic hierarchical structure of the Vietnamese state health system is illustrated in Fig. 1. In Tuan Giao, each commune has a health station, with the District Hospital (which has surgical capacity) serving as the main referral point for all communes. Services at the commune level are staffed by doctors, nurses, midwives (usually responsible for basic maternity care including ANC and normal delivery), medical assistants and pharmacists. Not all commune health stations had a full-time doctor on staff at the time this study was conducted. Although commune level services provide primary care, preventive services, family planning, and maternity care (including normal delivery), in practice, patients often self-refer to district and provincial level services. There is also a small number of private clinics operating in the area.

Most residents of Tuan Giao are from the Thai ethnic minority group [8], with a smaller population of Hmong, Kinh, Khang, and Kho Mu people. Please note that Thai people are a Vietnamese ethnic minority group, as distinct from Thai people who make up the population of Thailand.

Five communes were selected in cooperation with the District Health Service. These communes were purposively sampled in order to ensure communes with a range of characteristics were included (Table 1).

Women who were currently pregnant, or who had been pregnant in the previous 5 years were eligible to participate in focus groups, and were recruited with the assistance of the VWU at the commune and village level. All participants gave written consent, or gave oral consent after hearing the information in the participant information statement. We provided all participant information and consent forms to participants in Vietnamese, or translated them orally into local languages (Thai and Hmong) if required. All women were compensated 100,000 Vietnamese dong (approximately 4.45 USD at time of data collection) for their time, which the VWU suggested as an appropriate amount. We also conducted semi-structured interviews with health professionals working at the commune health station in each of the five communes; these results are reported separately [40]. Community members were recruited for focus groups without the involvement of health station staff, in order to minimise any perceived or actual coercion. We obtained ethics approval through the University of Sydney Human Research Ethics Committee (Project No. 2015/251), and the research plan was approved and supported by the DBP Public Health Service, the Tuan Giao District Health Service, and the VWU.

We conducted seven focus groups with 37 women who were currently pregnant or had children under 5 years old (see Table 2 for participant characteristics) in five villages. Two focus groups were made up of currently pregnant women (PWFG), three focus groups were made up of mothers of children under 5 years (MU5FG), and two focus groups were mixed (MFG). We purposively sampled for diversity, taking into account ethnicity, language spoken, distance of residence from the District Hospital, parity, and degree of health service utilisation.

We believe the variation of experience present in the data are sufficient to adequately support the reported results and answer the research questions [41].

Focus group discussions were chosen as the data collection method after discussions with local collaborators. Based on previous experience working with ethnic minority communities in DBP, we felt a group environment, where women could share their experiences and interact with their peers without being outnumbered by “outsider” researchers would be more conducive to an open discussion. Focus groups were made up of between 4 and 8 women, and lasted between 43 min and 1 h and 53 min. We conducted six focus groups in the homes of community leaders, and one in a community hall. Discussions were intentionally held away from commune health stations in order to allow women to speak freely about their experiences with health professionals. Each session was made up of several sections: introduction and consent process (written and/or oral as appropriate), warm-up discussion introducing participants and their babies, focus group discussion (see Appendix 1 for topic guide), and a closing demographic questionnaire. The broad topics covered include 1. Women’s experiences of pregnancy and childbirth, 2. Communication and relationship with maternal health care provider, 3. The role of family and community during pregnancy, childbirth and postnatal period, and 4. Access to and utilisation of health station and services. At several groups, older women who lived in the homes where focus groups were being conducted were also present. Although the older women were not generally present in the room for the entire duration of the focus group, some made comments during the discussion and gave consent to have their contributions recorded by researchers. We also held a focus group for older women; these results will be reported separately. Any men who were present were asked to leave the room for the duration of the discussion, on the assumption that the women could speak more freely about issues around pregnancy and childbirth. Focus groups were conducted primarily in Vietnamese, with some interpretation into Thai and Hmong, and were facilitated by a female Vietnamese researcher with a nursing background (DTL), under the supervision of a female Australian PhD student with extensive experience in qualitative research (SM). Interpretation into local languages was performed by local women, including village representatives of the VWU, the People’s Committee, and in one case a village midwife. The village midwife was not an employee of the commune health station. She was elected by the community to receive village midwife training and received a stipend for her work. We audio recorded all focus group discussions and took detailed field notes, which we discussed in regular meetings throughout the data collection period.

An independent third party translated audio recording of the focus groups discussions and transcribed them verbatim in English. We used NVivo 11 Software for Windows [42] to manage the transcribed data. We conducted a thematic analysis according to the following steps: 1. One author (SM) reviewed all transcripts and discussed initial impressions with KM and KF who reviewed a subset of transcripts. 2. SM developed a coding framework by coding data using an iterative approach employing both inductive (data-driven) and deductive (researcher-driven) code development. Codes were developed through an initial open coding process, whereby codes were derived from the raw data. Data was also categorised in light of the research aims and questions that guided the development of the focus group discussion guide. Emerging findings from interviews we conducted with health professionals in the same setting were also considered [40]. 3. SM then refined, grouped and categorised codes, comparing codes and examining them across the data set to develop themes. 4. SM summarised themes and discussed them with all authors [43].

Women reported that health professionals delivered information about pregnancy in a didactic, one-way style, with women acting as passive listeners. The information they recalled was mostly general and non-specific in nature, covering areas such as nutrition, check-ups and foetal development, vaccination, general self-care, and taking iron supplements. For example, regarding nutrition, women said health professionals tell them they need to ‘eat enough’, ‘get enough nutrition,’ and ‘eat from all food groups.’ They rarely mentioned being given specific dietary advice, although some women reported they were told they should eat more protein when they were pregnant.

When I had check-ups, they gave me advice. Eat enough nutrition, take proper rest, keep personal hygiene (Thai, PWFG).

They just told me to walk carefully, eat healthy, that’s all. (Thai, PWFG).

The verbal advice given to ethnic minority women by health professionals was supplemented by the Maternal and Child Health (MCH) Handbook. The MCH handbook was discussed in all focus groups, and most women reported receiving one. Women generally reported a lack of explanation of the health information in the MCH handbook from health professionals. Many women, especially the Thai women (where perhaps there is an expectation of higher literacy levels from health professionals than with Hmong women), described being given the MCH handbook, and told to take it home to read, with little or no explanation.

They just gave me the handbook and told me to read it. They didn’t say much. (Thai, MFG).

This may have been adequate for some ethnic minority women, but others stated that they struggled to understand the information in the MCH handbook, both due to the content itself, and the language and literacy barriers.

They didn’t say anything. They just told me to keep it carefully. [laughs] No I don’t [read the MCH handbook at home] (…) Because I cannot read. (Hmong, MU5FG).

Some women particularly specified that they did not have trouble reading the information in Vietnamese, rather it was the information itself they did not understand, while others were unable to read the MCH handbook at all.

They said they do look through the handbook at home but they cannot read so they don’t understand much of it. (…) Some of them cannot read, others can read but don’t understand the information, so they would ask other people around them. (Hmong, MFG)*.

Women frequently reported asking their husband to read the book for them and pass on the information if they were unable to read. Additionally, some women lacked the time or inclination to read the MCH handbook.

They told me to study it at home. There is information (…) everything is in there, it’s just that I was too lazy to read [laughs] (Thai, PWFG).

She doesn’t have time to read it. She works all day, then prepares dinner, then she wants to sleep. (Hmong, MU5FG)*.

However, women still valued the MCH handbook, although not always for reasons related to its function as a source of health information during pregnancy. Even when they could not fully understand the contents of the handbook, women acknowledged its importance and mentioned keeping it as a health record and reference, and even as a sentimental item for their child to read in the future.

Everything in this pink handbook is important (…) it’s just that I don’t understand much. (Thai, PWFG).

This handbook is very meaningful (…) when your children can read, they’ll see how much you love them and they’ll love you back. (Hmong, MFG).

The minimal detail and non-specific nature of health advice that women described being given to them may lead to women understanding and interpreting health information in a variety of ways in practice, as illustrated by the different perceptions and practices women had around taking iron supplements. Most women who discussed iron supplements had similar perceptions as to why they were prescribed, saying they were necessary when you ‘lack blood,’ to prevent future lack of blood, or for their baby’s health. However, their experiences of communicating with health professionals about iron supplements and how to take them were much more varied. Some women reported general, non-specific instructions like ‘take enough iron,’ and take iron when they ‘lack blood’ (although it is unclear how they would assess this themselves). Others recalled specific, correct instructions about how to take iron supplements. However, women were often unaware that iron should be taken consistently, or were confused about dosage. Some reported they were told to read the MCH handbook for instructions about how to take iron supplements, saying ‘they [health professionals] don’t explain much.’ Women reported inconsistencies between what they remembered being told by health professionals, and what they understood from their MCH handbooks.

They told me to take one pill in the evening. In the handbook, it is suggested to take two or three pills when I lack blood. I asked the doctor and they told me that if I did that I would die [laughs]. (Thai, PWFG).

Several women reported side effects from taking iron supplements. Some women received advice from health professionals to alleviate side effects while others were told they must endure their discomfort as a normal part of pregnancy. Several women reported that they stopped taking iron supplements due to their ‘incompatibility,’ often without telling health professionals. They continued to receive supplements at the health station, although they would not use them. One Hmong woman reported that she began taking her iron supplements again after the village midwife gave her instructions more tailored to her personal preferences.

They told me that there’s no other way, I still have to take the iron for my baby. But I couldn’t. They continued to give me iron but I never took it. I haven’t taken the iron since I started being pregnant. I had constipation. It hurt so much. I couldn’t sit or walk. (Thai, MU5FG).

They told me to take the iron twice a day, each time one pill. But I didn’t take it because I didn’t like the smell. Then [village midwife] came and told me to take just one pill per day, and if I feel nauseous I should take it before sleep at night. (...) Yes I did [take the iron after that]. (Hmong, MU5FG).

Women reported a range of experiences communicating directly with health professionals, and differing levels of ease doing so, which could be influenced by a variety of overlapping factors, including the language spoken by health professionals, health professionals’ gender, women’s literacy skills, and their comfort asking health professionals questions. Women had differing levels of comfort asking questions of health professionals. Hmong women mentioned that while they were comfortable discussing certain topics with male health staff, such as how to care for a sick child, there were other topics that could not be discussed between the genders. These topics were referred to in the group as ‘sensitive issues’ and were centred around women’s bodies (e.g. vaginal birth). This discomfort prevented them from asking questions about childbirth, and discussing safe delivery locations. This gendered communication barrier did not arise in the discussion with the Thai women, although it should be noted that the Thai women who participated had access to numerous female health professionals at their commune health stations.

She has many questions but she cannot ask them because they [health professionals] are male (…) She cannot ask the male staff about those issues so she has to wait till the female staff comes back to work (…) She can ask male staff about how to take care of the baby, but not questions about giving birth (Hmong, MFG)*.

If women had access to health professionals in more informal settings, such as their homes, some preferred to speak to them there, rather than in a formal health setting.

I ask [name] (…) she works at the health station, so if there is anything I don’t understand, I would ask her. [Name] who lives next to my house (…) She answers my questions about anything. I rarely read the handbook, I don’t have time. (Thai, PWFG).

Other women had a general aversion to asking questions of health professionals, even though they said they felt they could ask health professionals questions. They reported they were confident with the language, and they did not feel that health professionals discouraged question-asking. However, they were reluctant or ‘shy’ to ask health professionals about things they did not understand, which adds extra difficulty to a situation where they are required to be proactive.

Yes, I do want to ask but I can’t speak. (…) I can speak Kinh [Vietnamese] okay (…) I’m shy [laughs]. I don’t understand so that’s it. I don’t ask (Thai, PWFG).

This general aversion to question-asking may also be related to perceptions among women that health professionals may be dismissive of their questions and concerns. Several women described going to the health station when they were worried about something, and feeling they were having their concerns dismissed or effectively ignored by health professionals. One Thai woman reported she had bad stomach pain after taking iron supplements, and was worried about how often her baby was kicking her belly, but on telling the doctor her concerns ‘the doctor didn’t say anything.’

The challenges of interpersonal communication with health professionals extended from one-on-one interactions into the community setting. Although community health education was organised and targeted to women, it often appeared to be poorly communicated to women, or held at inconvenient times. Women who worked outside of the home in the fields often left very early in the morning, and sometimes stayed there overnight, and did not know a session had taken place until after the fact.

We didn’t know. When we came home, they said they did a communication session. We don’t know if they invited us or not but they said we weren’t home. (Hmong, MFG).

I have never been invited (Thai, PWFG).

Women who did attend community sessions reported that health professionals ran out of time to answer questions, adding extra barriers for women who wished to learn more. Time was also a barrier to communication during routine visits to the commune health station.

At the end of the session, the health staff said they ran out of time. If I don’t understand something, I could attend the next session or go to the health station to ask health staff there. (Hmong, MFG).

When I go to the health station, the health staff are always busy, there are so many patients, so many people need them. If I ask them, they wouldn’t have time for other people. (Thai, PWFG).