Menopause-related health literacy: a qualitative study of experiences and perceptions of menopause-related health care among Vietnamese-born women in Melbourne, Australia CURRENT STATUS: UNDER REVIEW

Health literacy refers to an individual’s capacity to access, understand, evaluate and use health information to make well informed health-related decision to maintain and promote optimal health. Low health literacy is linked with worse health outcomes and is more common in people from socio-economically disadvantaged backgrounds and from non-English speaking backgrounds and among people with limited education. Peri-menopausal and postmenopausal health behaviour predicts health in later life. This qualitative study was conducted in Melbourne, Australia. The aim of this study was to explored menopause-related health literacy and experiences with menopause-related health care among Vietnamese-born women who had immigrated to Australia as adults. Methods A qualitative study using semi-structured interviews was conducted with women aged between 45 – 60 years and peri or postmenopausal. Transcripts were analyised thematically.

limit their opportunities to access information about and benefit from menopause-related health promoting behaviours. Access to menopause-related health information in relevant community languages is essential to support immigrant women to make well informed menopause-related health decisions.

Background
Health literacy is defined as the capacity to access, understand, evaluate and use healthrelated information to make appropriate decisions regarding health behaviour and health care. This definition provided the foundation for the Integrated Health Literacy Model proposed by Sorensen et al. [1] which describes health literacy as a multidimensional concept consisting of different components and determinants and health system factors as well as the pathways linking health literacy to health outcomes. The Australian Government Commission on Safety and Quality in Health Care [2] separates health literacy into two components. First, an individual's capacity to make well informed health-related decisions and second, a health system that considers the individual's capacity to negotiate this system and recognises this as integral to public health. Low health literacy is associated with worse health outcomes and is more prevalent among people from socioeconomically disadvantaged backgrounds, people from non-English speaking backgrounds and those who have limited education. People with low health literacy are less likely to participate in health screening and are more likely to use emergency care and are at greater risk of hospitalisation [3]. In Australia, the Adult Literacy and Life Skills Survey reported that most older adults, from non-English speaking backgrounds have inadequate health literacy skills to enable well-informed health-related decisions [4].
Australia is a multicultural society where more than a quarter (26 %) of the population was born in other countries [5]. Immigration is often characterised by social and economic disadvantage [6]. Immigrant women are known to be particularly vulnerable, because they 4 may have had limited choices in the decision to immigrate, [7][8][9] may have had limited educational opportunities [9] and have difficulties accessing culturally and linguistically relevant health resources and health care in their new country of residence [10].
Vietnam is the fifth most common country of birth among Australians born overseas [11].
After the fall of Saigon and the Socialist Republic of Vietnam was declared in 1976, many Vietnamese fled their country and by 1981 nearly 50,000 Vietnamese-born refugees had settled in Australia. A family reunification program followed and by 2016 there were nearly 200,000 Vietnamese-born people living in Australia [5]. In Victoria, over 80,000 people were born in Vietnam of whom nearly 21,000 are women 45 years and older [11].
Health behaviour during the menopausal transition predicts health in later life [12]. To make well informed health-related decisions during the menopausal transition, women need to have robust health literacy skills and have access to a health care system that is accessible, navigable and responsive [2].
A recent review of research investigating perceptions of menopause-related health, health behaviour and health care among immigrant women found that immigrant women reported more vasomotor and physical symptoms and poorer mental health than women from the host country and concluded that more research is needed to better understand how immigrant women manage their menopausal transition and how to provide culturally relevant menopause-specific health care. [13] Little is known about how immigrant women access, understand, evaluate and use menopause-related health resources and the barriers and enablers predicting adequate menopause-related health literacy. The aim of this study was to describe how Vietnameseborn women who migrated to Australia in adulthood manage the menopausal transition and their postmenopausal health; how they access, understand, evaluate and use menopause-related health resources; and explore their experiences and satisfaction with 5 menopause-related health care and services.

Study design
Qualitative methods are used to gain a deep and fine-grained understanding of perceptions and lived experiences, in particular of aspects of human health about which little is known [14]. In this study data were collected data using individual semi-structured interviews [15].

Study setting
The study was conducted in Melbourne, Australia. The 2016 Australian Census data reported that nearly a third of people living in Victoria were born in a country other than Australia of which Vietnam was the fifth most common [5].
Australia has a two-tiered health care system. All citizens are entitled to primary, specialist and hospital-based health care without fees through the national Medicare scheme. It is funded publicly, including through a levy on all taxpayers. Individuals can also purchase private health insurance which can be used to fund hospital care and medical providers of choice [16].

Participants and recruitment
Women were eligible to participate if they were: born in Vietnam, aged between 45 and 60 years, and peri-or postmenopausal. Menopausal status was determined using the Stages of Reproductive Aging classifications which state that women whose menstrual bleeding has become increasingly more irregular and whose last menstruation occurred in the previous 3-12 months are considered to be peri-menopausal and women who have had 12 consecutive months of amenorrhoea in the absence of pathological or physical reasons are considered to be postmenopausal [17]. 6 A sample of up to 15 participants was anticipated to provide sufficient information to describe in detail experiences and perceptions of the menopausal transition and postmenopausal health, including menopause-related health literacy and health care services among women who had migrated to Australia from Vietnam [18].
Several strategies were used to inform potential participants about the study. Flyers in English and Vietnamese explaining the purpose of the study, eligibility criteria and the researchers' contact details (K. S. and T. N., a Vietnamese-born bilingual researcher) were distributed at food markets, community groups and community health services in areas with a high proportion of migrants from Vietnam. The flyer was also distributed electronically to community health centres, women's health organisations, and community and learning centres offering language classes. K. S. made phone contact with the facilitator of a Vietnamese Women's group who invited her to join this group to introduce the study. Finally, K. S. telephoned or emailed relevant community health staff to introduce the project and seek their support for it. Women who wished to participate in the study were asked to telephone K. S. or T. N. Integrated Model of Health Literacy [1]. Questions were asked about where participants searched for information; whether they were able to find what they needed; whether the 7 information was understandable and answered their question; whether the source and information was perceived as trustworthy and whether the information was relevant and easy to use. Sociodemographic information including age, year of immigration, marital status, employment status and level of education was gathered in brief fixed-response questions at the end of the interview.

Procedure
Women who volunteered to participate were contacted to confirm eligibility and, if eligible, a time for the interview was arranged. The interviews were conducted at a place convenient for the participant. All participants were provided with a written plain language statement in Vietnamese or English and written consent was obtained before the interview.
No strict order of questions was followed allowing for flexibility and for the interviewee's narrative to unfold. Participants' responses guided the conversation and determined the next question. Interviews conducted by K. S. in English, were audio-recorded with permission and transcribed verbatim. T. N. acted as interpreter in interviews with women who had insufficient English language proficiency. These were also audio-recorded with permission and the interpretation was transcribed. Additionally, K. S. kept detailed field notes and a reflective diary. To protect anonymity participants could either choose a pseudonym or, if they preferred, a pseudonym name was chosen from a website of female Vietnamese names. Participants were given a AUD$40 shopping voucher to cover travel and parking costs and in recognition of their time.

Data management and analysis
The transcripts were entered into Nvivo 11 for analyses. Data were analysed thematically as described by Braun and Clark [19]. This method involves six phases: becoming familiar with the data through transcription; repeatedly reading the transcripts; assigning initial codes inherent to topics in the interview guide; grouping codes into original themes introduced by participants; refining the themes and selecting quotes that best illustrate the themes. The initial analysis was conducted by K. S. Findings and interpretation were discussed with the research team until consensus was reached. The findings are presented using illustrative quotes.

Results
Twelve women agreed to participate and were interviewed. Five participants volunteered after reading the study flyer, the rest were recruited through snowballing. Of the 12 interviews, eight were conducted with the assistance of the bi-lingual researcher T. N. All interviews were conducted face-to-face. Ten interviews were conducted in the participant's home and two in an interview room at Monash University. The characteristics of the participants are shown in tables 1 and 2. Most were in their late fifties, postmenopausal and half of the participants were married. Seven women had completed their primary education and three women were engaged in paid employment.
[ Table 1 near here] [ Table 2 near here] Four themes emerged from the data: Menopausal experiences -It's natural, it's normal; Influences of culture on the experience of menopause; Barriers for menopause-related health literacy; and Barriers and enablers for optimal menopause-related health care.
Menopausal experiences -It's natural, it's normal I think is natural so [laughs] … nothing happens to my health, so everything is normal.
(Hung -translated) I feel like we don't need to do anything, and just accept it and its normal… I didn't worry [about menopause] just because I talked to other friends who used to experience it. And they told me already about it, that's why I think, that's normal. (Hien -translated) In fact, most participants who experienced emotional symptoms that they attributed to menopause laughed about how they affected them.
I feel uneasy and very easy to get angry with someone. If they talk to me [laughs heartily, keeps laughing and then laughingly says] leave me alone don't talk to me too much. Participants were asked about how they thought their culture of origin affected their experience of menopause. They did not elaborate whether there are cultural differences in perceptions of menopause between Australia and Vietnam because they were unaware of how people born in Australia view menopause. However, participants' reflections indicated that their experience of menopause was influenced by both Vietnamese and Australian culture.
Most participants reported that their personal experiences are similar to their Vietnamese contemporaries; they seek support from friends and family and mainly use traditional therapies to manage any bothersome menopausal symptoms.
When I used to work in Vietnam, I used to work in a bank as the bank officer and I had some colleagues, some were younger and some were older than me and some of them they experienced menopause and then they talked to me about the experience. Now I know what will happen and that's why I find it easy to overcome, that I don't have any shock. A few years ago, I had a friend who is younger than me and she got menopause some symptoms, and I can advise her and … [I said] it is common don't worry about it.
(Hien -translated) I also talk to some friends and um and just to ask whether they have similar symptoms. This was thought to be partially due to a lack of government policies and health care funding. I asked my friends and some elders who know about that, but they [said] that's normal every women experiences that. (Thi -translated) I didn't search for any information just talking to friends and they share some experience.
(Tien -translated) 13 Only some searched for menopause-related health information from other sources. Those who did accessed it from a Vietnamese language website or the local library. Both sources had perceived limitations. The internet only offered general health information and the menopause-related books in the library were in English and participants reported that their ability to understand and apply the knowledge was limited.
I am mh … not very well in English that's why I checked reading about information. When this one I understand and I apply for me and this one I don't understand so I leave it.

(Hanna)
In addition to the apparent difficulties in accessing and understanding information, participants showed limited ability to evaluate the health-related information they had Appraising health information offered on the internet poses particular challenges for individuals with low health literacy as it is difficult to judge the quality of the information and the credibility of its source.

Participants who had accessed information from Vietnamese language websites and from
YouTube were asked how they knew that these sources were trustworthy. The websites were judged as reliable because they were hosted by the Vietnamese government.
Although the information gathered from YouTube had been published by lay people, some participants had implemented the recommendations. They were aware that it was difficult to determine the reliability of this source. But because the recommendation they had followed related to eating specific foods, they believed that this could not be dangerous and therefore judged it as safe as indicted by Tien: That is why she only answered the question this one, and she didn't give any further  No, I will not trust a male doctor because I prefer a female doctor to check over my general health. (Xuan-translated) … but actually, he is a man and off course he is Vietnamese so he can understand what I said. But he is a man so it's difficult for me to share, share some woman's problems. So I am looking for a female doctor who can speak Vietnamese, but it's hard. (Linhtranslated) Many participants described their GPs as being time poor and rushed and some even felt that they were only interested in writing a prescription and were not inviting questions.
… to tell you the truth that is my, the GP are not help much because they have less time for any patient. Ah … they just have about 5 minutes or 10 minutes for one patient and so that's not enough time for us to ask anything. They just check, uh … how do you feel and she writes a prescription. (Tara) The doctor is seemingly busy so that's why I don't, I was so shy to ask more questions.

Discussion
The findings of this study are that women born in Vietnam who had migrated to Australia in adulthood perceive menopause as a natural phase of life that does not require specific health care; rarely seek menopause-related health care or health information; and want GPs to opportunistically initiate discussion of menopause and to provide menopauserelated health information when they consult them. Women who had sought menopauserelated health information found little information available in Vietnamese and described lack of English language proficiency as the most common barrier to accessing, understanding and applying health-related information.
Adequate health literacy is a key predictor for optimal health outcomes. Sorensen and colleagues' [1] model of health literacy has mostly been examined in quantitative surveys using questions with fixed response options. Pleasant et al [20] concluded that there were knowledge gaps in health literacy research about individual experiences, including how people access, understand, evaluate and use health information.
This study meets Pleasant et al's [20] call by using qualitative methods which generate in-depth understanding of human experiences, perceptions and attitudes about which little is known [18,21]. Strengths of the study include: participants were from a vulnerable, difficult to access minority group, they were recruited in community settings; were diverse in terms of menopausal status, age, length of time in Australia, marital status and educational status; and that volunteers who did not speak English were enabled to participate with the assistance of a bilingual, bicultural researcher. Cross-cultural and cross-lingual research pose unique challenges [22]. As qualitative interviews rely on participants' verbal accounts, some pivotal information may be lost in interpretation, particularly if the interpreter is unfamiliar with the cultural context of the study. To minimise this risk the research team included a Vietnamese-born researcher who is fluent in Vietnamese and English and familiar with Vietnamese culture. Furthermore, excerpts of transcripts of interviews conducted with the assistance of the bi-lingual researcher were checked for accuracy by a second bilingual and bicultural researcher.
Health literacy as proposed by Sorensen et al [1] requires four competencies: capacity to access, understand, evaluate and use health-related information.
Access refers to the ability to 'seek, find and obtain' health-related information. Our data suggests that accessing menopause-related health information is influenced by culture. In high resource countries health care providers are accepted as primary sources of health advice and information. If women discuss menopause-related issues with their female peers and family members it is mostly done after consulting a health care provider and in order to process the information [23,24]. This contrasts with our findings among Vietnamese-born women living in Australia, who primarily seek advice and information about menopause-related symptoms from older female relatives and friends and only occasionally use health care providers, the internet and printed material. This may in part be explained by cultural practices in their country of origin where health care is 19 predominantly sought for illnesses, and less for health promotion and information. Our data indicate that participants had limited knowledge about how and where to access information, which was worsened by their limited English language proficiency. The inability to access information leaves individuals vulnerable as it increases the likelihood of learning through informal sources which may provide incorrect information and promote unproven remedies.
Sorensen et al [1] defines 'understanding' as the capacity to comprehend health-related information and 'evaluation' as the processing and judging of information. The 'understanding' and 'evaluation' component of health literacy have been described as the ability to derive meaning from words and numbers in the medical context [25]. Killian and Coletti [26] argue that health professionals' vernacular act as a barrier for understanding and evaluating health-related information. To improve health information communication in Australia, health literacy recommendations have been established which include implementing policies and systems at an organisational level; integrating health literacy into education to both consumers and health care professionals; and ensuring effective communication by providing directions for the development, review and improvement of written information. [27] Despite this, studies on the readability of health-related information indicate that the content of most Australian health information websites [28] and printed material exceed the reading level of the average person [29]. The inability to communicate proficiently in the dominant language is a significant additional challenge in understanding and evaluating health-related information [30][31][32]. Our data indicate that limited English language proficiency and lack of accessible information in Vietnamese are significant barriers for Vietnamese-born women's ability to understand and evaluate menopause-related information.
Understanding of health and illness is influenced by culture. Studies investigating beliefs 20 about the aetiology of illness in south East Asian cultures have found that it is attributed to organic problems such as weakening of nerves, imbalance of yin and yang, obstruction of chi, or a curse by insulted spirits. In addition, some immigrants from South-East Asian nations believe their physical constitution is different to Caucasians' and consider Western drugs and drug dosages not appropriate for Asians. Consequently, they may accept a GPs prescription, but not fill it [33]. The Vietnamese-born women in this study followed their GPs' recommendations only if they aligned with their personal health beliefs. Their limited language proficiency affected their ability to access, understand, and evaluate menopause-related information and coupled with culturally influenced perceptions about health, reduced their ability to use and benefit from menopause-related health information.
Individual health literacy skills of accessing, understanding, evaluating and using healthrelated information are facilitated by a health care system that understands and acts upon the interrelated factors influencing health literacy. A systematic review of experiences among immigrant and refugee women in accessing sexual and reproductive health care in Australia [34] found that difficulties navigating the health care system including processes such as arranging appointments and lack of multilingual resources were barriers in accessing care and information. Similarly, the Vietnamese-born women in this study were unable to find menopause-related health information in their language, needed help from family members' proficient in English to navigate the health care system and respect for authority prevented them from asking health care professionals questions about menopausal health.

Implications for policy, practice and research
Our findings suggest that Vietnamese-born women perceive menopause as a natural event and therefore rarely consult authoritative sources about menopause. As a result, they may 21 miss out on health promoting opportunities to ensure optimal health in later life.
Access to health information in relevant community languages is needed to improve immigrant women's knowledge about peri-menopausal and postmenopausal health.
Resources should be developed in consultation with stakeholders from the community, provided in a variety of mediums including written, visual and auditory, and promoted through public awareness campaigns.
Health care practitioners are in an ideal position to actively screen and discuss health behaviour and make recommendations to improve health outcomes in later life. Research investigating barriers and enablers for health care practitioners to provide menopauserelated health care which is responsive to immigrant women's circumstances and needs is essential to inform health care policies and practice.

Availability of data and materials
The dataset used and/or analysed during the current study are available from the corresponding author on request.