AN ANTHROPOLOGICAL STUDY ON CERVICAL CANCER SCREENING AMONG FEMALE SEX WORKERS IN HO CHI MINH CITY, VIETNAM LE THI NGOC PHUC A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS (HEALTH SOCIAL SCIENCE) FACULTY OF GRADUATE STUDIES MAHIDOL UNIVERSITY 2015 COPYRIGHT OF MAHIDOL UNIVERSITY Thesis entitled AN ANTHROPOLOGICAL STUDY ON CERVICAL CANCER SCREENING AMONG FEMALE SEX WORKERS IN HO CHI MINH, VIETNAM ………………………………………… Ms. Le Thi Ngoc Phuc Candidate ………………………. Pimpawun Boonmongkon, Ph. Siriwan Grisurapong, Ph.
Penchan Sherer, Ph. Patcharee Lertrit, Assoc. (Medical Anthropology) Dean Program Director Faculty of Graduate Studies Master of Arts Program in Mahidol University Health Social Science Faculty of Social Sciences and Humanities Mahidol University Thesis entitled AN ANTHROPOLOGICAL STUDY ON CERVICAL CANCER SCREENING AMONG FEMALE SEX WORKERS IN HO CHI MINH, VIETNAM was submitted to the Faculty of Graduate Studies, Mahidol University for the degree of Master of Arts (Health Social Science) on April 16, 2015 ………………………………………… Ms. Le Thi Ngoc Phuc Candidate ………………………………………… Lect.
Darunee Phukao, Ph. Niphattra Haritavorn, Assoc. Pimpawun Boonmongkon, Ph. Penchan Sherer, Assoc.
Siriwan Grisurapong, Ph. Patcharee Lertrit, Assoc. (American Studies) Dean Dean Faculty of Graduate Studies Faculty of Social Sciences and Humanities Mahidol University Mahidol University ACKNOWLEDGEMENTS Firstly, I would like to express special thanks to my research supervisor Assoc. Pimpawun Boonmongkon, who guided me expertly and took care of me carefully through the whole of my thesis.
I also express heartfelt gratitude to my co-advisors Asst. Penchan Sherer and Assoc. Siriwan Grisurapong for their useful suggestion and guidance. Darunee Phukao and Asst.
Niphattra Haritavorn, the committee members for my thesis, gave me some comments. Secondly, I also would like to thank all the Professors and Lecturers in Department of Health and Society for their academic knowledge and experience during past two years. All knowledge what I got is very useful for me in the future. Also, I offer grateful thanks to all the staffs of the Health Social Science International Program for their kindness and friendliness.
I am grateful to Graduate Studies Scholarship for ASEAN countries and Hongwiwatana Fund Fellowships for its financial support that gave me a good chance to study in Mahidol University, Thailand and collected data in Vietnam. My deepest appreciations go to The Union Toward Future Group, which introduced me to participants. I am grateful to all my participants for their collaborative effort, giving their time, sharing their views and opening their hearts. This thesis would be impossible without their participation.
Finally, I would like to gratefully thank to my family for their support and encouragement when my work became stressful. Le Thi Ngoc Phuc AN ANTHROPOLOGICAL STUDY ON CERVICAL CANCER SCREENING AMONG FEMALE SEX WORKERS IN HO CHI MINH CITY, VIETNAM LE THI NGOC PHUC M. (HEALTH SOCIAL SCIENCE) THESIS ADVISORY COMMITTEE: PIMPAWUN BOONMONGKOL, Ph., PENCHAN SHERER, Ph., SIRIWAN GRISURAPONG, Ph. ABSTRACT The research aims to understand the attendance in cervical cancer screening among Vietnamese female sex workers in Ho Chi Minh City, and to explore how the socio- cultural factors influence their attendance.
Qualitative research was designed with in-depth interview, observation, key informant and secondary data. Fifteen female sex workers aged 18-44 years were recruited by a non-government group. In addition, two health professionals and three community leaders were recruited as key informants in this study. To analyze data, theoretical concepts of discourse by Michel Foucault, felt-stigma by Goffman, beliefs by Kleinman and perceived quality of health service were used.
The study found that the various institutionalized discourses on sex work and sex workers such as “a source of transmitted diseases”, “risk group definition of cervical cancer” influenced not only individualized discourses but also attendance in cervical cancer screening of female sex workers. These discourses created fear for cancer and stigma of female sex workers. Although most female sex workers considered that they were at risk for cervical cancer, they still postponed doing cervical cancer screening. The reasons for non-attendance were most often economic burden, beliefs about cervical cancer and screening, perceived quality of health services and felt-stigma.
Some female sex workers had fatalistic attitudes which were associated with the idea of God. Others believed that cervical cancer was a specific genital infection which resulted from white blood discharge, poor hygiene, having unsafe sex with multiple sexual partners. In addition, fear of cancer, fear of being blamed as “promiscuous woman” and embarrassment were mentioned as barriers to cervical cancer screening. In terms of perceived quality of health services, interpersonal relationships, adequate information and convenience affected their non-attendance in gynecological examination as well as cervical cancer screening.
The findings suggest that health promotion and education about the importance of cervical cancer screening are necessary for female sex workers by health professionals and peer-educators. In addition, to reduce the associated felt-stigma, messages to the public community may emphasize that all sexually active women may be at risk for human papillomavirus infection and cervical cancer. Furthermore, interaction between health providers and clients should be improved in healthcare settings. KEY WORDS: CERVICAL CANCER SCREENING / DISCOURSE / FEMALE SEX WORKERS / BELIEFS / FELT-STIGMA 124 pages v CONTENTS Page ACKNOWLEDGEMENTS iii ABSTRACT iv LIST OF TABLES ix LIST OF FIGURES x LIST OF ABBREVIATIONS xi CHAPTER I INTRODUCTION 1 1.1 Background and Justification 1 1.3 Research objectives 12 CHAPTER II LITERATURE REVIEW 13 2.1 Concept of discourse 13 2.2 Concept of felt-stigma 14 2.3 Concept of quality of health service 15 2.4 Concept of human body and beliefs 17 2.2 Overview about cervical cancer and cervical cancer screening 18 2.3 Related literature reviews 21 2.
Discourse on sex work and sex workers 21 2. Beliefs about cervical cancer affect health care 22 practice 2. Discourses on sex worker affect health care 25 practice 2. Stigma attached to being sex workers and 26 health care practice 2.
Perceived quality of health service affects 26 health care practice CONTENTS (cont.4 Explanation of conceptual framework 27 2.5 Conceptual framework 30 CHAPTER III RESEARCH METHODOLOGY 31 3.3 Entering into the research field 33 3.4 Participants selection criteria and recruitment process 35 3.1 In-depth interviews 37 3.3 Key-informant interviews 38 3.5 Secondary data analysis 39 3.6 Field notes writing 39 3.7 Data processing and analysis 40 3.8 Validity of the data 41 3. Researcher’s identity and trust building 41 3. Benefit and reciprocity 43 CHAPTER IV RESEARCH FINDINGS 44 4. General context of Ho Chi Minh City 44 vii CONTENTS (cont.2 Sex work in HCMC 48 4.1 History of sex work in Vietnam 48 4.2 Ways into sex work 49 4.3 Types of sex workers 51 4.
Social characteristics of informants 52 4. Discourses on sex work, sex workers 59 4.5 Discourses on sex workers who have cervical cancer and 66 cervical cancer screening 4.1 Discourses from medical professionals: HPV- 66 related discourse, cervical cancer screening is for those who have conscious awareness and stable income 4.2 Discourses from sex workers: “cervical cancer 67 is prolonged infection and highly sexually active diseases”, “cervical cancer screening is for rich sex workers” 4.6 Felt-stigma: “being exploited, discriminated, rejected, self- 68 blamed” 4.7 Beliefs on cervical cancer 70 4.1 Terms of cervical cancer 70 4.2 Notions of cervical cancer from FSWs’ 71 perspectives 4.3 How to prevent cervical cancer 77 CONTENTS (cont.8 Beliefs on cervical cancer screening: “screening is 79 detection”, “screening is the same gynecological examination” 4.9 Perceived quality of health care service 80 4.1 The physician-client relationship 81 4.2 Gender of doctor 82 4.4 Privacy and convenience 84 4.10 The pattern of cervical cancer screening among FSWs 86 4.11 The socio-cultural factors affect attendance in cervical 88 cancer screening 4.3 Social factor 91 CHAPTER V CONCLUSION, DISCUSSION, RECOMMENDATION 94 5.3 Limitations of the research 102 5.2 Recommendation for future studies 104 REFERENCES 106 APPENDICES 116 Appendix A Interview guideline 117 Appendix B Participant-observation guideline 120 BIOGRAPHY 124 ix LIST OF TABLES Tables Page 4.1 Social characteristics of informants 57 4.2 Cervical cancer screening practice during past two years 87 LIST OF FIGURES Figure Page 2.1 Map of Ho Chi Minh City 46 4.2 Female sex work is catching a client on the street 52 4.3 The development of cervical cancer was drawn by a female sex 70 worker 4.4 A key informant explained about cervical cancer 71 xi LIST OF ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral Treatment CIN Cervical Intraepithelial Neoplasia FSWs Female sex workers HCMC Ho Chi Minh City HIV The Human Immunodeficiency Virus HPV Human Papillomavirus IEC Information-Education-Communication MOLISA Ministry of Labor, Invalid and Social Affair NCADPPC National Committee for AIDS, Drugs, and Prostitution Prevention and Control NGOs Non-governmental Organizations STDs Sexually Transmitted Diseases VIA Visual Inspection with Acetic Acid WHO World Health Organization Fac. Studies, Mahidol Univ.1 Background and justification 1.1 Background According to a report by the World Health Organization (WHO, 2012), cervical cancer is the fourth most common cancer in women, and the seventh overall. While breast cancer, colorectal and lung cancers contributed more than 43% to all cancers (excluding non-melanoma skin cancer), cervical cancer made up nearly 8% of all cancers (Ferlay et al.
The incidence and mortality of cervical cancer in developing countries was higher than in developed countries (Sankaranarayanan, 2002; Zeferino, & Derchain, 2006). It was estimated that the incidence was 444,000 cases and 230,000 deaths. This rate was higher than stomach, corpus uteri and ovary cancers (Ferlay et al. Cervical cancer can impede reproduction, incur high medical costs, or lead to deaths although this disease can be successfully treated when it is diagnosed in time (Bruni, Alemany, Diaz, Xavier Bosch, & de Sanjosé, 2013).
In recent decades, most countries have attempted to promote cervical cancer screening in the population with the aim of reducing mortality. However, the proportion of women who have regular gynecological examinations, including cervical cancer screening is quite low (Anorlu, 2008; Dunn & Tan, 2010). Some women refuse to have a screening, and others who have screening do not follow up due to many reasons such as lack of knowledge, lack of facilities, cultural beliefs, lack of time and money and poor physician-patient relationship (Abdullahi, Copping, Kessel, Luck & Bonell, 2009; Agurto, Bishop, Sanchez, Betancourt, & Robles, 2004; Anorlu, 2008; Markovic, Kesic, Topic & Matejic, 2005). A large number of women have cultural beliefs related to cervical cancer.
They believe that cervical cancer is associated with gynecological symptoms including discharge, itching, and abdominal pain (Boonmongkon, Nichter & Pylypa, 2001). Others believe that cervical cancer comes Le Thi Ngoc Phuc Introduction / 2 from god as a form of punishment and people can do nothing about it (Abdullahi, Copping, Kessel, Luck & Bonell, 2009). Others believe that cervical cancer is associated with poor hygiene (Lee, Tripp-Reimer, Miller, Sadler & Lee, 2007). From these beliefs, they often delay going to the hospital for screening and get treatment early or they end up relying on self-medication (Boonmongkon, Nichter & Pylypa, 2001; Bush, 2000; Denberg, Wong & Beattie, 2000; Evans & Lambert, 1997; Lee, Tripp-Reimer, Miller, Sadler & Lee, 2007).
Moreover, they also have other beliefs about cervical cancer screening. They believe that screening is most important when there is a family history of cancer; otherwise, it may be irrelevant (Denberg, Wong & Beattie, 2000; Lee, Tripp-Reimer, Miller, Sadler & Lee, 2007). A few women actively participate in gynecological exams but they do not know or distinguish whether a Pap- smear is included in the gynecological exams or not (Boonmongkon, Nichter & Pylypa, 2001). In other cases, women sometimes still refuse to have regular medical screening due to embarrassment, pain or fear for cancer (Rezaie-Chamani, Charandabi & Kamalifard, 2012).
Aside from cultural beliefs, medical discourses also affect the way people understand and response related to their health, diseases and illnesses (Bush, 2000). According to Foucault, discourse is power through language production from professionals. Discourse is considered to be a social construction because it is produced and maintained by those who have the power and means of communication (Victor & Letseka, 2013).