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R E S EAR CH Open Access
‘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
Shannon McKinn1*, Thuy Linh Duong2
, Kirsty Foster3,4 and Kirsten McCaffery1,5
Background: Ethnic minority groups in Vietnam experience economic, social and health inequalities. There are
significant disparities in health service utilisation, and cultural, interpersonal and communication barriers impact on
quality of care. Eighty per cent of the population of Dien Bien Province belongs to an ethnic minority group, and
poor communication between health professionals and ethnic minority women in the maternal health context is a
concern for health officials and community leaders. This study explores how ethnic minority women experience
communication with primary care health professionals in the maternal and child health setting, with an overall aim
to develop strategies to improve health professionals’ communication with ethnic minority communities.
Methods: We used a qualitative focused ethnographic approach and conducted focus group discussions with 37
Thai and Hmong ethnic minority women (currently pregnant or mothers of children under five) in Dien Bien Province.
We conducted a thematic analysis.
Results: Ethnic minority women generally reported that health professionals delivered health information in a didactic,
one-way style, and there was a reliance on written information (Maternal and Child Health handbook) in place of
interpersonal communication. The health information they receive (both verbal and written) was often non-specific,
and not context-adjusted for their personal circumstances. Women were therefore required to take a more active role
in interpersonal interactions in order to meet their own specific information needs, but they are then faced with other
challenges including language and gender differences with health professionals, time constraints, and a reluctance to
ask questions. These factors resulted in women interpreting health information in diverse ways, which in turn appeared
to impact their health behaviours.
Conclusions: Fostering two-way communication and patient-centred attitudes among health professionals could help
to improve their communication with ethnic minority women. Communication training for health professionals could
be included along with the nationwide implementation of written information to improve communication.
Keywords: Communication, Ethnic groups, Minority groups, Female, Pregnancy, Vietnam, Maternal health, Qualitative
research, Primary health care

  • Correspondence: shannon.mckinn@sydney.edu.au 1
    Sydney School of Public Health, Edward Ford Building (A27), The University
    of Sydney, Sydney, NSW 2008, Australia
    Full list of author information is available at the end of the article
    © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
    International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
    reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
    the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
    (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
    McKinn et al. International Journal for Equity in Health (2017) 16:190
    DOI 10.1186/s12939-017-0687-7
    Vietnam has made noteworthy health advances over the
    last 25 years, particularly in regards to improving maternal and child health [1]. However, despite this national
    success story, regional and ethnic health inequalities persist [1, 2]. Ethnic minority groups have been found to be
    at increased risk of neonatal mortality, stillbirth, childhood malnutrition and stunting [3] and inequalities may
    be increasing in some areas, such as service utilisation
    [2]. There are 54 officially recognised ethnic groups in
    Vietnam, with the largest group, the Kinh, making up
    approximately 86% of the population [4]. Vietnam’s 53
    ethnic minority groups, with the exception of the Hoa
    (Chinese), are more likely to be poor and living in
    remote areas than the Kinh majority [3]. While ethnic
    minority groups are considered to be a national treasure,
    demonstrating the rich cultural diversity of Vietnam,
    historically they have been the target of government reforms aimed at improving living standards while largely
    sidelining traditional culture [3, 5]. Government policy
    has referred to ethnic minority groups as underdeveloped and backwards, while depicting the Kinh majority as more socially and economically advanced [6].
    These policies have advocated for ethnic minority
    groups to alter their lifestyles, as their traditional practices are seen as contributing to poverty and disease [6].
    Dien Bien Province (DBP) is a small, mountainous
    border province located in the northwest of Vietnam
    with a population of approximately 540,000 [7], around
    80% of who belong to an ethnic minority group [8]. The
    population of DBP experiences poverty, and child and
    maternal mortality at rates much higher than national
    averages [1, 9–11]. Previous research into ethnic minority health in Vietnam has shown significant disparities in
    service utilisation, with ethnic minority women less
    likely to access antenatal care (ANC) and give birth at a
    health facility [1, 2, 12–14], and ethnic minority parents
    less likely to seek medical care for their children when
    they are ill [15]. While geographical and physical access
    factors such as remoteness, lack of transportation, and
    difficult terrain are contributing factors to ethnic inequalities in service utilisation [12, 16, 17], it has been
    argued that ethnic inequalities are also the result of low
    levels of investment in physical and human capital [18].
    Those investments that do exist, such as cash subsidies
    on housing construction, agricultural grants, interestfree loans [19], and a targeted poverty reduction policy
    [3] may suffer from low returns due to social discrimination, cultural difference and inadequate information,
    further driving inequality [18]. Prior studies have shown
    ethnic minority people experience cultural and interpersonal barriers when accessing services, such as discrimination, poor attitudes from health staff and a lack of
    culturally sensitive services [4, 8, 16, 20].
    The cultural, interpersonal and spatial factors described above are obstacles that may adversely impact
    the patient-health professional interaction, an essential
    pillar of primary care. Moreover, with the high level of
    poverty, lower level of educational attainment, and lack
    of Vietnamese language and functional literacy skills
    among many ethnic minority women in DBP [8], it is
    reasonable to assume the level of health literacy in the
    population is low [21–23]. Although there is little research on health literacy in low and middle income
    countries (LMIC), previous research has established an
    association between low health literacy and experiencing
    communication difficulties with health professionals
    [24–26], and experiencing less patient-centred communication [27]. Several studies in other Asian countries
    with traditionally hierarchical social structures have also
    found that these power dynamics can flow into the
    patient-health professional relationship [28–31].
    Maternal and child health is a concern for the DBP
    Provincial Health Service, which has collaborated with
    the University of Sydney and the Vietnamese Women’s
    Union (VWU) to deliver maternal and child health
    workshops for health professionals and community
    leaders [32, 33]. During these workshops, limited health
    literacy and communication between health professionals and women have emerged as major issues
    impacting on quality of care. Conceptual models of the
    causal pathway between health literacy and health outcomes have suggested that improving communication
    (i.e. the patient-provider interaction) may mediate the
    effect of limited health literacy [34, 35]. This conceptualisation of health literacy provides the overarching framework for this research. The aim of this study is to
    explore how ethnic minority women experience communication with primary care health professionals in the
    maternal and child health setting. The overall aim of this
    research is to develop and support strategies to improve
    health professionals’ communication with ethnic minority communities in Vietnam.
    Study design
    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,”
    McKinn et al. International Journal for Equity in Health (2017) 16:190 Page 2 of 12
    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
    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,
    Fig. 1 Vietnamese health system structure. *Ministry of Health
    Table 1 Commune characteristics
    Commune characteristics N (%)
    Distance from District Hospital (range 4 km – 45 km)
    < 10 km 2 (40%)
    10–20 km 1 (20%)
    20–30 km 1 (20%)
    30–40 km 0 (0%)

40 km 1 (20%)
Predominantly sealed road access to District Hospital 4 (80%)
Ethnic makeup
Predominantly Thai 3 (60%)
Predominantly Hmong 2 (40%)
McKinn et al. International Journal for Equity in Health (2017) 16:190 Page 3 of 12
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].
Data collection
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.
Data analysis
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 (datadriven) 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].
Table 2 Participant characteristics
Participant characteristics N (%)
Age, years (range 18–33)
< 20 7 (19)
20–24 21 (57)
25–29 5 (14)
30–34 4 (11)
Thai 28 (76)
Hmong 9 (24)
Years of school
None 5 (14)
1–6 10 (27)
7–12 19 (51)
Post high school 3 (8)
Number of children
0 9 (24)
1 14 (38)
2 12 (32)
3 1 (3)
4 1 (3)
Currently pregnant 16 (43)
McKinn et al. International Journal for Equity in Health (2017) 16:190 Page 4 of 12
In focus group discussions, Thai and Hmong women on
the whole conveyed a wish to learn more about pregnancy, childbirth, their own and their children’s health.
They expressed their desire to ask more questions of
health professionals. Generally, they wanted more information and access to health professionals, a better understanding of their health and bodies, and more
opportunities to participate and learn from health professionals and each other. However, as the following
results show, many ethnic minority women were not
given adequate opportunity to fulfil these desires, due to
the nature of their communication with health professionals. Three main themes emerged regarding how
women experience communication with health professionals: 1) the pervasiveness of didactic, one-way delivery of non-specific health information; 2) variation in
women’s understanding and subsequent health behaviours and 3) the challenges of interpersonal communication with health professionals. Note that throughout this
section quotes marked with an asterisk are in the third
person because they are remarks made by local interpreters translating the responses of non-Vietnamese
Pervasiveness of didactic, one-way delivery of nonspecific health information
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
When I had check-ups, they gave me advice. Eat enough
nutrition, take proper rest, keep personal hygiene (Thai,
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
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).
Variation in women’s understanding and subsequent
health behaviours
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
McKinn et al. International Journal for Equity in Health (2017) 16:190 Page 5 of 12
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,
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).
The challenges of interpersonal communication with
health professionals
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
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
McKinn et al. International Journal for Equity in Health (2017) 16:190 Page 6 of 12
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).
Ethnic minority women in DBP generally expressed an
eagerness to learn more about pregnancy and newborn
care. The health information they did recall receiving
from health professionals was didactically delivered,
non-specific, and often poorly tailored to their situations
as ethnic minority women. Health professionals can act
as facilitators for ethnic minority women’s understanding
of health information, but with the pervasiveness of didactic, one-way communication from health professionals in practice, the onus was placed on women to
take a more active role in their communication with
health professionals in order to meet their information
needs. This may not come easily to them due to challenges including gender, language, time constraints, reluctance to ask questions, and a perceived lack of
interest or sympathy from health professionals when
women raised concerns about their pregnancies. Additionally, there is a growing reliance on giving women
written information, in the form of the MCH handbook.
These factors resulted in women interpreting information in various ways, which in turn impacted their health
behaviours during pregnancy and motherhood.
There has been little previous research focused on
patient-provider communication in Vietnam, generally
or in a maternal health context, let alone among a predominantly ethnic minority population. There has been
some research into patient preferences regarding
patient-provider communication in other Asian LMICs,
which has found that people have different communication needs and preferences based on local social norms
and cultural context (including traditionally hierarchical
social structure) [30, 44]. However, these norms do not
necessarily mean that patients in these countries are not
open to a more patient-centred communication approach [29, 45]. In Vietnam, a study of decision-making
preferences among urban women found a desire for active participation when choosing a contraceptive method
in consultation with a health professional, with an autonomous or shared decision-making approach preferred. A passive decision-making approach, in which
women’s concerns were secondary to the health professional’s opinion, was evaluated very negatively by
women. This was found despite the cultural context in
Vietnam which traditionally emphasises hierarchic role
differentiation and respect for authority figures [46].
Health professionals working in commune health stations were also interviewed for this study [40]. We found
that the commune health professionals generally perceived the main purpose of communication being information delivery, rather than an interpersonal interaction.
They perceived the effectiveness of their communication
as being based on women’s individual capacities to
understand health information, rather than actively
reflecting on the suitability of information and materials,
or on their own communication skills. This is also
reflected in these focus group results, as ethnic minority
women and health professionals described a situation in
which communication is frequently one-way, both in the
clinical and community setting, and driven by the
agenda of health professionals rather than by women’s
needs and preferences. Health professional-driven care
has also been found to impact other aspects of maternal
health service utilisation. A qualitative study into childbirth practices in the same province as the current study
found that health services failed to accommodate local
(i.e. ethnic minority) childbirth preferences, and that the
low level of service utilisation was partly due to ethnic
minority peoples’ rejection of the medicalised, health
care professional-centred approach found in public
health facilities [47]. Additionally, it should be noted that
health professionals working at the commune level may
also be marginalised within the health system as they
have limited power and autonomy themselves [16].
Both women and health professionals also described a
substantial reliance on sending ethnic minority women
home with often complex written information (MCH
McKinn et al. International Journal for Equity in Health (2017) 16:190 Page 7 of 12
handbook) in order to meet women’s information needs
during pregnancy and afterwards. Our results show that
ethnic minority women do value the MCH handbook,
particularly as a health record. This corroborates previous qualitative findings from Cambodia which found
women value the MCH handbook as a health record and
information source, wish to keep it as a reference, and
often share it with their family members [48]. However,
our findings also demonstrate that often women cannot
understand the information inside the MCH handbook,
both the content and the language used. Our results indicate that the MCH handbook may be increasing rather
than reducing demands placed on ethnic minority
women by health professionals by being neither sufficiently understandable (people of diverse backgrounds
and varying levels of health literacy can process and
understand key messages) nor actionable (people of
diverse backgrounds and varying levels of health literacy
can identify what they can do based on the information
presented) [49]. This is consistent with research in highincome countries which has demonstrated that most patient education materials are too complex for patients
with limited health literacy [49].
Previous research on the implementation of MCH
handbooks in other LMICs has shown success in increasing ANC attendance [48, 50–52], increasing rates
of delivery with a skilled birth attendant and facilitybased deliveries [48], improving maternal health-seeking
behaviour [53], and in increasing knowledge in specific
areas about pregnancy and child health. However, previous research has specified that the MCH handbooks
have likely worked to improve these indicators through
enhancing communication between health professionals
and pregnant women and allowing more personalised
guidance to take place. Results from a study in Palestine
showed that less-educated women rarely read the handbook at home, but they still became more familiar with
health information in the MCH handbook through personalised guidance provided by health professionals who
used the MCH handbook [53]. Our findings from DBP
show that the MCH handbook is not being used to enhance communication. Instead it is often used in place
of personalised and context-adjusted guidance from
health professionals, with women being directed to read
the handbook at home with little further explanation or
opportunities to ask question of health professionals.
This passive style of information delivery has previously
been found to be a major barrier to health promotion
activities among ethnic minority groups in Vietnam,
with communication and promotion methods found to
be almost entirely passive and information-based, as well
as context unadjusted across ethnic groups [54]. Traditionally, formal communication structures in Vietnam
have relied on a top-down, one-way hierarchical
structure, which has resulted in differences between
health knowledge and actual or reported health practices, with high levels of health knowledge not translating into behaviour change. These differences have been
found to be due to factors including the use of topdown didactic communication styles, and improper
audience segmentation, resulting in inappropriate
context-unadjusted messaging and exclusion of specific
groups [55]. A recent intervention to improve hypertension control has seen some success in challenging this
status quo, showing the acceptability of a culturally
adapted storytelling communication approach in rural
Vietnamese communities. The storytelling approach was
more successful in increasing hypertension medication
adherence than didactic content delivery [56].
The MCH handbook used in DBP was piloted in four
Vietnamese provinces (of which DBP was one) between
2011 and 2014. The MCH handbook has been evaluated
qualitatively and in a pre-post study [57, 58], but almost
entirely from the perspective of its usefulness for health
professionals and not from the perspective of pregnant
women and mothers. One study [57] reported on the
prevalence, fragmented implementation and amount of
overlap in various MCH home-based records (HBRs) being used throughout Vietnam, and attempted to identify
health professionals’ and women’s perceptions of using
HBRs, including the MCH handbook utilised in DBP.
The reported qualitative results of the study mainly discussed the user experience of health professionals, and
only focused on women’s preference to have HBRs integrated into one document – the MCH currently in use in
DBP. Another study aimed to assess the MCH handbook
in terms of changes in knowledge, attitudes and practices, and also included a qualitative element. While the
pre-post study found an improvement in knowledge, attitudes and practices in maternal and child health, the
reported qualitative results give little information about
how women used and understood the information in
their MCH handbooks, or how health professionals used
the MCH handbooks as a communication tool [58].
Strengths of this study include a heterogeneous sample, a rigorous analysis process, and the involvement of
local collaborators. The main limitations of this study
are that Vietnamese is not the first language of the ethnic minority women living in this community, although
it is the sole official language of Vietnam. Most women
who participated in the study spoke Vietnamese, some
with varying levels of confidence, and others needed to
speak through local interpreters. However, as this study
aimed to capture a wide range of experiences and opinions within the ethnic minority population, we felt it was
inappropriate to exclude these women. The use of local
interpreters may have also resulted in some distortions
in women’s responses, either self-imposed or interpreterMcKinn et al. International Journal for Equity in Health (2017) 16:190 Page 8 of 12
imposed. Local interpreters were often women of high
status and influence in their villages (representatives of
the VWU, village midwife, People’s Committee employee), and as such women may have censored their
own responses, or had their responses altered in translation. This is a cross-cultural study, and as such, some responses may have been misinterpreted by the authors.
We have attempted to limit misinterpretations by conducting an independent translation of all audio data, and
collaborating with a Vietnamese co-author. The data
collection process and any actual or potential misunderstandings were also regularly discussed by the authors in
regular meetings during data collection. Additionally,
self-reported practice in focus groups may differ from
actual behaviour, and there may be a related element of
social desirability bias. We have tried to minimise this
through the use of a neutral facilitator, and reassuring
participants of the confidential nature of their participation. Furthermore, due to the nature of the qualitative
approach, the generalisability of these findings may be
limited. We have attempted to enhance transferability by
thoroughly describing the research context and methods,
and relating our results to existing evidence so that
readers may better determine the relevance of these
findings to other settings.
The MCH handbook piloted in DBP and three other
provinces was earmarked by the Vietnamese government
in late 2015 to be scaled up as a nationally standardised
HBR document [57]. While a nationally standardised
HBR will likely be a useful tool for health professionals,
with 54 ethnic groups present in Vietnam, ethnic minority women in other provinces are likely to face some of
the same challenges Thai and Hmong women in DBP
have experienced. With the move to implement the
MCH handbook across Vietnam, government officials
and health professionals should be aware of the different
experiences and perspectives of ethnic minority women
in using the MCH handbook. The results of this study
show there is much scope for improving interpersonal
communication between ethnic minority women and
health professionals in the primary care setting in DBP,
including fostering two-way communication and
patient-centred attitudes among health professionals.
There is an opportunity to include communication
training for health professionals along with the nationwide implementation of the MCH handbook in order to
ensure that the provision of the MCH handbook enhances rather than replaces personalised communication
between pregnant women and health professionals.
Appendix 1: Focus group topic guide
Introduction and Welcome

  1. Pregnancy
     Tell us about when you realised that you were
    Prompt: What happened, how did you realise, when
    did you realise?
     When you realised that you were pregnant, what did
    you do?
    Prompt: How do you take care of yourself when
    you’re pregnant?
     How do you know how to take care of yourself
    when you’re pregnant?
    Prompt: Who do you ask for advice?
    Prompt: What kind of things do they tell you?
     How have you been during your pregnancy?
    Prompt: If they mention issues / complications /
    illness: what did you do?
     [For mothers]: How was your pregnancy?
    Prompt: If they mention issues / complications /
    illness: what did you do?
  2. Childbirth
     If you have had a baby, can you tell us about the
     Where would you like to give birth? / Where did
    you want to give birth?
    Prompt: Why?
     Where did you / will you give birth?
    Prompt: Why?
     Who was with you when you gave birth?
    Prompt: What did they do?
     Who would you like to have with you/liked to have
    had with you when you gave birth?
    Prompt: Why?
     Would you have liked anything to have been
    different when you gave birth?
  3. Communication and relationship with maternal
    health care provider
     Do/did you visit the health station during your
    Prompt: Why/why not?
    McKinn et al. International Journal for Equity in Health (2017) 16:190 Page 9 of 12
     What things do/did they do there for you?
    Prompt: What happens when you go to the health
    station when you’re pregnant?
    Prompt: What are/were you looking for from the
    health station staff?
     Do you feel like you can ask the health worker
    questions about your pregnancy / childbirth / your
    Prompt: What information do they give you?
    Prompt: Is the information helpful?
  4. Role of family and community
     What happens/happened after you had your baby?
    Prompt: How is your family involved with the baby?
    (Husband, Mother, MIL, etc).
     Does anyone (apart from a health worker) give you
    advice about pregnancy and having a baby?
    Prompt: What kind of information?
    Prompt: Is it helpful?
    Prompt: What do you do if this advice is different
    from the advice that the health worker tells you.
    Prompt: Whose advice about pregnancy and
    childcare do you most trust?
     Are there things that your family and or community
    expect you to do while you are pregnant or when
    your child is born?
  5. Health station
     How far away is the health station from where you
    Prompt: How do you get there?
    Prompt: Is it difficult to get there when you are
    pregnant or have a small child?
     Do you know what services the health station offers
    for pregnant women and mothers of young
    Prompt: What are they?
    Prompt: What do you think of these services?
    Prompt: Do you use them?
    ANC: Antenatal care; DBP: Dien Bien Province; HBR: Home-based record;
    LMIC: Low and middle-income countries; MCH: Maternal and child health;
    MU5FG: Mothers of children under five years focus group; PWFG: Pregnant
    women focus group; USD: US dollar; VWU: Vietnamese Women’s Union
    The authors would like to thank the women and communities who
    participated in this study, and welcomed us to their villages and homes. We
    also thank the Dien Bien Province Public Health Service, Hanoi Medical
    University, and Dr. Luong Duc Son, Dr. Ngoc Nguyen Tan and Dr. Trinh Duc
    Long for their support and assistance.
    This study was funded by the Hoc Mai Foundation, and the University of
    Sydney G.H.S. & I.R. Lightoller, and Royston George Booker Scholarships.
    Shannon McKinn is supported by a Sydney Medical School Foundation
    Scholarship. Kirsten McCaffery is supported by a National Health and Medical
    Research Council fellowship. Funding bodies had no role in study design,
    data collection, analysis, and interpretation, or writing the manuscript.
    Availability of data and materials
    Data underlying our findings cannot be made public for ethical reasons, as
    they contain information that could compromise the privacy and consent of
    research participants. Data requests may be sent to the corresponding
    author (KM).
    Authors’ contributions
    SM contributed to study design, data collection, data analysis, interpretation,
    drafting and revising the manuscript. DTL contributed to data collection,
    interpretation, and revising the manuscript. KF contributed to study design,
    data analysis, interpretation, and revising the manuscript. KM contributed to
    study design, data analysis, interpretation, and revising the manuscript. All
    authors gave final approval of the manuscript and are accountable for all
    aspects of the work.
    Ethics approval and consent to participate
    Ethics approval was obtained through the University of Sydney Human
    Research Ethics Committee (Project No. 2015/251). All participants gave
    written or verbal consent to participate in the study.
    Consent for publication
    Not applicable.
    Competing interests
    The authors declare that they have no competing interests.
    Publisher’s Note
    Springer Nature remains neutral with regard to jurisdictional claims in
    published maps and institutional affiliations.
    Author details
    Sydney School of Public Health, Edward Ford Building (A27), The University
    of Sydney, Sydney, NSW 2008, Australia. 2
    Faculty of Nursing and Midwifery,
    Hanoi Medical University, 1 Ton That Tung, Dong Da, Hanoi, Vietnam. 3
    for Global Health, Sydney Medical School, Edward Ford Building (A27), The
    University of Sydney, Sydney, NSW 2008, Australia. 4
    Kolling Institute at
    Northern Clinical School, Sydney Medical School, Royal North Shore Hospital,
    St Leonard, NSW 2065, Australia. 5
    Centre for Medical Psychology &
    Evidence-based Decision-making (CeMPED), The University of Sydney,
    Sydney, NSW, Australia.
    Received: 9 June 2017 Accepted: 24 October 2017
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Palmer Qualitative Critique Form  Name:
Citation (APA format)
Key Words (Used in Search or listed by Author):
Introduction/Literature Review Do the authors describe relevant findings from the literature on this topic?   Yes       No (Sometimes qualitative methods are used when little is known on  topic)           
Purpose Is the purpose of the research clearly stated? Theoretical Framework: Did the author(s) describe a theoretical framework or philosophical underpinnings supporting this study? Name of the theoretical framework?
Research Design (Please check the designed used in this study) Phenomenology                 Grounded Theory               Ethnography                       Historical                            Case Study                          Is the design appropriate to answer the research question?                       
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Data Analysis How is the data analyzed? How do the researchers add analytical rigor? Have the researchers discussed trustworthiness, triangulation, respondent validation or the use of more than one analyst as methods to add rigor?
Results Do the researchers discuss the relevance of the findings to clinical practice? Do the researchers discuss how this study adds to current science? Do the researchers make any suggestions for future research based on their findings? How will the findings influence nursing practice?    

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