Kwok & Sullivan: Health Seeking behaviours among Chinese-Australian health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine Copyright © 2007 SAGE Publications (Los Angeles, London, New Delhi and Singapore) DOI: 10.1177/1363459307077552 Vol 11(3): 401 – 415
Health seeking behaviours among Chinese-Australian women: implications for health promotion programmes Cannas Kwok & Gerard Sullivan University of Sydney, Australia
a b s t r a c t Preventive medicine is an important element of the Australian health care system. An essential aspect of the biomedical model of health care is screening for the early detection of disease in otherwise asymptomatic people. There is ample evidence that acceptance levels of western medicine vary and that a variety of health epistemologies and health practices coexist. To examine the extent to which Chinese-Australian women integrate western medicine practices in their health seeking behaviour, a qualitative study was conducted, which involved in-depth interviews in Cantonese with 20 women. Although adherence to western health beliefs and practices varied, in general these Chinese-Australian women sought medical help only after they felt unwell. Commonly, they first tried traditional remedies for minor diseases. Many saw no reason to participate in screening when they were asymptomatic. Direct communication with health care providers who speak the same language appears to be important to many Chinese-Australian women when seeking health care services. It is recommended that ethnic health workers should participate in screening programmes and other health promotion activities. keywords
Chinese; health promotion; health seeking behaviours
a d d r e s s Cannas Kwok RN, PhD, Faculty of Nursing and Midwifery, University of Sydney, Sydney, NSW 2006, Australia. [Tel: +61 2 93510804; fax: +61 2 93510779; e-mail:
[email protected]] a c k n o w l e d g e m e n t This study was supported in part by a grant from the NSW Nurses Registration Board.
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Introduction Western medicine, based on the biomedical model, has become dominant in many parts of the world over the last two centuries. In the late 19th century and during most of the 20th century, the predominant model was that of curative medicine, which focuses on medical professionals and institutions such as hospitals. This model is still influential, but the development of a new paradigm, surveillance medicine, in the late 20th century, has dramatically changed conceptions of health and illness (Nettleton and Burrows, 1994; Armstrong, 1995). Surveillance medicine switches the focus of medicine from the sick to the seemingly healthy population and targets everyone in society with recommendations about healthy lifestyles and taking preventive measures before symptoms appear (Armstrong, 1995). Preventive medicine is widely diffused in western societies and has become a goal of public health. It involves the use of medical procedures to treat diseases early in their development in order to improve outcomes (Bunton and Macdonald, 2002). Consequently, many health professionals encourage people to believe that although they feel well, they may be ill: for example, cancers may be developing in their bodies, or their bones may be degenerating, leading to osteoporosis. Therefore, health screening tests have become part of our lives as we seek to protect our health (Armstrong, 1995). In this article, the combination of curative, surveillance and preventive medicine based on biomedical science is referred to as western medicine. Mammographic screening is a good example of preventive medicine and has now taken on considerable importance as a public health measure (Plotkin, 1996). Asymptomatic women aged over 50 are highly recommended to have mammograms regularly. Nevertheless, women from many ethnic minorities, including Chinese women, are less likely to attend mammographic screenings than their western counterparts (Borrayo and Jenkins, 2001; Sadler et al., 2001; Jackson et al., 2003; Yu et al., 2003). In Australia, women from non-English-speaking backgrounds have markedly lower screening rates (48.9%) than Australian-born women (58.5%) (Australian Institute of Health and Welfare, 2003). However, data examining all types of breast examinations (breast self-examination, clinical breast examination and mammography) show that women of Chinese ancestry in particular, were 50 per cent less likely to have breast examinations, which is the lowest of all ethnic groups (Dollis et al., 1993). Helman (1990) suggests that cultural background has an important influence on many aspects of people’s lives, including their beliefs, behaviour, perceptions, emotions and attitudes to illness – all of which may have important implications for health and health care. Lupton (2003) argues that the ways in which lay people deal with health, illness or disease; how they feel about their body; their relationship with medical professionals; and their experience with health care services are aspects of the medical encounters that have been underexplored. Many health professionals take 402
Kwok & Sullivan: Chinese-Australian womens' health seeking behaviours it for granted that all share the same health beliefs, which are consistent with their own. However, in multicultural societies, a variety of health beliefs and practices co-exist. The health beliefs and practices of many people of Chinese ancestry (and others) draw on Chinese medicine, which has been practised for more than 3000 years (Hoizey, 1993). The philosophies of Confucianism, Taoism and Buddhism, and the theories of Yin/Yang and the ‘five elements’ are foundational to concepts of health and illness, health promotion and health seeking behaviour. Based on these philosophies, notions of balance and harmony are central to the concept of health and illness, and health seeking behaviour (Wang and Wu, 1973; Hoizey, 1993). In contrast, many Chinese view western medicine as strong and quickly effective, but potentially harmful to the body because of the side-effects of surgery or drugs. This view may be attributed to adherence to the Confucian doctrine of ‘chungyung’ (everything in moderation). In contrast, western medicine is seen as aggressive and less able than Chinese medicine to synchronize with the body’s natural way of re-attaining equilibrium, which can be effected through the use of acupuncture, herbs or qi gong. Chinese medicine operates from the premise of mobilizing energy from within the body to regain harmony (Lam, 2001). In parallel to the concepts of balance and harmony, Chinese approaches to treatment typically include non-invasive and natural remedies such as herbal medicine, in contrast to western approaches, which use more invasive or chemically based therapies such as surgery or drugs, and which often have harmful or unpleasant side-effects (Hoizey, 1993; Lam, 2001). Many Chinese, including those who live in western countries are strongly influenced by traditional Chinese culture and values, and seek healers such as herbalists and acupuncturists to treat illness before considering western therapeutic approaches (Wong et al., 1998). Many Australian health promotion programmes cater for a culturally and linguistically diverse clientele1 to some degree, but often this is limited to simple translation of brochures and information, with the occasional involvement of interpreters (Minas, 1996; WSAHPC, 1998). Printed material is usually available in the five most common community languages: English; Arabic; Chinese; Greek; and Italian. Some material is translated more widely. These measures, however, may be inadequate to encourage people from non-English-speaking backgrounds to access health services2 (e.g. Kwok et al., 2005). This article examines the extent to which older women of Chinese ancestry participate in health screening programmes, and the reasons for their behaviour.
Methods A social constructionist theoretical approach (Burr, 2003) was used in conjunction with qualitative methodology using in-depth interviews 403
health: 11(3) (Minichiello et al., 2004) to arrive at an understanding of the ChineseAustralian women’s views and behaviours in relation to health. A strength of this approach is that it allows researchers to understand the meaning of experiences from the perspective of participants in the research, and to learn about their worldview.
Sample The criteria for selecting the sample were women aged 50–69 years who were currently in good health. A purposive sample of 20 Chinese-Australian women was recruited through personal networks and by snowball sampling techniques. This number was considered adequate for the purposes of an exploratory study such as this one. A number of Chinese organizations such as a church, community centres and a seniors’ club were consulted to obtain the names of potential informants. They were first contacted by a liaison officer in each organization for a verbal agreement on participation in this study. Of the 20 informants, 12 were successfully recruited using this method. The remaining eight were introduced by informants and friends. All of the informants were immigrants from Hong Kong. Their length of stay in Australia varied from 3.5 years to 14 years. Almost all were married or had been married, had children and were living together with family members. More than half the sample had little formal education. This is not surprising, given that the average age of the group was 60. Chinese who grew up during times of war or social disruption tend to be less well educated as it was not then a priority, especially for girls. Informants’ educational level was positively correlated with English proficiency. However, the majority either did not speak English, or spoke very little English. Most of the informants were Buddhists; some were not religious, while two were Christians. Many informants had no employment history in Australia. Only two worked fulltime, while four were part-time workers. Of the 20 women interviewed, one-third reported initiating routine health screenings within the last year. Six had completed a breast self-examination but none did it regularly. Three of the 20 (excluding the six who had conducted a breast self-exam) had had a clinical breast examination that was for diagnostic purposes rather than prevention. Eight had undergone at least one mammogram. Of these, five had refused any more. Similar patterns applied to Pap smears and dental check-ups. Only eight reported ever having a Pap smear and two had ever had a dental check-up (see Table 1).
Data collection This study was approved by the Human Research Ethics Committee of the University of Sydney. An interview guide that contained closed-ended and open-ended questions was developed. The first, more structured part of the interview, collected informants’ demographic and factual data. The second part was largely unstructured, guided by only a few general questions to focus the discussion on informants’ health seeking behaviours and how these 404
Kwok & Sullivan: Chinese-Australian womens' health seeking behaviours Table 1 Preventive measures used by the 20 Chinese-Australian women participants Age
Mrs Wong Mrs Lee Mrs Tse Mrs Chau Mrs Chan Mrs Leung Mrs Po Mrs Young Mrs Yip MrsTse Mrs Kong Mrs Ng Mrs Chu Mrs Au Mrs Yu Mrs Ho Mrs Li Mrs Lee Ms Fung Ms Koo
65 58 63 54 51 60 55 52 58 60 56 63 68 55 62 59 69 59 63 60
Dental check-up
Pap smear BSE
CBE
Mammogram
3 3
3
3 3
3
3 3 3
3 3
3 3 3
3
3 3
3 3
3
3 3
3 3 3
3 3
Note: BSE = breast self-examination; CBE = clinical breast examination.
behaviours related to health screening, for example ‘What is your opinion about breast cancer screening?’ and ‘What do you do when you feel unwell?’ Interview questions were designed with reference to the existing literature on the topic, and were revised and modified as the research evolved. Twenty individual in-depth interviews were conducted in informants’ homes and, with their consent, were tape-recorded. Each interview took between 45 and 90 minutes. All interviews were conducted by the first-named author who is a Hong Kong Chinese immigrant to Australia, and shared language and cultural background with informants. This proved to be very helpful in establishing rapport so that the informants openly shared their stories and point of views. Even though some informants were fluent in English, all interviews were conducted in Cantonese, which proved to be the language in which informants felt best able to express themselves freely.
Data analysis The data were translated and transcribed into English for data analysis. The translated interviews were analysed line-by-line and labelled with codes for analysis according to the principles and procedures enumerated in Browne and Sullivan (1999). The authors reviewed translated interview transcripts. We constantly compared and contrasted our interpretations in order to minimize bias; to ensure categories and concepts were mutually exclusive; 405
health: 11(3) and to see how identified analysis categories clustered or connected. Disagreement was resolved by repeated textual reference and discussion. A case summary was written after each interview. These case summaries were categorized according to informants’ age, length of stay in Australia and experience in screening services. We also sorted the data into matrix tables. Data analysis began after the first interviews were conducted and continued until conceptually dense categories were derived from the data, consistent with the process recommended by Strauss and Corbin (1998). Thematic content analysis techniques as described Miles and Huberman (1994) were employed. Pseudonyms are used in this report to protect the privacy of informants.
Findings The findings reported in this article focus on the women’s perception of western medicine and their health seeking behaviours, especially in relation to screening practices.
Perceptions and use of western medicine The Chinese-Australian women interviewed in this study varied widely in their acceptance of western medicine. Some exclusively used Chinese medicine while others accepted western medicine. The majority believed that both Chinese medicine and western medicine have strengths and weaknesses, neither being perfect. Almost all the women who had not participated in screening valued Chinese medicine over western health care. They suggested that the power of western medicine has been exaggerated and thought that practitioners of western medicine are overly aggressive in their use of medical tests, antibiotics and surgery to treat illness. The failures of practitioners of western medicine were also a matter for comment. The opinion of Mrs Yu, a 62year-old woman who had been in Australia for nine years, was typical in this regard: Last time I had a severe abdominal pain I went to see a doctor. He did not give me any medication but just asked me to go for a blood test and wait for an ultrasound. As he was unable to tell anything from the ultrasound result, he asked me to have a CT scan. I find it too ridiculous. You just go for those damned tests one after the other. Western doctors know nothing about our bodies. That’s western medicine.
An even more extreme comment was made by Mrs Koo, a 60-year-old woman: The other day when I went to see a doctor for dizziness. She recommended me for cancer screening [mammography]. I was so angry because I felt she was cursing me to have cancer. I couldn’t believe it at all. I decided not to go back to her ever.
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Kwok & Sullivan: Chinese-Australian womens' health seeking behaviours Some of the women interviewed were negative about the way practitioners of western medicine treat the body as a machine that could be repaired, part by part. They regarded western medicine as not being holistic in the same way as Chinese medicine. Some women pointed to what they saw as fundamental differences between Chinese and western medicine. To quote some of our informants: Western doctors are always exaggerating the power of antibiotics. No matter what the disease is, the first choice is always antibiotics. I find it too strong for me. After taking an antibiotic, I always feel sleepy and even can’t wake up or open my eyes. You know, they are too strong. (Mrs Tse, 63, who refused to participate in mammographic screening) Chinese medicine works well with our bodies. It doesn’t have the side-effects of western pills. (Mrs Kong, a 56-year-old woman who worked as a nurse assistant in a hospital)
About half of the informants believed that the western approach to health care was much better than Chinese medicine. Not surprisingly, most of these were participants in screening. They were more appreciative of medical technology. They believed that people are now enjoying longevity partly because of it. Such appreciation made them more willing to present for screening. Typical positive comments about western medicine were: Forty to 50 years ago, lots of people died from tuberculosis. Tuberculosis at that time was just like cancer today. But now it can be diagnosed accurately by x-rays and also treated effectively by TB drugs. I believe that cancer will be brought under control sooner or later by advanced medicine. We now have cancer screening. (Mrs Chan, 51, who has undergone mammography once) I believe western medicine is better than Chinese medicine because a western body check-up can detect health problems at an early stage. My cholesterol level is a bit higher than normal. Having regular blood tests can let me know what happens inside and make it possible for me to take precautions. (Mrs Li, 69, who had participated in mammography) I don’t trust Chinese medicine because it is not well documented. Western doctors are registered under a system but Chinese doctors are not. Anybody can claim to be a Chinese doctor. Most of them are really ‘yellow green doctors’ (doctors who claim to be qualified but have no proper medical knowledge). Western medicine has very clear guidelines for dosage, but Chinese medicine has none. Chinese doctors can give you any amount of anything. (Mrs Chau, 54, who was a screening participant)
When analysing the interviews, we discovered that variation in acceptance of western medicine among informants appeared to be associated with their past experience in Hong Kong, a city where both Chinese and western medicine is practised. We found that those who expressed acceptance of western medicine had more positive experiences with it while living in Hong Kong than those who did not accept it. The experiences of the former 407
health: 11(3) led them to accept concepts implicit in western medicine such as secondary preventive intervention. However, it was also clear that a significant proportion of our informants did not value western medicine the way many health professionals presume is the case.
Health seeking behaviours The findings revealed that many of the Chinese-Australian women interviewed in this study integrated into their daily lives health measures learned in childhood, such as eating specific foods to keep yin and yang forces in balance. These behaviours are part of inherited culture and accordingly are automatic and not necessarily conscious. In general, the women took health for granted when they were ‘feeling normal’. Only when many of the women felt unwell would they consciously pay attention to their health. In response to the question ‘What do you mean by feeling unwell?’ most of them answered in terms of symptoms or the dysfunction of an organ. They spoke of having blurry eyes, headaches, abdominal pain, a sore throat, stomach-ache, dizziness, weakness, poor appetite and insomnia. Based on these symptoms, they recognized that they were sick and then sought medical help. For example, in regard to breast cancer, all informants who had not had a mammogram believed symptoms of some sort would occur if breast cancer developed. In parallel to their health seeking behaviours, only pain, lumps or discharge earned their attention to their breasts and prompted them to act differently. Typical comments were: If you find something wrong, you should go for it [mammogram]. (Mrs Li, a traditional Chinese-Australian woman in her late 60s) Yes, of course, I would go and check it out if I feel something wrong. Otherwise, a normal person would not bother [going for a screening test]. (Mrs Tse, a 63year-old woman)
This finding is consistent with the women’s use of dental services. Almost all of the women had been to a dentist for treatment of dental problems, but only two of them had ever had a dental check-up. Another characteristic of these women’s health seeking behaviour was the mixed cultural approach to searches for cures. Traditional Chinese remedies were usually tried first for illnesses they perceived as minor. In response to the question ‘What would you do if you feel unwell?’ more than half said they preferred trying self-remedies first. They would only make a decision on whether to see a practitioner of western medicine after admitting that their condition was not improving. Ms Young, a 52-year-old woman who was working as a hospital nurse, commented: It depends on how unwell I am and what the problem is. Well, I believe for some minor problems like headache and abdominal pain, we can use traditional remedies. If they don’t work well, I’d go to see a doctor [of western medicine].
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Kwok & Sullivan: Chinese-Australian womens' health seeking behaviours As explained by Mrs Kong, a 56-year-old woman with 10 years of formal education, when she felt unwell: ‘I often use traditional remedies first and then seek western remedies.’ Examples of these remedies are herbal oil for headaches or dizziness, or ‘Po Chai pills’ for vomiting or abdominal pain. Even those few Chinese-Australian women who preferred seeking advice from a practitioner of western medicine soon after they felt ill were more concerned with relief from the symptoms that interfered with their normal daily activities. They believed that consulting practitioners of western medicine is more appropriate for acute illness like fever, influenza and infections. However, while they believed that western medicine is good for symptom relief, most considered that it is less effective in eliminating the ‘root’ cause of the disease. A typical comment was: ‘For symptoms like fever, running nose and infections, I would prefer western medicine because it acts quicker than Chinese herbs. Nevertheless, I would see a Chinese herbalist for treatment of the “root” of the disease’ (Mrs Wong, a 66-year-old woman).
Images of practitioners of western medicine Another finding that helps explain why some Chinese-Australian women are reluctant to use western medicine is that they associate it with western medical practitioners, with whom they often had difficulty communicating. They felt that the patient management skills of western medical practitioners often lacked cultural sensitivity. In their view, these medical practitioners do not understand Chinese culture, and do not appear to take the feelings of Chinese patients into account. Even those informants who had faith in western medicine preferred to consult Cantonese-speaking practitioners of western medicine. Many of the women who had not participated in health screening believed that Caucasians are more susceptible to particular diseases while Chinese are more susceptible to others. Mrs Li, a traditional Chinese woman who has been in Australia for 14 years, made a typical comment in this regard: We are different in terms of susceptibility to diseases. I believe our health problems are different too. They have their own diseases. They are more likely to get heart disease because of their body size. We have more stomach cancer because we eat more salted fish. See the difference? If you’re not from the same culture as us, you would find it difficult to understand our health problems.
Regardless of their English proficiency, the majority of women interviewed in this study said that they felt more comfortable with asking questions and talking about their illness and treatments to someone who shared the same cultural heritage and preferably who spoke their native language. In the words of two of our informants: How can I tell them about my sickness? They won’t understand. I don’t bother to communicate with him [English-speaking practitioner of western medicine who is not of Chinese ancestry]. It is just like ‘a chicken talking to a duck’. (Mrs Ng, a 63-year-old with poor English skills)
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health: 11(3) Even though I have no problem with speaking their language, I still prefer seeing a doctor who [is of Chinese ancestry and] can speak Cantonese. I feel they would be more sensitive to my health problem. (Ms Young, 52)
One of the women who spoke no English told of her experience with an English-speaking western medical practitioner: When I had a bowel problem, I was referred to an English-speaking specialist [not of Chinese ancestry]. My son told me he was very famous in this area. I was a bit hesitant at first as I knew I would not be able to communicate with him. But I had no choice as I needed his help. Even though my son was going with me and he spoke with the doctor for me, I would still have preferred a doctor to whom I can speak in my own language [and who shared my cultural heritage]. (Mrs Chu, 68, has been in Australia for 14 years)
Discussion Despite the dominance of the biomedical model of health care in Australia and the promotion of health screening, there is ample evidence that a variety of health epistemologies, health practices and levels of acceptance of western medicine co–exist. Lay people (and particularly those from nonwestern cultural backgrounds) may not fully subscribe to western medical practice. This appears to be especially true for older people of Chinese ancestry who are much more likely to subscribe to Chinese medicine and to resort to traditional approaches to illness management. These people are generally less willing, or even refuse, to accept screening, mainly because they believe that the power of western medicine is exaggerated. The findings of this study are consistent with Lupton (1995) who argued that health promotion programmes often neglect a range of cultural beliefs that may play a role in health behaviour. Many immigrants in western societies hold beliefs that are different from those prevalent in the dominant culture. For many, the notion of ‘screening’ or early detection is unfamiliar. Health behaviour is subject to the influence of beliefs about health and disease (including causes, effective treatments and even recognition or identification of illness). Such interpretations and understandings are not necessarily determined or changed by medical knowledge. Some women in our study were aware of epidemiological findings related to particular diseases but had inconsistent personal experiences (e.g. they knew that research indicated that smoking is related to cancers and cardio-vascular diseases, but recalled a relative who smoked heavily and lived a long life). Others may regard their racial group or themselves as exceptional and therefore not represented in research findings. The women in our study (and we posit, people in general) did not necessarily see these beliefs as contradictory and in need of resolution. The beliefs may co–exist and be drawn upon in different circumstances. This is
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Kwok & Sullivan: Chinese-Australian womens' health seeking behaviours important because most health promotion programmes rely on a single, rational (scientific) belief system and presume that lay people will subscribe to it and modify their behaviour accordingly. This presumption and lack of recognition of alternative beliefs may be the basis of flaws in the effectiveness of health promotion programmes. It is important to recognize that women from non-western cultures may have different perceptions and use-levels of western medicine, which are affected by social and environmental factors, and also by personal experience and culture. This study suggests that many Chinese-Australian women tend to be crisis-oriented in their use of western medicine. This finding explains the results obtained in other studies which report that it is not uncommon for people of Chinese ancestry to under-use preventive health care services in western countries, including Australia (Chan and Quine, 1997), the USA (Watt et al., 1993; Ma, 2000) and the United Kingdom (Kwan and Bedody, 2000). Many people in the Chinese-Australian community continue to adhere to traditional Chinese health practices and health seeking behaviours that differ from those of the mainstream western medical paradigm. Traditional health seeking behaviours may significantly affect women’s attitudes towards health screening. Herein may lie the explanation for the much observed pattern of low participation in mammography by women of Chinese ancestry (e.g. McAllister and Bowling, 1993 in England; Jackson et al., 2003 in Canada; Yu et al., 2003 in the USA). Evidence for this conclusion includes comments by the women in this study that only pain, lumps or discharge would earn their attention to their breasts and prompt them to seek medical advice. Consistent with this attitude to health care, only two had ever had dental check-ups. Health beliefs and behaviour may change after immigration (Reid and Trompf, 1990; Rice, 1999). However, we found that despite their exposure to western culture, where the biomedical model of health care is dominant, many Chinese-Australian women seek help from western medicine only after their own attempts to treat the illness had failed. In this regard, our findings are consistent with those of Tang and Easthope (2000). Among the 20 Chinese-Australian women interviewed in this study, four were health professionals (nurses and allied health workers) whose training was based on the biomedical model. Although one might expect them to prefer western medicine for illness management, they resorted to the same practices as other Chinese women to treat minor illnesses. Their adherence to these practices is probably due to the persistence of traditions, or beliefs and practices passed from one generation to the next. Regardless of their length of stay in Australia or level of educational attainment, our informants appeared to share similar health seeking behaviours with their counterparts in Hong Kong (Koo, 1987) and in the USA (Ma, 1999, 2000). If going to see a practitioner of western medicine is not the first choice even when feeling sick, it is not surprising that it is difficult to persuade 411
health: 11(3) women of Chinese ancestry to seek advice from practitioners of western medicine when they do not feel ill. For these women, there appeared to be a tradition that they see a medical practitioner only when there is a specific problem, rather than for prevention of health problems. While health promotion and the practice of surveillance medicine are central to modern health care, for our informants the role of a practitioner of western medicine as someone who looks after the sick has not changed. Research literature indicates that medical practitioners’ recommendations strongly motivate western women to present for cancer screening tests (Fox and Stein, 1991; Fox et al., 1991; Beaulieu et al., 1996). This, however, may be counterproductive for some Chinese-Australian women. Our research indicates that some informants believe that many practitioners of western medicine are overly aggressive in their use of medical tests. Women holding these attitudes are less likely to accept a practitioner of western medicine’s recommendation to undergo a screening test while they have no evidence of illness. At least one informant even interpreted this recommendation as a curse rather than a preventive health measure. Further research is needed to investigate the effect of recommendations by practitioners of western medicine on Chinese-Australian women. In the biomedical model, biological differences among individuals are generally not seen to be fundamental and most diseases can be attributed to particular causes, which exclude race or ethnicity. However, the findings of this study indicate that lay people may have their own explanations of what causes disease, and these explanations may be culturally derived rather than based on scientific medical knowledge. This study supports Helman’s (1990) view that cultural background has an important influence on people’s health beliefs and health-related behaviour. Lupton (1995) further argues that the current health promotion paradigm, based on the biomedical model, often fails to take people’s health beliefs into account but that these have important implications for designing and implementing health promotion programmes, and particularly those oriented towards ethnic communities. Importantly, we found that many Chinese-Australian women are likely to be highly influenced by the ethnicity and language spoken by their medical practitioners. A sympathetic understanding between practitioner and patient is important in establishing trust, which in turn appears to be an important factor in patient compliance with medical advice. This result provides a clue to measures that may be effective in increasing participation in Chinese women’s participation in health screening programmes. A substantial proportion of Chinese-Australian women appear to prefer health care service providers with whom they are able to communicate in their own language, and whom they feel understand their cultural attributes, including beliefs. These women are unlikely to find interpreters very helpful. What is required is a practitioner who they trust. Using literal word-by-word translations into Chinese or other languages of health promotion materials is unlikely to be effective in increasing participation. More than interpreters, 412
Kwok & Sullivan: Chinese-Australian womens' health seeking behaviours the involvement of bilingual health workers is likely to make participation in health promotion and screening programmes more attractive to ChineseAustralian women.
Notes 1. Australia is a multicultural society. Approximately 28 per cent of the population of 20 million were born overseas, and a further 25 per cent have at least one parent born abroad. About 4 per cent of the population is of Chinese ancestry. The policy of cultural pluralism adopted by Australian governments from the 1970s is widely known as multiculturalism. A central tenet of multiculturalism is non-discrimination on the basis of ethnicity, which has an effect on the provision of community services to ensure access and equity (Kerkyasharian, 1998; Jupp, 2001; Jayasuriya, 2003). 2. The biomedical model predominates in the Australian health care system, which has much in common with those of other western countries in terms of its emphasis on scientific medical knowledge. Independent medical practitioners provide most community health care, which is heavily subsidized by the national health benefit system, known as Medicare. In most cases, public hospitals provide care for essential services without charge. Public health services provide advice about health promotion (Commonwealth Department of Health and Aged Care, 2000; Dixon and Mossialos, 2002). A range of complementary and alternative health care services (e.g. naturopaths, chiropractors and Chinese Medicine practitioners) is also available in Australian cities. In most cases, the Medicare system does not cover these services, but private health insurance companies may (Duckett, 2004).
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Author biographies c a n n a s k w o k is a post-doctoral fellow in the Faculty of Nursing & Midwifery, University of Sydney. Her primary research interest is ethnicity and women’s health. She is currently investigating breast cancer screening behaviours and breast cancer surviourship in Chinese community. g e r a r d s u l l i v a n is an associate professor at the University of Sydney, Australia. His research interests include comparative sociology, gay and lesbian studies, and equity in the provision of health, education and social services.
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