# Vietnamese Immigrants in Brisbane, Australia: Perception of Parenting Roles, Child Development, Child Health, Illness, and Disability, and Health Service Utilisation

Authors: Uyen N. T. L. Tran
Journal: International Journal of Population Research
 (2012)

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## Abstract

The limited research into Vietnamese immigrants suggests that this group may have different perceptions relating to parenting roles, child development, child health, illness, and disability, and differing patterns of health service utilisation. The author conducted a pilot study exploring how Vietnamese immigrants differ from Anglo-Australian in relation to these issues. The pilot, utilising a mixed quantitative and qualitative method, was conducted in Brisbane, Australia, with subjects being existing clients of a health centre. Two focus group discussions were conducted and a structured questionnaire developed from the discussions. Vietnamese immigrants in contrast to Australian-born Caucasians regard the general practitioner as the main health care provider and were less satisfied with English-speaking health services. This study highlights potentially important health-related issues for children of Vietnamese immigrants living in Brisbane, the importance of further research in this area, and the methodological challenges faced when conducting research into Vietnamese immigrants.


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## Body

## 1. Introduction

The literature indicates reduced access to health services and disparate health outcomes in people from culturally and linguistically diverse backgrounds (CLDBs) living in Western countries [1, 2]. Low socioeconomic status, which is more prevalent in people from CLDB, accounts for some but not all of the disparate outcomes [3–5].With Australia’s increasingly cultural and linguistically diverse society, in particular a growing Asian population, health outcomes and health service utilisation of this population is an issue of great relevance to Australian practitioners and policy-makers. Even though commonalities may exist between CLDB populations, further exploration regarding poor health outcomes and access to health services demonstrate the importance of specific factors that are unique to individual communities.During this study, staff at Inala Community Health’s Department of Child, Youth and Family Health indicated possible deficits in the delivery of health services to families from CLDB, especially those from a Vietnamese background. Staff believed that these deficits may be related to different cultural perceptions held by parents about children’s health, development, and the role of parenting. A greater understanding of cultural values and beliefs of people from CLDB, which underlie health behaviour, is essential if appropriate health services are to be provided.A significant amount of the immigrant health research emanates from the United States of America, where health insurance status is often a major influencing factor in health access and service utilisation [6–9]. However given the differences between the American and Australian health care systems, American research is often not generalizable to an Australian context.There have been few Australian studies which have explored health concerns and barriers to accessing health services amongst Vietnamese immigrants [10–12]. This literature indicates that families and women rate their children’s health as a high priority and have concerns in relation to their children’s general health, growth, and development and nutrition [11]. The Vietnamese family doctor is usually the first professional contact for any health-related problem [10]. The reasons cited for not utilising other mainstream health services include language barriers, inappropriate manner, and lack of cultural sensitivity of health professionals, transportation barriers, and waiting times [10, 11].Traditional cultural health beliefs and practices are often incongruent with those of Western society and may pose a barrier to accessing health services [13]. Cultural differences in practices relating to pregnancy, birth, breast-feeding, and child birth [14–20] and children’s oral health [13] have been identified in previous studies.Thus this study and paper aims to contribute to the limited knowledge about Vietnamese immigrants living in Australia, their perceptions regarding their parenting roles, and the health and development of their children and their utilisation of health services for their children.


## 2. Research Method

### 2.1. Hypothesis

Prior to commencement of the study the following hypotheses were proposed.(1)
Vietnamese immigrant parents living in Brisbane have different perceptions about parenting roles and child health, illness, disability, discipline, behaviour, and child health services, compared with Australian-born Caucasian parents.(2)
Vietnamese immigrant parents living in Brisbane underutilise child health services, have less knowledge of them, are less able to access them, and are less satisfied with those they have used compared with Australian-born Caucasian parents.


### 2.2. Study Design

This is an exploratory study that utilised mixed methods of data collection, both quantitative (structured questionnaire) and qualitative (focus group) methodology. The focus groups were conducted first and responses were then used to inform issues to explore further in the questionnaire. For the purpose of this paper, the study group or participants will be referred to as the Vietnamese group or participants and the comparison group referred to as the Australian group or participants.


#### 2.2.1. Setting

The study was conducted in Inala, Queensland in 2002. Inala is a suburb in the south-western outskirts of Brisbane. It is a low socioeconomic area with a culturally and linguistically diverse population and houses many recent immigrants [21]. The majority of Brisbane’s Vietnamese community lives in Inala and its surrounding suburbs [21]. In 2001, persons of Vietnamese ancestry comprised the third commonest ancestry group in Inala (16.7%).


#### 2.2.2. Subjects

All subjects were existing clients of the Inala Community Health Centre. Inclusion criteria were adults over the age of 18 years, who lived in the Inala and surrounding area, gave informed consent, and had at least one child under the age of 5 years. The Vietnamese participants were first generation Vietnamese immigrants and the Australian group were Australian-born Caucasian. People from other cultural backgrounds were excluded to maintain cultural homogeneity. Exclusion criteria were known mental illness or intellectual disability in the adult subjects. The focus group and questionnaire participants were all existing clients of the Inala Community Health Centre. As this was a pilot and the intention is to follow-up with a full study, convenience sampling was used.


#### 2.2.3. Focus Group

There were two focus groups, one with five Vietnamese immigrant parents and the other with nine Australian-born Caucasian parents. The chief investigator, who is bilingual in English and Vietnamese, and a child health nurse, facilitated both focus groups. A Vietnamese Liaison Officer was also present during the Vietnamese focus group.


#### 2.2.4. Questionnaire

The questionnaire was developed by the Principal investigator using a well-accepted process described in the literature [22] and was based on issues which were uncovered from the focus group analysis. It comprised of standard question types including open-ended, dichotomous, forced-choice, rating questions using Likert scales [22] and vignettes [23]. The vignettes were created by the Principal investigator, who is a paediatrician. They were common scenarios in which the investigator has experienced cultural differences, between Vetnamese and Anglo-Australian parents, in clinical practice.A pilot questionnaire was critically reviewed by a panel of paediatricians and professionals who work with the Vietnamese community to assess the questions for relevance. Professionals working with the Vietnamese community consisted of staff at the Inala Community health Centre as well as a Vietnamese general practitioner and a Vietnamese counsellor. The two native Vietnamese speakers, who are fluent in English, were asked to examine the questions for their ease of translation. Once the reliability of the questions had been confirmed, a qualified translator was asked to translate the questions into Vietnamese. They were then back translated into English for confirmation of meaning and equivalence [24].The questionnaire was pretested by a small number of Vietnamese-born and Caucasian Australian-born parents to examine for content validity, ease of use, and relevance. The same panel of parents repeated the questionnaires two weeks later to examine retest reliability. The results were compared using correlation coefficients. The results from both the Australian and Vietnamese groups possessed high test-retest reliability, with a combined correlation coefficient of 84% (Pearson’s) and 97.5% (Spearman’s). Second attempt score did not vary more than 8% different from first scores for each individual. The individual questions were also examined and were deemed to be answered consistently the second time compared with the first time.The final questionnaire was administered to the Vietnamese and Australian study groups. The Vietnamese group were given the choice of the Vietnamese or English version, with all but one person choosing the Vietnamese version. There was one designated data collector for each group: a child health nurse for the Australian group and a Vietnamese Liaison Officer for the Vietnamese group. Although the questionnaires were self-administered, the designated data collectors were on hand to clarify any questions. The Vietnamese Liaison Officer, who is a qualified interpreter, assisted in interpreting the open-ended questions and vignettes in a culturally appropriate way and translating the data into English.All information, consent forms, and the questionnaire were translated into Vietnamese by a qualified Vietnamese language translator and then back translated for accuracy. This is a methodologically sound and well-accepted approach in cross-cultural research [24].


#### 2.2.5. Recruitment

Focus Groups
The Vietnamese focus group participants were selected from parents attending the Community Centre’s Bacillus-Calmette-Guerin (BCG) Immunisation Clinic. They were approached by the Vietnamese liaison officer and gave verbal consent to participate in the focus group discussions. The Australian focus group participants were primarily parents who attended the Centre’s parenting groups and baby clinics, who verbally agreed to participate in the focus group discussions.Questionnaire
In recruiting participants for the questionnaire (See Supplementary Material available online at doi:10.1155/2012/932364), existing clients of Inala Community Health Centre’s immunisation clinics, child health clinics, and parenting groups, with children between 0 and 5 years of age, were directly approached by the Centre’s child health nurses and/or the Vietnamese Liaison Officer. The majority of the Vietnamese-born participants were clients attending the BCG immunisation clinics and the rest were clients of the Home Visiting Program. The participants were given an information sheet, either in English or Vietnamese, outlining the details and purpose of the study.
While there is some power gradient involved, as the parents are clients of the child health nurses and the interpreter, the nonthreatening nature of the study was explained. Using a Vietnamese recruiter helped to reduce the power gradient [25]. The participants were assured of confidentiality and anonymity and were informed of their right to refuse or participate. All parents signed a consent form.


### 2.3. Method of Analysis of Data

The focus group discussions were not taped because the literature indicates that this is not well accepted by Vietnamese women [10]. All efforts were made to accurately transcribe the main issues; however, without taping the sessions, content analysis was not possible. When analysing the responses for roles of health professionals, a panel of experts (two Caucasian Australian-born health care workers and two Vietnamese-born health care workers) independently scored the answers as correct, partly correct, or incorrect. The questions left unanswered were assumed to be incorrect (the participants who left the questions unanswered informed the Vietnamese interpreter that they did not know the answers). The vignette responses were also independently scored as correct, acceptable, or incorrect, by two paediatricians.The questionnaire responses were entered into SPSS and descriptive statistics generated. The two study groups were examined in terms of demographic variables, utilisation of health services, satisfaction with health services, and understanding and perception of health professionals roles, common issues in child development and health, and causation of childhood conditions. For continuous variables one-way analysis of variance (ANOVA) and the Chi-squared tests for categoric variables were used.Due to the small number of study participants, some of the variables were recoded with categories collapsed together. Frequency distribution curves were studied to determine which categories were to be collapsed together.


## 2.1. Hypothesis

Prior to commencement of the study the following hypotheses were proposed.(1)
Vietnamese immigrant parents living in Brisbane have different perceptions about parenting roles and child health, illness, disability, discipline, behaviour, and child health services, compared with Australian-born Caucasian parents.(2)
Vietnamese immigrant parents living in Brisbane underutilise child health services, have less knowledge of them, are less able to access them, and are less satisfied with those they have used compared with Australian-born Caucasian parents.


## 2.2. Study Design

This is an exploratory study that utilised mixed methods of data collection, both quantitative (structured questionnaire) and qualitative (focus group) methodology. The focus groups were conducted first and responses were then used to inform issues to explore further in the questionnaire. For the purpose of this paper, the study group or participants will be referred to as the Vietnamese group or participants and the comparison group referred to as the Australian group or participants.


### 2.2.1. Setting

The study was conducted in Inala, Queensland in 2002. Inala is a suburb in the south-western outskirts of Brisbane. It is a low socioeconomic area with a culturally and linguistically diverse population and houses many recent immigrants [21]. The majority of Brisbane’s Vietnamese community lives in Inala and its surrounding suburbs [21]. In 2001, persons of Vietnamese ancestry comprised the third commonest ancestry group in Inala (16.7%).


### 2.2.2. Subjects

All subjects were existing clients of the Inala Community Health Centre. Inclusion criteria were adults over the age of 18 years, who lived in the Inala and surrounding area, gave informed consent, and had at least one child under the age of 5 years. The Vietnamese participants were first generation Vietnamese immigrants and the Australian group were Australian-born Caucasian. People from other cultural backgrounds were excluded to maintain cultural homogeneity. Exclusion criteria were known mental illness or intellectual disability in the adult subjects. The focus group and questionnaire participants were all existing clients of the Inala Community Health Centre. As this was a pilot and the intention is to follow-up with a full study, convenience sampling was used.


### 2.2.3. Focus Group

There were two focus groups, one with five Vietnamese immigrant parents and the other with nine Australian-born Caucasian parents. The chief investigator, who is bilingual in English and Vietnamese, and a child health nurse, facilitated both focus groups. A Vietnamese Liaison Officer was also present during the Vietnamese focus group.


### 2.2.4. Questionnaire

The questionnaire was developed by the Principal investigator using a well-accepted process described in the literature [22] and was based on issues which were uncovered from the focus group analysis. It comprised of standard question types including open-ended, dichotomous, forced-choice, rating questions using Likert scales [22] and vignettes [23]. The vignettes were created by the Principal investigator, who is a paediatrician. They were common scenarios in which the investigator has experienced cultural differences, between Vetnamese and Anglo-Australian parents, in clinical practice.A pilot questionnaire was critically reviewed by a panel of paediatricians and professionals who work with the Vietnamese community to assess the questions for relevance. Professionals working with the Vietnamese community consisted of staff at the Inala Community health Centre as well as a Vietnamese general practitioner and a Vietnamese counsellor. The two native Vietnamese speakers, who are fluent in English, were asked to examine the questions for their ease of translation. Once the reliability of the questions had been confirmed, a qualified translator was asked to translate the questions into Vietnamese. They were then back translated into English for confirmation of meaning and equivalence [24].The questionnaire was pretested by a small number of Vietnamese-born and Caucasian Australian-born parents to examine for content validity, ease of use, and relevance. The same panel of parents repeated the questionnaires two weeks later to examine retest reliability. The results were compared using correlation coefficients. The results from both the Australian and Vietnamese groups possessed high test-retest reliability, with a combined correlation coefficient of 84% (Pearson’s) and 97.5% (Spearman’s). Second attempt score did not vary more than 8% different from first scores for each individual. The individual questions were also examined and were deemed to be answered consistently the second time compared with the first time.The final questionnaire was administered to the Vietnamese and Australian study groups. The Vietnamese group were given the choice of the Vietnamese or English version, with all but one person choosing the Vietnamese version. There was one designated data collector for each group: a child health nurse for the Australian group and a Vietnamese Liaison Officer for the Vietnamese group. Although the questionnaires were self-administered, the designated data collectors were on hand to clarify any questions. The Vietnamese Liaison Officer, who is a qualified interpreter, assisted in interpreting the open-ended questions and vignettes in a culturally appropriate way and translating the data into English.All information, consent forms, and the questionnaire were translated into Vietnamese by a qualified Vietnamese language translator and then back translated for accuracy. This is a methodologically sound and well-accepted approach in cross-cultural research [24].


### 2.2.5. Recruitment

Focus Groups
The Vietnamese focus group participants were selected from parents attending the Community Centre’s Bacillus-Calmette-Guerin (BCG) Immunisation Clinic. They were approached by the Vietnamese liaison officer and gave verbal consent to participate in the focus group discussions. The Australian focus group participants were primarily parents who attended the Centre’s parenting groups and baby clinics, who verbally agreed to participate in the focus group discussions.Questionnaire
In recruiting participants for the questionnaire (See Supplementary Material available online at doi:10.1155/2012/932364), existing clients of Inala Community Health Centre’s immunisation clinics, child health clinics, and parenting groups, with children between 0 and 5 years of age, were directly approached by the Centre’s child health nurses and/or the Vietnamese Liaison Officer. The majority of the Vietnamese-born participants were clients attending the BCG immunisation clinics and the rest were clients of the Home Visiting Program. The participants were given an information sheet, either in English or Vietnamese, outlining the details and purpose of the study.
While there is some power gradient involved, as the parents are clients of the child health nurses and the interpreter, the nonthreatening nature of the study was explained. Using a Vietnamese recruiter helped to reduce the power gradient [25]. The participants were assured of confidentiality and anonymity and were informed of their right to refuse or participate. All parents signed a consent form.


## 2.2.1. Setting

The study was conducted in Inala, Queensland in 2002. Inala is a suburb in the south-western outskirts of Brisbane. It is a low socioeconomic area with a culturally and linguistically diverse population and houses many recent immigrants [21]. The majority of Brisbane’s Vietnamese community lives in Inala and its surrounding suburbs [21]. In 2001, persons of Vietnamese ancestry comprised the third commonest ancestry group in Inala (16.7%).


## 2.2.2. Subjects

All subjects were existing clients of the Inala Community Health Centre. Inclusion criteria were adults over the age of 18 years, who lived in the Inala and surrounding area, gave informed consent, and had at least one child under the age of 5 years. The Vietnamese participants were first generation Vietnamese immigrants and the Australian group were Australian-born Caucasian. People from other cultural backgrounds were excluded to maintain cultural homogeneity. Exclusion criteria were known mental illness or intellectual disability in the adult subjects. The focus group and questionnaire participants were all existing clients of the Inala Community Health Centre. As this was a pilot and the intention is to follow-up with a full study, convenience sampling was used.


## 2.2.3. Focus Group

There were two focus groups, one with five Vietnamese immigrant parents and the other with nine Australian-born Caucasian parents. The chief investigator, who is bilingual in English and Vietnamese, and a child health nurse, facilitated both focus groups. A Vietnamese Liaison Officer was also present during the Vietnamese focus group.


## 2.2.4. Questionnaire

The questionnaire was developed by the Principal investigator using a well-accepted process described in the literature [22] and was based on issues which were uncovered from the focus group analysis. It comprised of standard question types including open-ended, dichotomous, forced-choice, rating questions using Likert scales [22] and vignettes [23]. The vignettes were created by the Principal investigator, who is a paediatrician. They were common scenarios in which the investigator has experienced cultural differences, between Vetnamese and Anglo-Australian parents, in clinical practice.A pilot questionnaire was critically reviewed by a panel of paediatricians and professionals who work with the Vietnamese community to assess the questions for relevance. Professionals working with the Vietnamese community consisted of staff at the Inala Community health Centre as well as a Vietnamese general practitioner and a Vietnamese counsellor. The two native Vietnamese speakers, who are fluent in English, were asked to examine the questions for their ease of translation. Once the reliability of the questions had been confirmed, a qualified translator was asked to translate the questions into Vietnamese. They were then back translated into English for confirmation of meaning and equivalence [24].The questionnaire was pretested by a small number of Vietnamese-born and Caucasian Australian-born parents to examine for content validity, ease of use, and relevance. The same panel of parents repeated the questionnaires two weeks later to examine retest reliability. The results were compared using correlation coefficients. The results from both the Australian and Vietnamese groups possessed high test-retest reliability, with a combined correlation coefficient of 84% (Pearson’s) and 97.5% (Spearman’s). Second attempt score did not vary more than 8% different from first scores for each individual. The individual questions were also examined and were deemed to be answered consistently the second time compared with the first time.The final questionnaire was administered to the Vietnamese and Australian study groups. The Vietnamese group were given the choice of the Vietnamese or English version, with all but one person choosing the Vietnamese version. There was one designated data collector for each group: a child health nurse for the Australian group and a Vietnamese Liaison Officer for the Vietnamese group. Although the questionnaires were self-administered, the designated data collectors were on hand to clarify any questions. The Vietnamese Liaison Officer, who is a qualified interpreter, assisted in interpreting the open-ended questions and vignettes in a culturally appropriate way and translating the data into English.All information, consent forms, and the questionnaire were translated into Vietnamese by a qualified Vietnamese language translator and then back translated for accuracy. This is a methodologically sound and well-accepted approach in cross-cultural research [24].


## 2.2.5. Recruitment

Focus Groups
The Vietnamese focus group participants were selected from parents attending the Community Centre’s Bacillus-Calmette-Guerin (BCG) Immunisation Clinic. They were approached by the Vietnamese liaison officer and gave verbal consent to participate in the focus group discussions. The Australian focus group participants were primarily parents who attended the Centre’s parenting groups and baby clinics, who verbally agreed to participate in the focus group discussions.Questionnaire
In recruiting participants for the questionnaire (See Supplementary Material available online at doi:10.1155/2012/932364), existing clients of Inala Community Health Centre’s immunisation clinics, child health clinics, and parenting groups, with children between 0 and 5 years of age, were directly approached by the Centre’s child health nurses and/or the Vietnamese Liaison Officer. The majority of the Vietnamese-born participants were clients attending the BCG immunisation clinics and the rest were clients of the Home Visiting Program. The participants were given an information sheet, either in English or Vietnamese, outlining the details and purpose of the study.
While there is some power gradient involved, as the parents are clients of the child health nurses and the interpreter, the nonthreatening nature of the study was explained. Using a Vietnamese recruiter helped to reduce the power gradient [25]. The participants were assured of confidentiality and anonymity and were informed of their right to refuse or participate. All parents signed a consent form.


## 2.3. Method of Analysis of Data

The focus group discussions were not taped because the literature indicates that this is not well accepted by Vietnamese women [10]. All efforts were made to accurately transcribe the main issues; however, without taping the sessions, content analysis was not possible. When analysing the responses for roles of health professionals, a panel of experts (two Caucasian Australian-born health care workers and two Vietnamese-born health care workers) independently scored the answers as correct, partly correct, or incorrect. The questions left unanswered were assumed to be incorrect (the participants who left the questions unanswered informed the Vietnamese interpreter that they did not know the answers). The vignette responses were also independently scored as correct, acceptable, or incorrect, by two paediatricians.The questionnaire responses were entered into SPSS and descriptive statistics generated. The two study groups were examined in terms of demographic variables, utilisation of health services, satisfaction with health services, and understanding and perception of health professionals roles, common issues in child development and health, and causation of childhood conditions. For continuous variables one-way analysis of variance (ANOVA) and the Chi-squared tests for categoric variables were used.Due to the small number of study participants, some of the variables were recoded with categories collapsed together. Frequency distribution curves were studied to determine which categories were to be collapsed together.


## 3. Results

Focus Groups
The main findings are summarised in Table1. Discussions revolved around five main issues: health service utilisation, understanding of the roles of health professionals, child development issues, issues relating to parenting and discipline, and  perception of causation of chronic disabilities and medical conditions.Table 1
Focus group findings.
IssueVietnameseAustralianHealth ServicesPrimarily GP1Use community health services and GPSatisfied with GPLess satisfied with GPDifficulty accessing community health services because of transportation problems; want home visitsWant community centres to run fathers’ groupsRoles of health professionalsUnderstood roles of GP, and paediatricianUnderstood roles of GP, paediatrician, CHN2, PT3Confused roles of psychologist and psychiatristConfused roles of psychologist and psychiatristDid not know roles of PT, OT4, SLP5, CHN, and SW6Did not know roles of OT, SLP, and SWChild DevelopmentOffered child(ren) variety of toysEmphasis on educational toysSolid food introduced same time as Caucasian groupAllowed child to feed independently later for fear of messParentingPreferred explanation for discipline rather than spankingMostly infants so discipline not as relevantCausation of chronic medical conditions, and disabilitiesAsthmaCold, wind, allergiesGenetics, environment, grass, sandMental IllnessTrauma, use of OCP7, previous abortion, KarmaGenetics, stressEpilepsyDon’t knowGenetics, trauma, drugsADHD8Don’t knowSocial factors, parenting, foods, preservativesCP9Don’t knowGenetics, inutero problems, vitamin deficiencies1General Practitioner, 2Community Health Nurse, 3Physiotherapist, 4Occupational therapist, 5Speech and Language Pathologist, 6Social Worker, 7Oral contraceptive pill, 8Attention deficit hyperactivity syndrome, 9Cerebral Palsy.Questionnaire
The questionnaire completion rate varied depending on the questions. The Vietnamese participants tended to leave questions blank if they did not know the answer or completed some of the questions about satisfaction with health services incorrectly, that is, attempted to answer question about a service they had not used.


### 3.1. Demographics

Table2 compares the demographic characteristics of the two questionnaire study groups. The majority of participants were mothers and were in married or common-law relationships. The Australian group were slightly older, although this was not statistically significant. They had more children (P=.024) who tended to be older (P=.05), and these differences were statistically significant. In both groups most participants had not proceeded to tertiary education (only two Vietnamese participants had done some university studies and one Australian participant had completed university). The majority of participants were not in paid employment, with only one participant (Vietnamese) working outside the home.Table 2
Demographics of questionnaire participants.
VariableVietnamesen=12 (%)Australiann=10 (%)1PRoleMother12 (100)10 (100)—Father0 (0)0 (0)N Respondents (%)12 (100)10 (100)Age of parent (years)Responders (%)12 (100)10 (100).16<306 (50)2 (20)≥306 (50)8 (80)N Respondents (%)12 (100)10 (100)Years in Australia (mean, SD)6.5 (3.14)Born hereN Respondents (%)12 (100)10 (100)Marital statusMarried/Common-Law8 (80)9 (90).53Other2 (20)1 (10)N Respondents (%)10 (83.3)10 (100)Number  of  children (mean, SD)1.83 (0.72)2.70 (0.95).024N Respondents (%)12 (100)10 (100)Age children (mean, SD)2.13 (2.13)3.75 (1.33).05N Respondents (%)12 (100)10 (100)Income2Low (<$20,000)3 (60)1 (11.1).09Middle ($20,000–$29,000)0 (0)4 (44.4)High (>$30,000)2 (40)4 (44.4)N Respondents (%)5 (41.6)9 (90)Level of educationSome secondary3 (27.3)4 (40).66Completed secondary8 (72.7)6 (60)N Respondents (%)11 (91.6)10 (100)OccupationHome duties10 (90.9)10(100).52Fulltime work1 (9.1)0 (0)N respondents (%)11 (91.6)10 (100)1One participant recruited was excluded from study analysis as it did not meet eligibility criteria.2Based on Australian Bureau of Statistics DataHousehold Income and Income Distribution 2002-2003.More than half of the Vietnamese participants did not respond to the income question, but of those who responded, 60% had incomes below $20,000 a year compared to only 11.1% of the Australian group, although this difference was not statistically significant.41.7% of the Vietnamese participants had lived in Australia for at least nine years, with the mean years in Australian 6.5 (SD 3.14), but most participants only rated their spoken English ability and understanding and ability to read English as “all right” or “very little or not at all”.Tables3 and 4 compare the general health and community health services (out of all the child health services available at Inala Community Health Centre) utilised by the two groups, showing that the Vietnamese group used therapy services and information seminars significantly less than the Australian group. Of the community services, immunisation clinics, home visiting services, and antenatal services were the most utilised by Vietnamese participants.Table 3
Utilisation of health services by questionnaire participants.
Services used—sometimes/oftenVietnameseN=12AustralianN=10PGeneral PractitionerN Utilising12 (100)10 (100)—N Respondents (%)12 (100)10 (100)HospitalN Utilising9 (90)8 (80).50N respondents (%)10 (83.3)10 (100)Community Health CentreN Utilising10 (83.3)10 (100).50N respondents (%)10 (100)10 (100)Medical SpecialistN Utilising8 (66.7)8 (80).42N respondents (%)12 (100)10 (100)Health ProfessionalN Utilising8 (80)8 (66.7).42N respondents (%)12 (100)10 (100)TherapistN Utilising1 (9.1)7 (70).007N respondents (%)11 (91.7)10 (100)Alternative PractitionerN Utilising12 (100)10 (100).41N respondents (%)2 (16.7)3 (30)Table 4
Use of services at inala community health centre.
Services usedVietnameseN (%)N Respondents (%) =12 (100)CaucasianN (%)N Respondents (%) =10 (100)PInformation seminars04 (40).03Parent information groups02 (20).20Home visits6 (50)5 (50).67Triple P (Parenting workshops)03 (30).08Immunisation clinics9 (75)5 (50).22Infant Feeding Clinic1 (8.2)1 (10).71Therapy (PT, OT, SLP)05 (50).01Paediatrician clinic1 (8.2)4 (40).11CYMHS12 (16.7)1 (10).57Antenatal clinic4 (33.3)7 (70).10Day management1 (8.3)2 (20).43Other01 (10).461Child, Youth, and Mental Health Services.Table5 displays the results from the semantic differential questions, used to explore parental perception of various health services and professionals. Participants were asked to place an X on a visual analogue scale, corresponding to how their perceptions regard a particular service (see Supplementary Material). As the scale contained 5 boxes, the response was translated to a numerical value between “1” being most negative and “5” being most positive. A mean overall satisfaction score was calculated for each professional/service. Both groups held positive perceptions of general practitioners, hospitals, and community health centres.Table 5
Satisfaction with health services used.
Services usedMean (SD) [Respondents (%)]PVietnameseAustralianGP4.45 (0.69)4.47 (0.49).94[12 (100)][10 (100)]Hospital4.41 (0.72)4.83 (0.29).14[12 (100)][8 (80)]Com Health Cent4.50 (0.70)4.72 (0.44).42[12 (100)][9 (90)]Medical Specialist4.03 (0.80)4.68 (0.77).14[6 (50)][9 (90)]Health Professional4.16 (0.83)4.81 (0.30).065[5 (41.6)][8 (80)]Therapist4.00 (0.00)4.84 (0.42).029[2 (16.7)][7 (70)]Alternative Practitioner4.33 (0.58)4.67 (0.58).52[3 (25)][3 (30)]The Vietnamese group were less positive about medical specialists, although this was not statistically significant. The Vietnamese group rated other health professionals (dentists, optometrists) less positively than the Australian group with the difference almost reaching statistical significance (P=.065). The two Vietnamese respondents rated therapists significantly less positively than the Australian group (P=.029). Both groups rated alternative practitioners quite positively on all qualities, but the number of respondents was small in both groups.Table6 displays the degree of satisfaction participants had with community child health services used, with “1” being the least satisfied and “5” being the most satisfied. However the number of respondents was very low for all services apart from home visiting, immunisation clinic, and antenatal clinic. The degree of satisfaction with all these services was high for both groups, with no statistical difference between the groups.Table 6
Satisfaction with community child health services used.
Services usedMean (SD) (Respondents (%))PVietnameseAustralianHome Visiting4.67 (0.52)4.33 (0.82).27[6 (50)][6 (60)]Immunisation Clinic4.75 (0.46)4.67 (0.82).41[8 (66.67)][6 (60)]Feeding5.00 (0.00)5.00 (0.00)—[1 (8.33)][3 (30)]Paediatrician5.00 (0.00)5.00 (0.00)—[1 (8.33)][3 (30)]CYMHS5.00 (0.00)4.00 (0.00)0.5[1 (8.33)][1 (10)]Antenatal4.75 (0.500)4.86 (0.38).45[4 (30)][7 (70)]Table7 tabulates participants’ understanding of health professionals’ roles, with the Vietnamese group having less knowledge than the Australian group of roles. In particular many in the Vietnamese group were unfamiliar with the roles of therapists. Also of note was the high rate confusion in both groups of psychiatrists and psychologists roles. There was a significant difference between the two groups in understanding the role of physiotherapist and speech pathologist, P=.036 and P=.008, respectively.Table 7
Understanding of professionals’ roles.
ProfessionalPartially/fully correctPVietnameseN (%)AustralianN (%)Physiotherapist2 (33.3)9 (90).036N Respondents (%)6 (50)11 (100)Speech Pathologist2 (33.3)10 (100).008N Respondents (%)6 (50)10 (100)Occupational Therapist2 (33.3)7 (70).18N Respondents (%)6 (50)10 (100)Psychologist2 (33.3)5 (50).45N Respondents (%)6 (50)10 (100)Psychiatrist3 (42.9)5 (50).58N Respondents (%)7 (58.3)10 (100)Community Health Nurse5 (71.4)7 (70).69N Respondents (%)7 (58.3)10 (100)General Practitioner7 (70)9 (90).29N Respondents (%)10 (83.3)10 (100)Paediatrician6 (75)9 (90).41N Respondents (%)8 (66.6)10 (100)Table8 outlines participant responses to the following vignettes: one, management of an acute diarrhoeal illness; two, approach to a child who is a picky eater; three, approach to an 18-month-old child who drinks only milk; four, approach to 2.5-year-old child who wants to feed independently; five, management of a 20-month-old child who is not walking; six, management of a 2-year-old child who is not talking; seven, perception regarding importance of tummy time when playtime; eight, perception regarding importance of books; and nine, perception regarding child playing in the mud.Table 8
Vignettes.
VignettePartially/fully correctPVietnameseN (%)N Respondents (%) = 11 (91.6)AustralianN (%)N Respondents (%) = 10 (100)Diarrhoea10 (90.9)10 (100).52Picky eater5 (45.5)9 (90).043Excessive milk9 (81.8)10 (100).26Feeding7 (63.6)10 (100).06Delayed walker3 (27.3)5 (50).27Delayed language4 (40)6 (60).21Tummy time7 (58.3)8 (80).27Reading6 (54.5)10 (100).023Cleanliness11 (100)10 (100).50Tantrum10 (90.9)10 (100).52Both groups had a high rate of partially or fully correct responses for the vignettes, but the vignettes about delayed walking and delayed speech and language produced the greatest rate of incorrect responses from both groups. The Vietnamese group were statistically difference from the Australian group, with more incorrect responses for the vignettes about picky eater, feeding, and reading/books. The majority of participants in the Vietnamese group answered that they would “buy more books for their child but let her decide what she wanted to play with”, for the vignette about reading and books. The majority of participants from both study group responded that they would “explain to their child that it was dinner time and it would be nice if she came”, for the tantrum vignette, with only one participant (Australian) responding that they would take the child to “quite time” (time out).Table9 tabulates the responses of the two groups with regard to the causation of medical and neurodevelopmental conditions. Forced choice options were generated from the prior focus group discussions. Results have been presented descriptively, rather than as “correct” or “incorrect” answers, as some causes are debatable, and descriptive data give more insight into cultural beliefs around disease and illness. The Vietnamese group were more likely to answer that “upbringing” was a cause of Attention Deficit Hyperactivity Syndrome (ADHD) and were less likely to believe that “genetics” was a cause, with these differences being statistically significant. Additionally the Vietnamese group were less likely to respond that “genetics” was a cause of asthma, cerebral palsy (CP) or mental illness, with the former almost reaching statistical significance (P=.056) and the latter being a statistically significant difference (P=.004). Of note, one Vietnamese participant answered that “what one did in a previous life” was a cause of CP. The same participant also stated that this was a cause of epilepsy. Another Vietnamese participant stated that “abortion” (previous abortion) was a cause for mental illness in a woman.Table 9
Causes of conditions.
ConditionCauseVietnameseN (%)AustralianN (%)PADHDUpbringing4 (44)0.029Preservatives3 (27.3)6 (60).24Previous life00—Genetics3 (27.3)8 (80).043N respondents (%)8 (66.7)9 (90)AsthmaGenetics7 (63.6)10 (100).055Catch it1 (9.1)0.52Preservatives02 (20).21Cold weather7 (64)4 (36).14N respondents (%)11 (91.7)10 (100)CPGenetics1 (9.1)8 (80).004Diet3 (27.3)3 (30).19Birth trauma5 (62.5)3 (30).18Previous life1 (13)0.44N respondents (%)8 (66.7)10 (100)EpilepsyPrevious life1 (11.1)0.47Abortion00—Head injury5 (56)6 (55).59Genetics5 (56)9 (82).26N respondents (%)9 (75)10 (100)Mental illnessPrevious life00.21Genetics3 (25)9 (90).017Psychological trauma6 (66.7)8 (80).44Abortion2 (22.2)0.21N respondents (%)9 (75)10 (100)


## 3.1. Demographics

Table2 compares the demographic characteristics of the two questionnaire study groups. The majority of participants were mothers and were in married or common-law relationships. The Australian group were slightly older, although this was not statistically significant. They had more children (P=.024) who tended to be older (P=.05), and these differences were statistically significant. In both groups most participants had not proceeded to tertiary education (only two Vietnamese participants had done some university studies and one Australian participant had completed university). The majority of participants were not in paid employment, with only one participant (Vietnamese) working outside the home.Table 2
Demographics of questionnaire participants.
VariableVietnamesen=12 (%)Australiann=10 (%)1PRoleMother12 (100)10 (100)—Father0 (0)0 (0)N Respondents (%)12 (100)10 (100)Age of parent (years)Responders (%)12 (100)10 (100).16<306 (50)2 (20)≥306 (50)8 (80)N Respondents (%)12 (100)10 (100)Years in Australia (mean, SD)6.5 (3.14)Born hereN Respondents (%)12 (100)10 (100)Marital statusMarried/Common-Law8 (80)9 (90).53Other2 (20)1 (10)N Respondents (%)10 (83.3)10 (100)Number  of  children (mean, SD)1.83 (0.72)2.70 (0.95).024N Respondents (%)12 (100)10 (100)Age children (mean, SD)2.13 (2.13)3.75 (1.33).05N Respondents (%)12 (100)10 (100)Income2Low (<$20,000)3 (60)1 (11.1).09Middle ($20,000–$29,000)0 (0)4 (44.4)High (>$30,000)2 (40)4 (44.4)N Respondents (%)5 (41.6)9 (90)Level of educationSome secondary3 (27.3)4 (40).66Completed secondary8 (72.7)6 (60)N Respondents (%)11 (91.6)10 (100)OccupationHome duties10 (90.9)10(100).52Fulltime work1 (9.1)0 (0)N respondents (%)11 (91.6)10 (100)1One participant recruited was excluded from study analysis as it did not meet eligibility criteria.2Based on Australian Bureau of Statistics DataHousehold Income and Income Distribution 2002-2003.More than half of the Vietnamese participants did not respond to the income question, but of those who responded, 60% had incomes below $20,000 a year compared to only 11.1% of the Australian group, although this difference was not statistically significant.41.7% of the Vietnamese participants had lived in Australia for at least nine years, with the mean years in Australian 6.5 (SD 3.14), but most participants only rated their spoken English ability and understanding and ability to read English as “all right” or “very little or not at all”.Tables3 and 4 compare the general health and community health services (out of all the child health services available at Inala Community Health Centre) utilised by the two groups, showing that the Vietnamese group used therapy services and information seminars significantly less than the Australian group. Of the community services, immunisation clinics, home visiting services, and antenatal services were the most utilised by Vietnamese participants.Table 3
Utilisation of health services by questionnaire participants.
Services used—sometimes/oftenVietnameseN=12AustralianN=10PGeneral PractitionerN Utilising12 (100)10 (100)—N Respondents (%)12 (100)10 (100)HospitalN Utilising9 (90)8 (80).50N respondents (%)10 (83.3)10 (100)Community Health CentreN Utilising10 (83.3)10 (100).50N respondents (%)10 (100)10 (100)Medical SpecialistN Utilising8 (66.7)8 (80).42N respondents (%)12 (100)10 (100)Health ProfessionalN Utilising8 (80)8 (66.7).42N respondents (%)12 (100)10 (100)TherapistN Utilising1 (9.1)7 (70).007N respondents (%)11 (91.7)10 (100)Alternative PractitionerN Utilising12 (100)10 (100).41N respondents (%)2 (16.7)3 (30)Table 4
Use of services at inala community health centre.
Services usedVietnameseN (%)N Respondents (%) =12 (100)CaucasianN (%)N Respondents (%) =10 (100)PInformation seminars04 (40).03Parent information groups02 (20).20Home visits6 (50)5 (50).67Triple P (Parenting workshops)03 (30).08Immunisation clinics9 (75)5 (50).22Infant Feeding Clinic1 (8.2)1 (10).71Therapy (PT, OT, SLP)05 (50).01Paediatrician clinic1 (8.2)4 (40).11CYMHS12 (16.7)1 (10).57Antenatal clinic4 (33.3)7 (70).10Day management1 (8.3)2 (20).43Other01 (10).461Child, Youth, and Mental Health Services.Table5 displays the results from the semantic differential questions, used to explore parental perception of various health services and professionals. Participants were asked to place an X on a visual analogue scale, corresponding to how their perceptions regard a particular service (see Supplementary Material). As the scale contained 5 boxes, the response was translated to a numerical value between “1” being most negative and “5” being most positive. A mean overall satisfaction score was calculated for each professional/service. Both groups held positive perceptions of general practitioners, hospitals, and community health centres.Table 5
Satisfaction with health services used.
Services usedMean (SD) [Respondents (%)]PVietnameseAustralianGP4.45 (0.69)4.47 (0.49).94[12 (100)][10 (100)]Hospital4.41 (0.72)4.83 (0.29).14[12 (100)][8 (80)]Com Health Cent4.50 (0.70)4.72 (0.44).42[12 (100)][9 (90)]Medical Specialist4.03 (0.80)4.68 (0.77).14[6 (50)][9 (90)]Health Professional4.16 (0.83)4.81 (0.30).065[5 (41.6)][8 (80)]Therapist4.00 (0.00)4.84 (0.42).029[2 (16.7)][7 (70)]Alternative Practitioner4.33 (0.58)4.67 (0.58).52[3 (25)][3 (30)]The Vietnamese group were less positive about medical specialists, although this was not statistically significant. The Vietnamese group rated other health professionals (dentists, optometrists) less positively than the Australian group with the difference almost reaching statistical significance (P=.065). The two Vietnamese respondents rated therapists significantly less positively than the Australian group (P=.029). Both groups rated alternative practitioners quite positively on all qualities, but the number of respondents was small in both groups.Table6 displays the degree of satisfaction participants had with community child health services used, with “1” being the least satisfied and “5” being the most satisfied. However the number of respondents was very low for all services apart from home visiting, immunisation clinic, and antenatal clinic. The degree of satisfaction with all these services was high for both groups, with no statistical difference between the groups.Table 6
Satisfaction with community child health services used.
Services usedMean (SD) (Respondents (%))PVietnameseAustralianHome Visiting4.67 (0.52)4.33 (0.82).27[6 (50)][6 (60)]Immunisation Clinic4.75 (0.46)4.67 (0.82).41[8 (66.67)][6 (60)]Feeding5.00 (0.00)5.00 (0.00)—[1 (8.33)][3 (30)]Paediatrician5.00 (0.00)5.00 (0.00)—[1 (8.33)][3 (30)]CYMHS5.00 (0.00)4.00 (0.00)0.5[1 (8.33)][1 (10)]Antenatal4.75 (0.500)4.86 (0.38).45[4 (30)][7 (70)]Table7 tabulates participants’ understanding of health professionals’ roles, with the Vietnamese group having less knowledge than the Australian group of roles. In particular many in the Vietnamese group were unfamiliar with the roles of therapists. Also of note was the high rate confusion in both groups of psychiatrists and psychologists roles. There was a significant difference between the two groups in understanding the role of physiotherapist and speech pathologist, P=.036 and P=.008, respectively.Table 7
Understanding of professionals’ roles.
ProfessionalPartially/fully correctPVietnameseN (%)AustralianN (%)Physiotherapist2 (33.3)9 (90).036N Respondents (%)6 (50)11 (100)Speech Pathologist2 (33.3)10 (100).008N Respondents (%)6 (50)10 (100)Occupational Therapist2 (33.3)7 (70).18N Respondents (%)6 (50)10 (100)Psychologist2 (33.3)5 (50).45N Respondents (%)6 (50)10 (100)Psychiatrist3 (42.9)5 (50).58N Respondents (%)7 (58.3)10 (100)Community Health Nurse5 (71.4)7 (70).69N Respondents (%)7 (58.3)10 (100)General Practitioner7 (70)9 (90).29N Respondents (%)10 (83.3)10 (100)Paediatrician6 (75)9 (90).41N Respondents (%)8 (66.6)10 (100)Table8 outlines participant responses to the following vignettes: one, management of an acute diarrhoeal illness; two, approach to a child who is a picky eater; three, approach to an 18-month-old child who drinks only milk; four, approach to 2.5-year-old child who wants to feed independently; five, management of a 20-month-old child who is not walking; six, management of a 2-year-old child who is not talking; seven, perception regarding importance of tummy time when playtime; eight, perception regarding importance of books; and nine, perception regarding child playing in the mud.Table 8
Vignettes.
VignettePartially/fully correctPVietnameseN (%)N Respondents (%) = 11 (91.6)AustralianN (%)N Respondents (%) = 10 (100)Diarrhoea10 (90.9)10 (100).52Picky eater5 (45.5)9 (90).043Excessive milk9 (81.8)10 (100).26Feeding7 (63.6)10 (100).06Delayed walker3 (27.3)5 (50).27Delayed language4 (40)6 (60).21Tummy time7 (58.3)8 (80).27Reading6 (54.5)10 (100).023Cleanliness11 (100)10 (100).50Tantrum10 (90.9)10 (100).52Both groups had a high rate of partially or fully correct responses for the vignettes, but the vignettes about delayed walking and delayed speech and language produced the greatest rate of incorrect responses from both groups. The Vietnamese group were statistically difference from the Australian group, with more incorrect responses for the vignettes about picky eater, feeding, and reading/books. The majority of participants in the Vietnamese group answered that they would “buy more books for their child but let her decide what she wanted to play with”, for the vignette about reading and books. The majority of participants from both study group responded that they would “explain to their child that it was dinner time and it would be nice if she came”, for the tantrum vignette, with only one participant (Australian) responding that they would take the child to “quite time” (time out).Table9 tabulates the responses of the two groups with regard to the causation of medical and neurodevelopmental conditions. Forced choice options were generated from the prior focus group discussions. Results have been presented descriptively, rather than as “correct” or “incorrect” answers, as some causes are debatable, and descriptive data give more insight into cultural beliefs around disease and illness. The Vietnamese group were more likely to answer that “upbringing” was a cause of Attention Deficit Hyperactivity Syndrome (ADHD) and were less likely to believe that “genetics” was a cause, with these differences being statistically significant. Additionally the Vietnamese group were less likely to respond that “genetics” was a cause of asthma, cerebral palsy (CP) or mental illness, with the former almost reaching statistical significance (P=.056) and the latter being a statistically significant difference (P=.004). Of note, one Vietnamese participant answered that “what one did in a previous life” was a cause of CP. The same participant also stated that this was a cause of epilepsy. Another Vietnamese participant stated that “abortion” (previous abortion) was a cause for mental illness in a woman.Table 9
Causes of conditions.
ConditionCauseVietnameseN (%)AustralianN (%)PADHDUpbringing4 (44)0.029Preservatives3 (27.3)6 (60).24Previous life00—Genetics3 (27.3)8 (80).043N respondents (%)8 (66.7)9 (90)AsthmaGenetics7 (63.6)10 (100).055Catch it1 (9.1)0.52Preservatives02 (20).21Cold weather7 (64)4 (36).14N respondents (%)11 (91.7)10 (100)CPGenetics1 (9.1)8 (80).004Diet3 (27.3)3 (30).19Birth trauma5 (62.5)3 (30).18Previous life1 (13)0.44N respondents (%)8 (66.7)10 (100)EpilepsyPrevious life1 (11.1)0.47Abortion00—Head injury5 (56)6 (55).59Genetics5 (56)9 (82).26N respondents (%)9 (75)10 (100)Mental illnessPrevious life00.21Genetics3 (25)9 (90).017Psychological trauma6 (66.7)8 (80).44Abortion2 (22.2)0.21N respondents (%)9 (75)10 (100)


## 4. Discussion

This study has elicited important issues relating to Vietnamese immigrant and refugee parents’ perception of child health, development, and their utilisation of child health services, with the intention of further exploration of these issues with a subsequent full-scale study.The main study findings and implications are summarised in Tables10 and 11. The findings do partly support the initial hypotheses that Vietnamese immigrant parents living in Brisbane have different perceptions about parenting roles and child health, illness, disability, discipline, behaviour, and child health services, compared with Australian-born Caucasian parents, and that they underutilise child health services, have less knowledge of them, are less able to access them, and are less satisfied with those they have used compared with Australian-born Caucasian parents. Two important themes emerged from this study: utilisation of child health services and perceptions of parenting roles, child health, and child development.Table 10
Summary of main study findings.
Vietnamese participants compared with Australian participants(1) Have different perceptions of early childhood development.(2) Stigmatise mental and physical conditions more.(3) Regard general practitioner as the primary as first point of call for children’s health issues.(4) Have little knowledge of available community child health services and do not tend to utilise these services apart from home visiting and antenatal services.(5) Have little knowledge of allied health professionals’ roles.(6) Are less satisfied with community health services they have had contact with previously.Table 11
Implications of study findings.
(1) Structures questionnaire study methodology may not be appropriate for study type.(2) More qualitative methodology such as focus group discussions or unstructured interviews may be preferable.(3) Potential differences in perceptions of the Vietnamese and Australian parents regarding child development warrant further study.(4) Reasons for Vietnamese parents not accessing community child health services warrant further study.


### 4.1. Utilisation of Health Services

The majority of the Vietnamese study participants had Vietnamese family doctors, with whom they primarily consulted for issues relating to their children’s health. Very few were familiar with the services provided by the Community Health Centre, apart from the BCG Immunisation Clinic, antenatal clinic, and the Home Visiting Program. In Queensland infants with parents from an Asian background are offered BCG vaccine to protect them from contracting tuberculosis, and information about where to obtain immunisations is given to parents at the time of discharge from the maternity hospital. The Home Visiting Program at the time of this study was offered to all first-time mothers who requested the service or who were referred from the maternity hospital after giving birth.The Vietnamese focus group participants expressed a wish for more home visiting services, to obtain assistance and advice about their infants’ feeding and sleeping. However, Vietnamese questionnaire participants were less familiar with the role health professionals such as therapists, social workers, and community nurses. This is not surprising, considering that these professional roles do not exist in the traditional Vietnamese health system. Vietnamese participants first consulted their relatives and then their Vietnamese family doctor, for child health-related problems. Many preferred to delay and see their general practitioner rather than attend a community health centre and utilise the services of an interpreter. The vast majority of questionnaire participants in both groups gave the response “never needed their service” as a reason for never using a particular health service. The rest gave reasons of “do not know about them” and “too expensive”, but nobody gave reasons of “transport problems”, “language”, “culture”, or any other reason. Of those who had utilised other health services (therapy services, paediatricians, dentists and optometrists) the Vietnamese participants were less satisfied than Australian participants.Several Australian studies have explored health concerns and barriers to accessing health services in Vietnamese families and arrived at similar conclusions as our study [10–12]. These studies concluded that Vietnamese participants were highly concerned about their children’s general health, growth, and development and nutrition [11].Similar to the findings from this study, some studies found that Vietnamese-born immigrants expected from community health centres such services as home visiting, advice and information, health checks, and bilingual professionals [11, 12], but only 30% of Vietnamese people were aware of, and 10% utilised community health services [10]. Reasons given by participants in these studies for not utilising health services again were language barriers, inappropriate manner, lack of cultural sensitivity, transportation barriers, and waiting time [10, 11]. Health professionals interviewed perceived that barriers to Vietnamese people accessing services included culture, language, transport, privacy, and lack of understanding of preventative health [10, 11]. Maltby’s study found Vietnamese parents to be less comfortable with services where the use of interpreters was required [10]. High quality of “care” was perceived as being kept informed of what was going on [10]. Another barrier to accessing health services may be traditional health beliefs.Vietnamese people tend to define their health problems in terms of physical symptoms, including emotional or psychological disturbances, which avoids the stigmata of mental illness [26]. Initially symptoms are self-managed by adopting Chinese medical tenets and practices: for example, dermal practices such as Cao Gioa and adjustment of diet between “hot” and “cold” foods to balance humoral forces of yin and yang [7, 26]. When self-care does not work, they seek a medical doctor to get medicine for the symptoms. If they go to a doctor and do not get medicine, they often feel “cheated” [26]. Western medicines are used more often for infectious diseases, and traditional medicine is preferred for digestive problems, insomnia, and colds [27].A study into Vietnamese-born parents’ oral health practices [13] concluded that Vietnamese parents in Australia retain traditional oral health practices and utilised oral health and dental services only when symptoms arose (e.g., toothache), rather than in a preventative manner. In addition to the lack of awareness of preventative dental health, the study parents cited language difficulties as being a major barrier to accessing school-based oral health programs for their children [13].Australian research into use of children’s hospital services by families from culturally and linguistically diverse (CALD) backgrounds found that CALD families were very satisfied with their children’s care, though they also tended to not complain or express dissatisfaction for fear of repercussion or appearing to stand out [28]. The major barrier to accessing services was not just language but communication issues, which resulted in cultural mismatches. Issues from a patient or parent perspective included ability to express oneself clearly, understanding medical jargon, and communicating effectively with health professions [28]. Staff faced barriers in seeking to understand family needs and impart health information [28]. Interpreter services in part ameliorated these communication issues but the study raised concerns about appropriate use of and access to interpreter services [28].


### 4.2. Perception of Parenting Roles, Child Development, Child Health, Illness, and Disability

Both Vietnamese and Australian questionnaire participants recognised when to seek medical attention for an acute illness and both groups understood principles of infant nutrition.Whilst there was no difference between the age (around six months) at which participants in the two focus groups introduced solid foods, the Vietnamese focus group participants tended to delay independent feeding, preferring to wait until the child was old enough to “not make a mess” (around 2 years). This was also consistent with the result from the feeding vignette in the questionnaire, which only 63.6% of Vietnamese study participants answered correctly. The focus group discussions found that the Vietnamese participants tended to allow their children to play with any toys that they wanted, whereas the Australian participants bought what they perceived to be educational toys. This was also consistent with the result of the reading vignette in which there was a difference between the two groups in correct responses, with only 54.5% of the Vietnamese group responding that they would read more to their child, and the rest responding that they would buy more books but let the child play with what they wanted.The Vietnamese questionnaire participants were less likely to encourage “tummy time” in play than the Australian participants. Tummy time refers to placing the infant in the prone position during play and is thought to be important in encouraging development of crucial weight bearing upper body and upper limb muscles and consequently gross motor skills, such as pushing up and crawling [29]. Wise and Da Silva in their report for the Australian Institute of Family Studies (AIFS) described parenting as encompassing a number of different aspects, including beliefs, values, goals, and behaviours [30]. Each of these dimensions can be influenced by child characteristics, parent characteristics, physical and social context, and child rearing customs [30]. Harkness and Super [31] coined the term “parental ethnotheories” to help explain cultural differences in parenting. Ethnotheories are collective beliefs held by a cultural group about children’s development and behaviour. Aspects of childrearing (e.g., Parenting goals, discipline practices, and beliefs about child development) are influenced by the characteristics of “individualistic” (Westernised) and “collectivist” (traditional) societies [32]. Individualistic societies value autonomy and independence and encourage children to demonstrate initiative from an early age, as well as honest expression of emotion [30]. In collectivist societies, children are taught to place community responsibility above individual interest, and emotional control is emphasised [30]. Parents of Anglo-Celtic origin often hold earlier expectations for development than parents from other cultures [30]. Acculturation as in the case of immigration can moderate the influence of culture on childrearing [30]. The findings from this study support the notion that Vietnamese parents tend to expect their children to achieve independent developmental milestones such as gross motor skills, and feeding skills, at a later age than Anglo-Australian parents, and that child rearing practices and beliefs of Vietnamese parents are influenced by collectivist philosophy.Research has examined differences in the way various cultures parent and how this may impact on the child’s development [33–36]. This literature indicates that most infants achieve major developmental milestones at similar ages [33], but developmental rate and more subtle aspects of development may differ between different cultures and ethnic groups [34, 36]. Coll [35] in a review of this literature concluded that differences in parental goals, perceptions, and interactions with infants and children result in alternative or different pathways, which are within a normal range of development.Research undertaken by Wise and colleagues for the AIFS has studied cultural variations in parenting beliefs and behaviours between Anglo-Australian parents, Vietnamese parents, and Somali parents [30]. Main findings of relevance were that Anglo parents valued independence in the child significantly more than Vietnamese parents, and child compliance was valued significantly more by Vietnamese parents than Anglo parents [30].Vietnamese-focus group participants tended to use “softer” methods of explaining rather than “time-out”. This is consistent with literature on more permissive and tolerant parenting of younger children in the Vietnamese culture [18]. The Australian focus group participants primarily had infants; so this topic was not as relevant to them. In contrast, the majority of questionnaire participants in both groups responded that they would use a “softer method” of explanation rather than “time-out” for the vignette about the child having a tantrum.Vietnamese focus group and questionnaire participants were more likely to attribute nonmedical rather than medical factors as being causative for medical and neurodevelopmental conditions such as ADHD, epilepsy, and CP. One Vietnamese questionnaire respondent perceived “what you did in a previous life” to be a cause of epilepsy and CP, and another person perceived that attempted abortion was a cause of mental illness in a mother. One Vietnamese focus group participant perceived that Karma, attempted abortion, and taking the oral contraceptive pill were also causes of mental illness in children. These findings are consistent with the current literature, which indicates that Asians living in Western countries tend to stigmatise disability and mental illness more than their Western counterparts [37–43]. One such study explores the perceptions of various groups of ethnic university students and found that Asian-Americans, particularly those Asian born, saw physical and mental disabilities as being more stigmatised than did African-Americans, Latin-Americans, and European-Americans [38]. An Australian study found that Asian students, especially those who spoke a language other than English at home, were more negative toward and less knowledgeable about mental illness than European-Australian students [39].Another Australian study, which explored parental perceptions of child psychopathology and disease causation, of Vietnamese parents living in Perth, found that the majority of parents (75.5% to 78.1%) thought that child mental illness was caused by biological/chemical imbalance in the brain, trauma or bad experiences, and a metaphysical or spiritual imbalance. 57.2% endorsed a genetic or hereditary cause, and 17.6% indicated karma as the cause of child mental illness.One reason for Vietnamese immigrants’ more negative perception of mental illness may be the Confucian tradition of sacrificing individual needs to that of the overall group needs [40]. Since a person with a disability may not contribute to the collective good in a way that a healthy person might contribute [40], they are perceived as less important. A strong emphasis on conformity and a general intolerance of differences in Asian cultures may also be a relevant factor [41, 42]. Another contributing factor may be the commonly held belief that mental illness is a manifestation of weakness of the mind [37]. A psychiatrist is referred to as either a “nerve doctor” or a “doctor for the insane”, which emphasises Vietnamese people’s beliefs that mental illness are “bizarre and out of this world” in nature [37]. As a result of these beliefs, Vietnamese people rarely seek out mental health services [37].


### 4.3. Conflicting Study Findings

There are a number of possible explanations for conflicting findings from the Vietnamese focus group discussions and questionnaire. Firstly, there may be inherent differences in these two groups, which influence perceptions regarding these issues. Participants from both groups were mostly recruited from the Centre’s BCG Immunisation Clinic. However sociodemographic information about the focus group participants would have been helpful in comparing these two groups. The second explanation is measurement or information bias due to two different methodological approaches, thus eliciting different responses. Of note the questionnaire response rate in the Vietnamese group was only 7/12 compared with 11/11 for the Australian group. The literature on cross-cultural research supports this explanation by indicating that focus groups or face-to-face interviews may be a more effective data collection method than structured questionnaire, as they can foster trust and allow participants to describe their view and experiences in a context in which cultural nuances can be recognised [25]. The Parenting-21 Study conducted by the AIFS utilised a semistructured questionnaire which was completed by the interviewer in a face-to-face interview [16]. The third possibility is that the sample size is too small for findings from the focus groups and questionnaires to be valid.


### 4.4. Study Limitations and Generalisability

There are limitations to this study, which may contribute to conflicting study findings. The main source of potential bias was differences in recruitment method for Vietnamese and Australian participants. The Vietnamese participants attended the BCG Immunisation clinic, whereas the Australian participants were attendants of the parents’ groups and baby clinics. This problem with recruitment was unavoidable, as no immunisation clinic exists for Caucasian Australian children at the Centre, and no existing Vietnamese clients utilised other services at the Centre.Utilisation of an inappropriate data collection method, of a structured questionnaire, may have resulted in measurement bias as it does not give the flexibility to express views and perceptions fully and can misinterpret cultural nuances [25].The majority of questionnaire participants both Vietnamese and Anglo-Australian were from a low sociodemographic background with no tertiary education and low income. The demographic profile of study participants is representative of Inala’s population [44]. For example, in the 2001 Census, the median weekly family income for Inala was from $500 to $599, whereas that for Australia is from $800 to $999.However these findings cannot be generalizable to Anglo-Australian or Vietnamese parents from higher sociodemographic backgrounds. In addition although 50% of the Vietnamese questionnaire participants had been in Australia for eight years or more, most of them rated their spoken English ability and understanding and ability to read English as “all right” or “very little or not at all”. Thus the study results are not necessarily generalizable to Vietnamese immigrants who are more acculturated into Australian society.


## 4.1. Utilisation of Health Services

The majority of the Vietnamese study participants had Vietnamese family doctors, with whom they primarily consulted for issues relating to their children’s health. Very few were familiar with the services provided by the Community Health Centre, apart from the BCG Immunisation Clinic, antenatal clinic, and the Home Visiting Program. In Queensland infants with parents from an Asian background are offered BCG vaccine to protect them from contracting tuberculosis, and information about where to obtain immunisations is given to parents at the time of discharge from the maternity hospital. The Home Visiting Program at the time of this study was offered to all first-time mothers who requested the service or who were referred from the maternity hospital after giving birth.The Vietnamese focus group participants expressed a wish for more home visiting services, to obtain assistance and advice about their infants’ feeding and sleeping. However, Vietnamese questionnaire participants were less familiar with the role health professionals such as therapists, social workers, and community nurses. This is not surprising, considering that these professional roles do not exist in the traditional Vietnamese health system. Vietnamese participants first consulted their relatives and then their Vietnamese family doctor, for child health-related problems. Many preferred to delay and see their general practitioner rather than attend a community health centre and utilise the services of an interpreter. The vast majority of questionnaire participants in both groups gave the response “never needed their service” as a reason for never using a particular health service. The rest gave reasons of “do not know about them” and “too expensive”, but nobody gave reasons of “transport problems”, “language”, “culture”, or any other reason. Of those who had utilised other health services (therapy services, paediatricians, dentists and optometrists) the Vietnamese participants were less satisfied than Australian participants.Several Australian studies have explored health concerns and barriers to accessing health services in Vietnamese families and arrived at similar conclusions as our study [10–12]. These studies concluded that Vietnamese participants were highly concerned about their children’s general health, growth, and development and nutrition [11].Similar to the findings from this study, some studies found that Vietnamese-born immigrants expected from community health centres such services as home visiting, advice and information, health checks, and bilingual professionals [11, 12], but only 30% of Vietnamese people were aware of, and 10% utilised community health services [10]. Reasons given by participants in these studies for not utilising health services again were language barriers, inappropriate manner, lack of cultural sensitivity, transportation barriers, and waiting time [10, 11]. Health professionals interviewed perceived that barriers to Vietnamese people accessing services included culture, language, transport, privacy, and lack of understanding of preventative health [10, 11]. Maltby’s study found Vietnamese parents to be less comfortable with services where the use of interpreters was required [10]. High quality of “care” was perceived as being kept informed of what was going on [10]. Another barrier to accessing health services may be traditional health beliefs.Vietnamese people tend to define their health problems in terms of physical symptoms, including emotional or psychological disturbances, which avoids the stigmata of mental illness [26]. Initially symptoms are self-managed by adopting Chinese medical tenets and practices: for example, dermal practices such as Cao Gioa and adjustment of diet between “hot” and “cold” foods to balance humoral forces of yin and yang [7, 26]. When self-care does not work, they seek a medical doctor to get medicine for the symptoms. If they go to a doctor and do not get medicine, they often feel “cheated” [26]. Western medicines are used more often for infectious diseases, and traditional medicine is preferred for digestive problems, insomnia, and colds [27].A study into Vietnamese-born parents’ oral health practices [13] concluded that Vietnamese parents in Australia retain traditional oral health practices and utilised oral health and dental services only when symptoms arose (e.g., toothache), rather than in a preventative manner. In addition to the lack of awareness of preventative dental health, the study parents cited language difficulties as being a major barrier to accessing school-based oral health programs for their children [13].Australian research into use of children’s hospital services by families from culturally and linguistically diverse (CALD) backgrounds found that CALD families were very satisfied with their children’s care, though they also tended to not complain or express dissatisfaction for fear of repercussion or appearing to stand out [28]. The major barrier to accessing services was not just language but communication issues, which resulted in cultural mismatches. Issues from a patient or parent perspective included ability to express oneself clearly, understanding medical jargon, and communicating effectively with health professions [28]. Staff faced barriers in seeking to understand family needs and impart health information [28]. Interpreter services in part ameliorated these communication issues but the study raised concerns about appropriate use of and access to interpreter services [28].


## 4.2. Perception of Parenting Roles, Child Development, Child Health, Illness, and Disability

Both Vietnamese and Australian questionnaire participants recognised when to seek medical attention for an acute illness and both groups understood principles of infant nutrition.Whilst there was no difference between the age (around six months) at which participants in the two focus groups introduced solid foods, the Vietnamese focus group participants tended to delay independent feeding, preferring to wait until the child was old enough to “not make a mess” (around 2 years). This was also consistent with the result from the feeding vignette in the questionnaire, which only 63.6% of Vietnamese study participants answered correctly. The focus group discussions found that the Vietnamese participants tended to allow their children to play with any toys that they wanted, whereas the Australian participants bought what they perceived to be educational toys. This was also consistent with the result of the reading vignette in which there was a difference between the two groups in correct responses, with only 54.5% of the Vietnamese group responding that they would read more to their child, and the rest responding that they would buy more books but let the child play with what they wanted.The Vietnamese questionnaire participants were less likely to encourage “tummy time” in play than the Australian participants. Tummy time refers to placing the infant in the prone position during play and is thought to be important in encouraging development of crucial weight bearing upper body and upper limb muscles and consequently gross motor skills, such as pushing up and crawling [29]. Wise and Da Silva in their report for the Australian Institute of Family Studies (AIFS) described parenting as encompassing a number of different aspects, including beliefs, values, goals, and behaviours [30]. Each of these dimensions can be influenced by child characteristics, parent characteristics, physical and social context, and child rearing customs [30]. Harkness and Super [31] coined the term “parental ethnotheories” to help explain cultural differences in parenting. Ethnotheories are collective beliefs held by a cultural group about children’s development and behaviour. Aspects of childrearing (e.g., Parenting goals, discipline practices, and beliefs about child development) are influenced by the characteristics of “individualistic” (Westernised) and “collectivist” (traditional) societies [32]. Individualistic societies value autonomy and independence and encourage children to demonstrate initiative from an early age, as well as honest expression of emotion [30]. In collectivist societies, children are taught to place community responsibility above individual interest, and emotional control is emphasised [30]. Parents of Anglo-Celtic origin often hold earlier expectations for development than parents from other cultures [30]. Acculturation as in the case of immigration can moderate the influence of culture on childrearing [30]. The findings from this study support the notion that Vietnamese parents tend to expect their children to achieve independent developmental milestones such as gross motor skills, and feeding skills, at a later age than Anglo-Australian parents, and that child rearing practices and beliefs of Vietnamese parents are influenced by collectivist philosophy.Research has examined differences in the way various cultures parent and how this may impact on the child’s development [33–36]. This literature indicates that most infants achieve major developmental milestones at similar ages [33], but developmental rate and more subtle aspects of development may differ between different cultures and ethnic groups [34, 36]. Coll [35] in a review of this literature concluded that differences in parental goals, perceptions, and interactions with infants and children result in alternative or different pathways, which are within a normal range of development.Research undertaken by Wise and colleagues for the AIFS has studied cultural variations in parenting beliefs and behaviours between Anglo-Australian parents, Vietnamese parents, and Somali parents [30]. Main findings of relevance were that Anglo parents valued independence in the child significantly more than Vietnamese parents, and child compliance was valued significantly more by Vietnamese parents than Anglo parents [30].Vietnamese-focus group participants tended to use “softer” methods of explaining rather than “time-out”. This is consistent with literature on more permissive and tolerant parenting of younger children in the Vietnamese culture [18]. The Australian focus group participants primarily had infants; so this topic was not as relevant to them. In contrast, the majority of questionnaire participants in both groups responded that they would use a “softer method” of explanation rather than “time-out” for the vignette about the child having a tantrum.Vietnamese focus group and questionnaire participants were more likely to attribute nonmedical rather than medical factors as being causative for medical and neurodevelopmental conditions such as ADHD, epilepsy, and CP. One Vietnamese questionnaire respondent perceived “what you did in a previous life” to be a cause of epilepsy and CP, and another person perceived that attempted abortion was a cause of mental illness in a mother. One Vietnamese focus group participant perceived that Karma, attempted abortion, and taking the oral contraceptive pill were also causes of mental illness in children. These findings are consistent with the current literature, which indicates that Asians living in Western countries tend to stigmatise disability and mental illness more than their Western counterparts [37–43]. One such study explores the perceptions of various groups of ethnic university students and found that Asian-Americans, particularly those Asian born, saw physical and mental disabilities as being more stigmatised than did African-Americans, Latin-Americans, and European-Americans [38]. An Australian study found that Asian students, especially those who spoke a language other than English at home, were more negative toward and less knowledgeable about mental illness than European-Australian students [39].Another Australian study, which explored parental perceptions of child psychopathology and disease causation, of Vietnamese parents living in Perth, found that the majority of parents (75.5% to 78.1%) thought that child mental illness was caused by biological/chemical imbalance in the brain, trauma or bad experiences, and a metaphysical or spiritual imbalance. 57.2% endorsed a genetic or hereditary cause, and 17.6% indicated karma as the cause of child mental illness.One reason for Vietnamese immigrants’ more negative perception of mental illness may be the Confucian tradition of sacrificing individual needs to that of the overall group needs [40]. Since a person with a disability may not contribute to the collective good in a way that a healthy person might contribute [40], they are perceived as less important. A strong emphasis on conformity and a general intolerance of differences in Asian cultures may also be a relevant factor [41, 42]. Another contributing factor may be the commonly held belief that mental illness is a manifestation of weakness of the mind [37]. A psychiatrist is referred to as either a “nerve doctor” or a “doctor for the insane”, which emphasises Vietnamese people’s beliefs that mental illness are “bizarre and out of this world” in nature [37]. As a result of these beliefs, Vietnamese people rarely seek out mental health services [37].


## 4.3. Conflicting Study Findings

There are a number of possible explanations for conflicting findings from the Vietnamese focus group discussions and questionnaire. Firstly, there may be inherent differences in these two groups, which influence perceptions regarding these issues. Participants from both groups were mostly recruited from the Centre’s BCG Immunisation Clinic. However sociodemographic information about the focus group participants would have been helpful in comparing these two groups. The second explanation is measurement or information bias due to two different methodological approaches, thus eliciting different responses. Of note the questionnaire response rate in the Vietnamese group was only 7/12 compared with 11/11 for the Australian group. The literature on cross-cultural research supports this explanation by indicating that focus groups or face-to-face interviews may be a more effective data collection method than structured questionnaire, as they can foster trust and allow participants to describe their view and experiences in a context in which cultural nuances can be recognised [25]. The Parenting-21 Study conducted by the AIFS utilised a semistructured questionnaire which was completed by the interviewer in a face-to-face interview [16]. The third possibility is that the sample size is too small for findings from the focus groups and questionnaires to be valid.


## 4.4. Study Limitations and Generalisability

There are limitations to this study, which may contribute to conflicting study findings. The main source of potential bias was differences in recruitment method for Vietnamese and Australian participants. The Vietnamese participants attended the BCG Immunisation clinic, whereas the Australian participants were attendants of the parents’ groups and baby clinics. This problem with recruitment was unavoidable, as no immunisation clinic exists for Caucasian Australian children at the Centre, and no existing Vietnamese clients utilised other services at the Centre.Utilisation of an inappropriate data collection method, of a structured questionnaire, may have resulted in measurement bias as it does not give the flexibility to express views and perceptions fully and can misinterpret cultural nuances [25].The majority of questionnaire participants both Vietnamese and Anglo-Australian were from a low sociodemographic background with no tertiary education and low income. The demographic profile of study participants is representative of Inala’s population [44]. For example, in the 2001 Census, the median weekly family income for Inala was from $500 to $599, whereas that for Australia is from $800 to $999.However these findings cannot be generalizable to Anglo-Australian or Vietnamese parents from higher sociodemographic backgrounds. In addition although 50% of the Vietnamese questionnaire participants had been in Australia for eight years or more, most of them rated their spoken English ability and understanding and ability to read English as “all right” or “very little or not at all”. Thus the study results are not necessarily generalizable to Vietnamese immigrants who are more acculturated into Australian society.


## 5. Conclusions

Findings have highlighted issues relating to Vietnamese parents’ perceptions and beliefs regarding children’s health, illness, and development, as well as child health service utilisation, which have not yet been extensively studied in the past. Vietnamese parents in comparison to Anglo-Australian parents have a more collectivist view of child rearing and place less expectation on infants and young children to achieve independence. Vietnamese parents tend to attribute nonbiological or metaphysical causation such as Karma to mental illness or neurodevelopmental conditions such as epilepsy, ADHD, and CP. They have less familiarity with the range of health services available for their children and are generally less satisfied with the English-speaking mainstream services that they have utilised in the past.There is a need for further examination of these issues with future studies, using more culturally appropriate qualitative methods and larger sample sizes. A better understanding of these issues within Vietnamese Communities in Brisbane and throughout Australia will result in the delivery of more culturally sensitive and effective health services to children and families within these communities.



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*Source: 932364-2012-01-23.xml*