Communication and Health Literacy in Dien Bien Province, Vietnam: Experiences and Perceptions of Primary Health Care Professionals and Ethnic Minority Women
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Communication and health literacy in Dien Bien Province, Vietnam: experiences and perceptions of primary health care professionals and ethnic minority women Shannon Kathleen McKinn, BIntSt, MIPH Sydney School of Public Health, Faculty of Medicine and Health University of Sydney A thesis submitted in fulfilment of the requirements for the Degree of Doctor of Philosophy September 2018 i Declaration The work presented in this thesis is, to the best of my knowledge and belief, original except as acknowledged in the text. I hereby declare that I have not submitted this material, either in full or in part, for a degree at this or any other institution. Shannon McKinn 28 September, 2018 ii Abstract Background: Patient‐centred care is care that is respectful of and responsive to individual patient preferences, needs, and values, and ensures that patient values guide all clinical decisions. It is a generally recognised element of high quality health care. A key component of patient‐centred care is patient‐centred communication and information provision, which are especially vital in resource‐poor settings where people may have little recourse for sourcing accurate health information. An important element of improving patient‐centred communication in these settings is improving health literacy. However, there has been little research about patient‐ centred communication and health literacy in low and middle‐income countries, such as Vietnam. Vietnam has made impressive progress over the past few decades in improving maternal and child health, but significant and continuing inequities in health outcomes persists. Ethnic minorities experience maternal, infant, and child mortality at higher rates than the population as a whole, and are less likely to access antenatal care and to give birth in a health facility. Dien Bien Province, a remote, rural province, has a majority ethnic minority population, and is one of the poorest provinces in the country. Low health literacy and poor communication between health care professionals and ethnic minority patients are concerns for the Provincial Health Service, which has previously collaborated with the University of Sydney to deliver maternal and child health workshops in the province. Aims: The aim of this thesis is to investigate the communication experiences, and the factors underlying communication, between ethnic minority women with limited health literacy and primary health care professionals in the maternal health setting in iii Dien Bien Province, Vietnam. Paper 1 (Chapter 3) investigates how ethnic minority women utilise maternal health services, and the factors that influence their decisions to seek and not seek skilled health care during pregnancy and childbirth. Papers 2 (Chapter 4) and 3 (Chapter 5) explore the perceptions and experiences of primary health care professionals and ethnic minority women around patient‐provider interaction and consider the factors that influence patient‐provider communication. Paper 4 (Chapter 6) examines the nature of maternal and collective health literacy in ethnic minority communities and explores how ethnic minority women understand and use health information in order to care for and make health decisions for themselves and their children. Methods: This is a qualitative study, using a focused ethnography methodology. Data was collected in five communes of Tuan Giao District in Dien Bien Province. Data was generated from in‐depth interviews with 22 primary health care professionals and two key informants, and focus group discussions with 42 ethnic minority women (pregnant women and mothers and grandmothers of children under five years old). Data was analysed using thematic analysis methods, including Framework Analysis. Key findings: Paper 1 found that primary health services were technically available and accessible to ethnic minority women, however these services were likely to be underutilised, particularly during childbirth, because of community and health professionals’ perceptions of those services as being of low quality. Paper 2 showed that while health professionals saw communication as an important part of their role, their overall perception of communication was as a one‐way path for delivering health information, and they rarely acknowledged the interactive nature of communication. iv They perceived communication problems to be due to patient factors, rather than reflecting on the suitability of the information being delivered, or their own abilities as communicators, placing the burden for improving communication on patients. Paper 3 found that ethnic minority women experienced communication with health professionals as didactic and paternalistic, with health professionals often relying on written information over interpersonal communication. The women faced challenges when interacting with health professionals, and interpreted health information in diverse ways. Paper 4 utilised the concept of distributed health literacy to describe the nature of maternal health literacy in Dien Bien Province. The findings aligned with the four areas of distributed health literacy, with ethnic minority women drawing on family and social networks to share knowledge and understanding, assess and evaluate information, communicate with health professionals, and support decision‐making. This paper also extended the distributed health literacy model to consider how family and social networks were involved in non‐supportive decision‐making, which was not aligned with women’s preferences and had the potential to impact negatively on women and children’s health. Chapter 7 draws the findings of the four papers together using the PEN‐3 model, a culture‐centred health promotion framework, in order to make recommendations for future health literacy and communication interventions in Dien Bien Province. Conclusion: This thesis adds new knowledge to the limited amount of research exploring health literacy and patient‐centred communication in low and middle‐ income countries, and in Vietnam specifically. This research provides an in‐depth exploration of the experiences and perceptions of ethnic minority women and health v professionals, and applies a health literacy lens to thinking about how these groups communicate with each other, and how communication can be improved. Three main areas for improvement were identified. Firstly, communication is perceived as important by health professionals, although it is often paternalistic in practice. A health literacy approach to communication training for both health professionals and community members, focused on oral communication and the verbal exchange, can complement written information that is already being utilised. Secondly, the physical and social infrastructure for community‐based health communication and health literacy strengthening activities already exists, however consultation with communities, particularly women, about the content, delivery, and timing of these activities could be improved to increase the effectiveness of community‐based health communication. Thirdly, family and social networks of ethnic minority women should be more involved in health communication and health literacy strengthening activities in order to enhance distributed health literacy within families and communities. The dominant health professional‐centred communication style does not provide ethnic minority women with opportunities to become better informed about their health and the health of their children. However, there is evidence to suggest that patient‐centred approaches to communication can be successfully implemented in Vietnam, and that patients often do not conform to cultural stereotypes suggesting that they prefer to be passive in their interactions with health professionals. Adopting more patient‐centred approaches to health communication with women from diverse ethnic backgrounds in Vietnam could help to increase the use of maternal health services and reduce inequities in maternal health outcomes. vi List of Included Publications The publications which comprise this thesis are listed below: 1. McKinn S, Duong TL, Foster K, McCaffery K. A qualitative analysis of factors that influence ethnic minority women in Vietnam to (not) seek maternal health care. BMC Pregnancy and Childbirth, under review. 2. McKinn S, Duong TL, Foster K, McCaffery K. Communication between health workers and ethnic minorities in Vietnam. Health Literacy Research and Practice 2017; 1(4): e163‐72. doi: 10.3928/24748307‐20170629‐01 3. McKinn S, Duong TL, Foster K, McCaffery K. ‘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. International Journal for Equity in Health 2017; 16:190. doi: 10.1186/s12939‐017‐0687‐7 4. McKinn S, Duong TL, Foster K, McCaffery K. Distributed health literacy in the maternal health context in Vietnam. Health Literacy Research and Practice 2019;3(1):e31‐e42. doi: 10.3928/24748307‐20190102‐01 vii Author’s Attribution Statement I, Shannon McKinn (SM), carried out this work between October 2014 and September 2018 at The University of Sydney’s School of Public Health. I was responsible for coordinating this research, and the four papers presented in this thesis, under the guidance of my primary supervisor Professor Kirsten McCaffery (KM) and associate supervisor Professor Kirsty Foster (KF). Miss Duong Thuy Linh (DTL) also contributed to this work. The research was conducted with the support of the