Perceptions of Oral Illness Among Chinese Immigrants in Montreal: A Qualitative Study� Mei Dong, D.D.S., M.Sc.; Christine Loignon, Ph.D.; Alissa Levine, Ph.D.; Christophe Bedos, D.D.S., Ph.D. Abstract: Providing culturally competent care has been a growing concern for health care professionals in recent years. Being culturally competent means taking into account the culture of patients in order to provide high-quality services. Accordingly, the objective of this study was to better understand how oral illness was perceived by the largest visible minority group in Canada: Chinese immigrants. We conducted qualitative research based on in-depth interviews with twelve Chinese immigrants in Montreal, Canada. The participants had a high level of education and had lived in Canada for thirteen years or less. The interviews were transcribed, and thematic analyses were then performed. Among the participants, traditional beliefs coexisted with scientific dental knowledge. On the one hand, the subjects had a fairly good understanding of dental caries in terms of etiology, process, prevention, and treatment. On the other hand, they held strong traditional beliefs concerning gingival swelling and bleeding, which had an influence on their attitudes toward dental care and professional services. Oral health care professionals should be informed about Chinese immigrants’ oral health beliefs and the acculturation process in order to understand their patients better and provide culturally competent care. Dr. Dong is a graduate student, Faculty of Dentistry, McGill University; Dr. Loignon is a postdoctoral student, Faculty of Dentistry, McGill University; Dr. Levine is a research associate, Faculty of Dentistry, McGill University; and Dr. Bedos is Associate Professor, Faculty of Dentistry, McGill University and Adjunct Professor, Faculty of Medicine, Université de Montréal. Direct correspondence and requests for reprints to Dr. Christophe Bedos, Division of Oral Health and Society, Faculty of Dentistry, Strathcona Building (238F), McGill University, 3640 University Street, Montreal, Quebec, ���������������� Canada H3A 2B2; �������������� 514-398-7203, ext. 0129 phone; ��������������������������������������������� 514-398-8242��������������������������������� fax;
[email protected]. ��������������������������� Key words: oral health beliefs, traditional medicine, oral diseases, Chinese immigrants, Canada Submitted for publication 3/19/07; accepted 8/6/07
N
orth America is a land of immigrants. Since the sixteenth century, successive waves of new arrivals have built an ethnically and culturally diverse society. Currently, immigration fulfills well-recognized economic and demographic needs since the fertility rate of the Canadian-born population has declined for almost half a century.1 In Canada, 18 percent of the population is foreignborn, with nearly 180,000 new immigrants arriving every year.2 Whereas European nations were the main source of immigrants to Canada for many decades, Asia is now the leading continent of origin. People from China, in particular, have become the largest visible minority group: in 2001, more than a million Chinese immigrants accounted for 3.5 percent of the Canadian population.2 This creates a challenge for health care professionals as immigrants’ experiences and perspectives on illness may differ from those of the predominant biomedical culture.3 Consequently, it is not surprising that providing culturally competent health care has become a growing concern for health care professionals in North America.4,5 Cultural competence signifies sensitivity to the culture of patients in order to provide high-quality services. Culture is a broad
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term that includes people’s health values and beliefs, such as the way they perceive oral health and illness, interpret symptoms, and seek dental care. However, despite the growing size of the Chinese community in Canada, dental professionals and other health care providers know relatively little about the beliefs and care-seeking behavior related to the oral health of individuals in this population. Only a handful of studies on the oral health care beliefs and behaviors of the Chinese culture have been published in western countries6-10 and in Hong Kong.11,12 Kwan ���������������� and Holmes,13 for instance, found that the traditional beliefs of Chinese immigrants in England remain strong and may lead to misunderstandings or conflicts with oral health care professionals. However, we lack information concerning how Chinese immigrants in Canada regard oral health and how they define, prevent, and treat their oral health problems. The purpose of this study was therefore to explore the representation of oral health and illness among Chinese immigrants now residing in Canada. Our long-term goal is to help dentists become culturally competent and to facilitate their adoption of a patient-centered approach.
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Methods Between April and June 2005, we conducted in-depth, one-on-one, semistructured interviews with adult Chinese immigrants. We chose this qualitative approach because it is a relevant method for understanding people’s cultural values, beliefs, and perspectives.14 The research was undertaken in Montreal, the second largest city in Canada with 3.4 million inhabitants. Montreal is a multicultural city with an important Chinese community. Indeed, the People’s Republic of China has become one of the top sources of newcomers in this city, with 14,000 immigrants relocating their primary place of residence to Montreal between 1991 and 2001.2 In this study, we recruited people who were 1) born in China; 2) first-generation immigrants; 3) current residents of Montreal; 4) economic immigrants (an economic immigrant is a skilled ������������������������� worker or spouse of a skilled worker who did not come as a refugee��� ); and 5) aged twenty and over. Our sample size was determined by the principle of saturation, which means that we stopped recruiting participants when the last interviews brought no original information and no new insights were likely to be obtained in conducting additional ones.15 We interviewed twelve immigrants, but we obtained saturation after the tenth interview as we learned nothing new with the last two interviews. The principal investigator contacted the main Chinese community center in Chinatown, which is located in Montreal’s downtown. She introduced the research to the employees and volunteers of the center, thereby developing a partnership based on respect and mutual trust. The employees of the center then introduced the investigator to Chinese immigrants who fulfilled the criteria for eligibility. Participants originated in urban areas of various provinces of mainland China (Table 1). They did not share the same mother tongue, but all had received their education in Mandarin, which is the official and main common language in China. Although they had a high level of education, as they were economic immigrants, all had a low family income in Canada (as defined by Statistics Canada’s low-income cut-offs16) due to unemployment or short-term employment. Because of their difficulties in finding jobs, some of them undertook university studies, hoping to improve their future job prospects. The familial and social network (circle of friends and acquaintances) of the study participants primarily consisted of other Chinese immigrants, even though they were open to
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Table1. Demographic characteristics of the participants (N=12) Demographic Characteristics
Number of Participants (N)
Age (years) 20-40 41-70
6 6
Gender Male Female
5 7
Primary language spoken Mandarin Shanghainese Min Cantonese
7 2 2 1
Province of origin in China* Beijing Fujian Guangdong Heilongjiang Henian Liaoning Shanghai Shanxi
2 2 1 1 1 2 2 1
Years in Canada 0-3 4-7 8-13
4 6 2
Marital status Married Single
10 2
Education (degree) College (post-secondary technical school) 1 University (bachelor or higher degree) 11 Occupation Unemployed Employed temporarily part-time Student
5 2 5
*Beijing and Shanghai are cities that are considered as provinces due to their significant size.
meeting nonimmigrants and people from different cultural backgrounds. Interviews were conducted in the participants’ homes or in suitable public spaces chosen by the interviewees. The environment was quiet, and the interviews were not interrupted by noise or any other disturbance. Before the interview started, each participant was asked to sign a consent form approved by the Ethics Committee of McGill University’s Faculty of Medicine. The interviews were conducted in Chinese (Mandarin) by the principal
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investigator. She used an interview guide that was developed for this study. The first draft of the guide was inspired by our previous qualitative research aiming to understand underprivileged people’s perceptions and experiences of oral health and disease in Montreal.17,18 The primary investigator then tested and improved this preliminary interview guide with a convenience sample of six Chinese immigrants.� The final interview guide had four sections. The introductory section focused on the participants’ immigration pathway and included questions on their experience of immigration, their reason for emigrating, and their social and family network in Canada. The second section concentrated on health and illness in a general way and contained these themes: perception of health, perception of illness, and management of illness. The third section was the core of the interview and included three main themes: perception of oral health and illness, experience of oral illness and dental consultation, and oral hygiene practices. For each of these themes, the interview guide included examples of questions to start with. The theme “perception of oral health and illness,” for instance, included questions such as the following: “Could you talk to me about oral illness?” and “Could you tell me how you identify oral illness?” The last section of the interview guide focused on the sociodemographic characteristics of the participants: they were asked about their age, family status, region of origin in China, education level, primary language spoken, and family income in Canada. The interviews lasted approximately one and a half hours each. They were audiotape-recorded and immediately transcribed verbatim by the principal investigator. The texts were then translated into English and reviewed by a bilingual Chinese-English speaker. In some cases, we conducted a follow-up interview in order to complete data collection and/or verify the interpretations. Data analysis consisted of three main steps: 1) completing a contact summary sheet, 2) coding, and 3) reducing and interpreting data. As recommended by Miles and Huberman,19 the contact summary sheet was completed immediately after each interview in order to summarize the discussion, identify the main themes, and, in some cases, raise new hypotheses. It also helped the research team, which included two researchers with a dental background and two with a background in sociology, to identify methodological issues and prepare for subsequent interviews. The text of the interviews was coded with QSR NVivo 2.0 software by the principal investigator. She
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started with a list of codes based on the research questions and then refined and revised the codes through a recursive process������������������������������������ , eliminating the less useful ones, and combining smaller categories into larger ones or, conversely, subdividing large categories into smaller ones. Two of the authors (CL and AL) contributed to this process: they checked the transcripts that were coded first and met with the principal investigator in order to improve the coding. Finally, two months after the last interview was coded, the principal investigator repeated the coding for all transcripts, and the comparison of the results revealed an excellent reliability.������������������������������� We then summarized and indexed the data by theme and subtheme and organized them into a table describing how the participants view oral illness. As researchers systematically checked and validated the interpretations, the analytic process was recursive and interactive.
Results Study participants’ perceptions of oral illness and dental care behaviors are summarized in this section. Transcripts of verbatim comments by the participants are presented to illustrate main themes. All participants considered oral health to be a very important issue and were open to scientific medical and dental knowledge. When asked to identify oral problems, they mentioned dental caries, gum swelling, and gum bleeding. Gum bleeding, however, was not perceived as a genuine disease because it tends to disappear by itself and is considered a common problem (Table 2).
Dental Caries The majority of participants used both biomedical (“caries,” “decayed tooth”) and traditional terms (“tooth worm”) to name dental caries. A minority of them, however, employed only the traditional term, describing holes left by cavities as caused by “tooth worms.” Participants agreed that a black spot on the surface of the tooth was a sign of early dental caries. They perceived caries as a continuous and irreversible process that leads to a cavity, toothache, and, ultimately, the destruction of the tooth. For example: “Dental caries begins with a tiny black spot on the tooth’s surface. When a black spot develops, dental enamel is damaged. Without proper methods to control the spot’s development, dentine will be damaged. If
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Table 2. How Chinese immigrants perceive oral illness
Caries
Gum Swelling
Gum Bleeding
Terms used
Caries/decayed tooth Tooth worm
Gum swelling Tooth bed swelling
Gum bleeding Tooth bed bleeding
Symptoms revealing the problem
Black spot Hole/cavity Toothache
Swollen gums Red gums Pain
Blood in saliva during tooth brushing and/or meal
Perceived process
Continual/irreversible
Reversible
Reversible
Perceived etiology
Lack of oral hygiene (bacteria, worm) Diet (sweet & acidic food) Genetics
Local factors: lack of oral hygiene General factor: internal fire
Lack of vitamin C
Perceived means of prevention Oral hygiene Diet Regular check-up
Local factors: oral hygiene (brushing & mouth rinsing) General factors: rest, avoiding stress, healthy diet (avoidance of hot food)
Vitamin C intake through fruits & vegetables; tablets
Perceived treatment needed Consulting a dentist
Local factors: antibiotics; consulting a dentist General factors: traditional herbs (Xiguashuang)
Self-treatment: Vitamin C intake (fruits & vegetables; tablets)
the situation continues, the tooth can become infected.” (Participant G) [Translation] Several participants reported that they conducted self-examination with a mirror in order to identify early symptoms or asked a friend to examine their teeth. According to the participants, caries is related to diet, especially acidic or sweet food such as candy or sugar. They also perceived bad oral hygiene as a risk factor because it leads to an accumulation of bacteria or worms. In addition, some interviewees also mentioned genetics as a potential etiological factor. One mother commented on different factors: “Sweet foods may be related to dental caries. My first son does not like to eat sweet foods. He does not like to eat sugar; cookies; cakes. I believe that the reason he gets cavities is because of poor oral hygiene. My third son likes to eat sugar. His cavities are caused by the sugar.” (Participant D) [Translation] In agreement with their perceived etiology of dental caries, participants considered good oral hygiene to be an important way to prevent dental
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caries. They regarded the individual as responsible for protecting his or her teeth from caries through brushing and flossing. A traditional method, rinsing the mouth with cold boiled water or salted water, was also seen as a good way to prevent caries and as complementary to diet and other hygiene measures. For example: “In the morning, I use salt water to rinse my mouth. I think salt water can kill bacteria and clean my mouth. This is what I think. I do not know whether it works or not. It is the traditional Chinese way to clean the mouth. I do not know where I got this from. Then I brush my teeth. I brush my teeth twice a day. I usually do it after finishing my breakfast and before going to bed.” (Participant B) [Translation] As dental caries was perceived to be an irreversible disease, the participants thought that consulting a dentist was essential to disease management. Participants indicated that early treatment of caries would allow them to keep their teeth and fillings longer. For example:
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“A regular checkup is important. . . . Routine examination is very important. Without routine checkups, a small spot will become a big spot.” (Participant H) [Translation]
Gum Swelling As was the case when describing dental caries, participants used both scientific (“gum swelling”) and traditional terms (“tooth bed swelling”) to describe gingival inflammation. In addition to the swelling, participants identified redness of the gum, mobility of a tooth, and pain as other symptoms. They also explained that it is possible to distinguish toothache from gingival pain; they pointed out that, in the case of gingival swelling, food is not the source of pain and is not an irritant. The participants perceived gum swelling as a reversible illness that could be caused by local factors (bad oral hygiene) and general factors (“internal fire”). Internal fire was described as a “fire” existing in the human body due to stress, lack of sleep, and an unhealthy diet such as an excess of “hot food” (“fried food,” meat, “spicy food”) or a lack of fruits and vegetables. For example: “Nervousness, pressure, depression: all cause the temperature increase in the body. When I decided to immigrate to Canada, I was depressed. I knew I would miss my parents and friends as well as the familiar environment. I felt sad. My gingiva swelled. It was on fire. Too much heat in the body. When I had a baby in Canada, I was nervous. No relatives here. My gum swelled again. It was also on fire again.” (Participant C) [Translation] “Fire is a concept in Chinese medicine. Fire is not outside the human body. It is inside the body. It is related to one’s mood. This is the main problem linked to fire. If an individual has too many worries or is too busy and is not well rested or faces too much stress, the fire flares up. The second is related to diet. If an individual eats a lot of food that can cause fire and he or she does not drink enough, fire will accumulate in the body. The foods that I refer to are those fried foods or ‘too-hot food.’ Those foods can irritate the fire.” (Participant G) [Translation]
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In order to prevent gingival swelling, participants described how they addressed local and general etiological factors. Some described the importance of maintaining good oral hygiene, in particular brushing the teeth and rinsing the mouth with salted water. Other participants described the importance of lessening stress, increasing the amount of rest, improving mood, and proper diet such as avoiding fried or spicy food or excessive meat consumption. Some participants also believed that drinking traditional herb teas could keep the gums from swelling. An example that combined factors is: “I believe that the main problem is oral hygiene. . . . The individual also needs to pay attention to diet. He or she needs to consider what he should eat and what he should not. Do not eat food that can cause the fire. . . . Also I find being well rested is very important. Do not stay up too late. . . . Good mood is very important. I try to keep a good mood. Optimism is very important. I try to be optimistic. Try to tolerate everyone. This includes my wife and my children.” (Participant G) [Translation] In order to treat gingival swelling, interviewees referred to remedies found in both traditional and western medicine. If “internal fire” was regarded as the main causal factor, participants referred to traditional Chinese medication—available in Chinese pharmacies or convenience stores in Montreal—that could be used to reduce the “fire” and resolve the gingival problem. Study participants perceived no harm in self-treatment and the use of traditional herbs such as Xiguashuang, convinced that Chinese medications had the added benefit of having fewer side effects than western medications. If local factors were regarded as the main cause of gingival swelling, some participants suggested self-treatment with antibiotics imported from China and consulting a dentist in cases where the antibiotics failed. For example: “I once went to see a Canadian dentist because of toothache. He told me I had no dental caries. I realized that I had too much fire. If I tell westerners about the fire, they do not understand what I mean. I used Xiguashuang that I bought by myself. I used it twice a day. The toothache disappeared.” (Participant G) [Translation]
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Gum Bleeding The majority of participants believed that gingival bleeding (traditionally named “gum bed bleeding”), detected as blood in saliva when brushing teeth or eating, was not an oral disease. Rather, it was perceived as a common and almost normal phenomenon because it is reversible and might even stop by itself. For example: “I have gingival bleeding when I brush my teeth vigorously. If I brush my teeth gently, I have no gingival bleeding. I am not sure whether gum bleeding is a dental disease or not. I just think it is very common. It may not be a dental disease. I did not go to see a dentist for my gingival bleeding.” (Participant E) [Translation] Lack of Vitamin C was identified as the main etiological factor of gum bleeding by most participants. They thought that a deficiency of Vitamin C was due to diet, in particular a lack of fresh fruits and vegetables. For example: “It is related to lack of Vitamin C. Not eating enough fresh vegetables and fruits can cause this. I do not know whether it is true or not.” (Participant J) [Translation] As a consequence, participants suggested increasing the intake of Vitamin C in order to prevent or treat gingival bleeding, even though they did not perceive it as an important problem. Fresh fruits and vegetables were considered effective and affordable sources of Vitamin C, but participants also mentioned self-treatment with Vitamin C tablets. According to them, the amount of Vitamin C taken should be adapted to the severity of the bleeding. For example: “Eating a lot of vegetables. Eating as much Vitamin C as possible. I do my best to eat a lot of vegetables with a lot of Vitamin C. I will buy a lot of fresh vegetables and fruits.” (Participant J) [Translation] “If I find gum bleeding without swelling, I think it is caused by a lack of Vitamin C. I will increase the intake of Vitamin C.” (Participant A) [Translation]
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Discussion To the best of our knowledge, our study is the first to provide a detailed description of how Chinese immigrants perceive oral illness. The study findings reflect the views and perceptions of a small number of Chinese immigrants in Montreal, and we need to be careful when interpreting and generalizing our results to other areas of North America. The first point that we would like to address is the sample size. We obtained saturation after the tenth interview, which means that no new relevant information was added during the last two interviews; we therefore considered that our data were credible and that additional interviews would not be useful in this particular group of immigrants. The second point is that our sample consisted of relatively recent Chinese economic immigrants in Montreal (they emigrated thirteen years ago or earlier). They had a high level of education and were involved in the city’s Chinese community; their circle of friends and acquaintances mostly consisted of people from a Chinese background. Our results may not, therefore, apply to other types of Chinese immigrants—those who live in different geographical areas, for instance. As well, the findings may not apply to individuals from a lower educational level, among whom traditional Chinese values and beliefs might remain stronger. Conversely, they might not apply to those who are more assimilated in the Canadian society, among whom the process of acculturation may have led to the loss of traditional values and beliefs. Our study reveals an important issue: traditional beliefs coexist with biomedical dental knowledge among these highly educated Chinese immigrants. On the one hand, participants had a fairly good understanding of dental caries in terms of etiology, process, prevention, and treatment, which may be due to the fact that information about caries has become widely available in Canada and in China. Hence, there were no major cultural barriers between the study participants and oral health care professionals in regard to dental caries. On the other hand, traditional beliefs were very strong, especially with respect to gingival swelling and bleeding. In the case of gingival swelling, for instance, participants identified etiological factors that had their basis in both western scientific culture and traditional Chinese medicine. For example, participants associated gingival swelling with oral hygiene
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but also linked it to “internal fire,” which signals an imbalance of body humors in traditional Chinese medicine.20,21 The methods for preventing and treating gingival swelling showed the same dichotomy: on the one hand, participants suggested improving oral hygiene, using antibiotics, and eventually consulting a dentist; on the other hand, they recommended rest, avoiding stress, limiting the intake of hot food, and taking traditional herbal remedies. It is important to analyze our findings through an acculturation framework. According to Berry22,23 and Bourhis et al.,24 immigrants face two important questions: 1) �������������������������������������� is it “of value to maintain immigrant cultural identity”? and 2) is it “of value to adopt the cultural identity of the host community”? In our study, immigrants seemed to value both traditional Chinese and western medical cultures and combined them with respect to dental care. This refers to a mode of acculturation identified as “integration,” which is associated with low “acculturative stress” and, as research shows, is the preferred form of acculturation in different cultural communities in Canada.24 We must add that, as the acculturation process depends on several factors, it could have taken a different form in another social context. In England, for instance, Kwan ����������������� and Williams8 and Kwan and Holmes13 showed a different and possibly more problematic pattern of acculturation. These investigations found that Chinese immigrants lacked faith in dentists and believed that preventive oral health measures were ineffective. We ���������������������������������������� must, therefore, exercise caution in transposing our results to another context or another social group. Our study is important because it raises issues related to dental public health and education. In terms of dental education, our results suggest that, in countries with a high immigration rate from China, oral health care professionals should have a basic understanding of Chinese people’s traditional beliefs and the acculturation process. Indeed, Bourhis et al.24 emphasize that the way members of the host community perceive and accept immigrants’ identity—the “host community acculturation orientation”—influences the quality of their interaction. In our case, a conflict might arise between dentists and Chinese immigrants if the former do not accept or respect the traditional culture of their patients. We thus recommend that lectures on traditional medicine and immigrants’ beliefs be provided to dentists through continuing education programs and to undergraduate dental students in Canada. We think that this would help clinicians to better communicate with their
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Chinese patients and would contribute greatly to a patient-centered approach that includes the exploration of the beliefs and illness experiences of their patients.25 We must add that including this topic in the dental curricula should also apply to other ethnic minority groups, including the aboriginal populations of Canada (First Nations) and the United States (Native Americans). Our study also raises issues in terms of dental public health. As Chinese immigrants are open to scientific culture and take advantage of both biomedical and traditional approaches, it would be useful to provide them with basic scientifically based health care information when they arrive in their new country, as has been done with Latino communities in California, for instance.26 Through information sessions provided by oral health care professionals in Chinese community centers, or through pamphlets that could be made available to the public, new immigrants could learn to improve their management of dental health and illness and thus facilitate their communication with dentists as well as their adaptation to the culture of their new country.
Conclusion This study indicates that a culture of traditional medicine remains strong among Chinese immigrants in Montreal, even though members of this community are open to biomedical dental knowledge. As a result, in order to provide culturally competent care, oral health professionals should become informed about the acculturation process and develop an understanding of how oral diseases are perceived by immigrants. Based on their willingness to consume and selectively use western medical concepts, our findings indicate that Chinese immigrants should be provided with basic scientific information about oral health. Further studies should be conducted among Chinese immigrants with a lower level of education, since their knowledge of, and openness toward, western medicine might differ from that of immigrants with higher levels of education. In addition, research conducted within a life-course perspective could enable us to better understand immigrants’ acculturation processes.
Acknowledgments
The authors are very grateful to the participants for their contribution, as well as to the Montreal Chinese Community Centre. They would also like to
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thank the McGill Faculty of Dentistry, the Canadian Institutes of Health Research (CIHR), and the Fonds de la Recherche en Santé du Québec (FRSQ) for their financial support.
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