The Healthcare Needs of International Clients in China: A Qualitative Study

Introduction

Throughout the 20th and 21st centuries, interconnectedness across the globe has increasingly occurred. This globalization is defined as “economic integration and communication exchange, cultural diffusion, and travel”.¹ Since the creation of China’s Thousand Talents Plan in 2008, and other similar talent acquisition policies, many international experts and overseas Chinese have come to work in China, especially in scientific and technological fields. Additionally, with the development of international trade and the trend of economic globalization, multinational enterprises and international schools have established operations in China. This has attracted many international executives, entrepreneurs, workers and teachers to work or start their own businesses in China.²

Known for its e-commerce and mobile payment, Hangzhou, the capital of Zhejiang Province is the birthplace of China’s internet technology and industry. Many internet companies and multinational enterprises are located in Hangzhou, which brought a great numbers of experts and professionals to live in Hangzhou.³ By the end of 2019, nearly 55,000 overseas talents had come to Hangzhou.⁴ To date, the number of foreign registered enterprises has reached 4980 and the number of resident foreigners in Hangzhou is more than 15,000.⁵ Most of them were from western countries, such as USA and England, with international insurance (eg MSH and Cigna).

Unfortunately, as Labonté stated: “Health and disease have long been fellow travelers along the migratory pathways of people, goods, and capital.”⁶ Seeking healthcare services is an important part to their work and life in China, and an important factor affecting their quality of life. These highly educated people have more concerns for healthcare, such as regular health check-ups, and western medicine and treatment. International experts typically prefer high quality and convenient medical services. Good medical support can ease their anxiety, and is conducive to their social integration, employment and mental health.⁷

The increase in the international population visiting or working in China is of great significance to the city’s economic globalization, cultural diversification, and international talent pool, but the demands for international health care became a significant challenge for the hospitals in the city. The establishment of the international clinic was an immediate response to the aforementioned needs for most of the tertiary hospitals. There was also an overall improvement of the national healthcare system to meet the internationalization of the country. Therefore, high-quality management of the international clinic became the key in the international health services. The international clinic of the study hospital in Hangzhou was established in 2009, and it is based on a primary care delivery model facilitated with Family Medicine physicians and supported by 34 clinical specialty physicians. The hospital is accredited by Joint Commission international and Magnet recognition, was the first medical institution in Zhejiang province to provide bilingual medical service per appointment for international clients.

Nevertheless, with the significant healthcare demands of the international clients, difficulties and conflicts arose for the hospital and staff in providing the health care services. For example, cultural differences, language barriers, customs and taboos made the management of the clinic challenging.⁸ According to the World Federation of Critical Care Nurses’ (WFCCN) international clients have the right to receive culturally sensitive care by nurses with cultural competence.^9,10 Due to the cultural, social, and economical differences, the healthcare needs of domestic clients and international clients vary. Some international clients may not be able to find a suitable hospital in China, or be unable to communicate well with care providers, resulting in a sense of mistrust and uncertainty, leading to serious dissatisfaction or other medical problems. Therefore, the delivery of quality health services requires organizational preparedness to identify and respond to the needs of international clients.¹¹ Assessing the international clients’ needs to investigate their healthcare experiences and expectations is an essential step to build a high-quality care in the international clinics. Simultaneously, exploring the opinions of the healthcare professionals who have had experiences taking care of international clients will add different perspectives for providing a better care service.

Materials and Methods

Participants

International clients (n=24) who had the experience of seeking healthcare in our international clinic were recruited to join the focus group interviews. Two nurses and physicians working in the international clinic were also interviewed to explore their opinions.

Participants were deemed eligible if they: (1) were aged 18 years or over; (2) currently in China; (3) were international clients with different nationality aside from China; and (4) were able to attend face-to-face focus groups in Hangzhou, or were willing to do online focus groups on the scheduled dates. Participants were excluded if they had been diagnosed with schizophrenia or a related psychotic disorder. Any research team members who recruited participants to a particular focus group was not then involved in running that group. Focus group interviews were conducted in the meeting room of the international clinic. Informed written consent was gained from all participants at the beginning of each focus group.

Data Collection/Focus Groups, Interviews and Topic List

The interviews were conducted in English and the topic guide is outlined in Table 1. All the focus group discussions were tape recorded in their entirety and observational notes were taken during the session. Each focus group consisted of eight clients and lasted 60–90 minutes. Results from the focus group interviews were discussed with the research team. The outcomes were documented and used for data analysis. Three bilingual moderators, YH, YL and CD conducted the interviews. YH, majored in English and has passed the TEM-8. YL was educated in the United States. CD completed the exchange scholar program of Boise State University in the USA.

Table 1 Focus Group Topic Guide

Four healthcare providers’ interview lasted about 60 mins and was conducted in English and tape recorded by research members. The main questions for the healthcare providers were: How do you feel about your medical services and care process? How is care for international clients organized at this moment? What's the biggest challenge of your work in the international department? What are your expectations of this research project?

Data Analysis

Numerical data based on participants’ characteristics were analyzed using SPSS V25. The analysis of qualitative interview data adopted the process of inductive content analysis, including open coding, creating categories and abstraction.¹² All recorded data were transcribed verbatim into Word documents in English within 24 hours after the interview. Interview transcriptions were entered into NVivo 12, and a comprehensive process of data coding and theme identification was undertaken. This began with line-by-line coding of the transcripts to make context‐based inferences from the data. Two researchers, CD and YL read and re-read the data carefully. Next, codes were explored to identify similar patterns and grouped together as categories.¹³ Meaningful statements were extracted and frequently occurring views were coded and summarized during this procedure. The categories were further abstracted during the process to generate themes to identify the key concepts related to healthcare needs of international clients, medical staffs’ challenges with providing international services. The data analysis results were verified with the interviewees to ensure that the results could represent their real thoughts. Additional supporting quotes for each theme are provided in Table 2.

Table 2 Supporting Quotes for Each Theme

Rigor

Collection of data from international clients of different nationalities, checking of all interviews and rigorous data analysis by two researchers independently collectively contributed to credibility. The analysis results were returned to the interviewees for confirmation.

Results

Participant Characteristics of Focus Groups

In total, 24 foreign clients participated across the three focus groups, face to face. They had a mean age of 29.7 years (range: 18–45 years). An overview of the characteristics of the participants is presented in Tables 3 and 4.

Table 3 Participants Background Information of Focus Groups

Table 4 Participants Background Information of Healthcare Providers’ Interviews

Six Major Themes

Six major themes of international patients’ healthcare needs were identified including privacy and confidentiality, effective communication, multicultural sensitive care, pleasant environments, qualified care and procedures, and respect. Attitudes and beliefs of international care professionals and their team members were interpreted within these key concepts.

Privacy and Confidentiality

Privacy protection was concerned by most of the international clients interviewed. The clients stressed out the importance of single clinic room with the door closed, and it was evidenced by the following statements:

International patient NO1: I feel safe here, every time I come to visit, doctor will wait for me in a clinic room without other patients around, and he or she never forgets to close the door. That is really important. [Focus group 3].

International client NO2: Yes, privacy is important. I do not want anyone else to get my medical records … I have been to some other public hospitals in China, different kind of experiences for foreigners that you share the room with other people, doctors talking to you, other clients looking at you. [Focus group 2].

International patient NO4: Privacy is the most important thing for me. It’s embarrassing when I have to ask a personal question with other people around … and the curtains in the waiting area allow me to be separated, especially when I need some rest. [Focus group 2].

The physician discussed that clients’ consent is required to inquire and explain privacy issues fully, such as obtaining patient information, asking for the patient’s signature, or making copies of their identity documents:

Doctor (N1): The patient’s medical information and examination results should be authorized by the patient before they can be given to the family members. International clients will pay more attention to personal privacy protection than Chinese clients. For example, it is common in China for several clients to wait in a clinic, but it is difficult for international clients to accept.

Some participants reported the importance of privacy protection during physical examination:

International patient NO7: I remember the last time for the EKG test, the nurse covered me with a blanket, my body was not fully exposed. [Focus group 1].

International patient NO5: That is so embarrassed. I remember once I had to take my pants off for the ultrasonic checkup. Then someone came in when I was not fully dressed. [Focus group 2].

Effective Communication

Some clients mentioned that seeking treatment in a foreign country easily causes psychological anxiety and distrust and emphasized the importance of effective and accurate communication (including type of language spoken) between international clients and care professionals:

International patient NO2: Some staff cannot really understood what I meant, especially when I went to another department for consultation. Not everyone in the hospital speaks English, so I feel nervous when I am alone seeking helps in a foreign country. [Focus group 1].

In addition, others reported good communication skills helped reduce their stress and anxiety. Some participants also described the importance of non-verbal communication which includes facial expressions, gestures, intonation, eye contact, and body posture:

International patient NO3: My doctor is very friendly, and when I express uncomfortable feelings, she listened to me quietly, holding my hands, without interrupting me, she is like family to me. [Focus group 2].

Nurse (N4): When greeting the client, I would like to use a slightly higher tone of voice, giving the client a warm and positive feeling. Be enthusiastic and caring, be a good listener, means a lot to my client.

Professionals mentioned that targeted conversations and body language were helpful to improve communication efficiency and therapeutic effect:

Doctor (N2): It is important to speak calmly and gently when I have to tell the bad news. Speaking slowly and focusing on the important points are also very useful to get the information across and receive the feedbacks from them[clients].

Some participants stated that using medical terms could result in misunderstandings, which would affect the process and safety of medical treatment:

International patient NO6: Medical language sometimes could be really confusing, even in your first language. The doctor explains to me very well when I do not understand. [Focus group 2].

Some participants described the importance of completing medical records in English:

Doctor (N1): Most clients here need the English records and results, so we must be able to write and speak in English, that is the basic skill in the international clinic.

International patient NO5: It is very positive that I do not feel stressed in the international clinic, everybody is very professional, very nice, you know I do not speak Chinese, but everybody’s English level is so good. They are able to explain everything to me clearly and patiently. English medical records are also available. [Focus group 3].

Multicultural Sensitive Care

Both the clients and healthcare providers pointed out the needs for multiculturally sensitive care.:

Nurse (N3): Some foreign clients were more relaxed and cooperative with us when they have their family members around. For example, I met a female patient from western countries who expected her husband to accompany during gynecological examinations or surgeries.

One female Muslim client highlighted the value for her of cultural sensitivity; as she stated:

International patient NO8: I am a Muslim, so I want a female doctor to look after me. I do not want the medical staff to stare at me or discuss about my clothes. [Focus group 1].

Some participants felt that the international clinic should be western-style instead of Chinese-style, taking into account the habits of international clients:

International patient NO7: Procedure here is all reasonable. Even like blood sample taking, blood pressure measuring, it’s westernized. Being a foreigner, it could be really confusing if I go to a traditional Chinese style hospital. [Focus group 2].

International client NO2: They serve some coffee and iced drinks in the international clinic, which I know is not the traditional food habit. [Focus group 3].

Nurse (N3): We should fully respect each patient’s cultural and religious habits and refrain from discussing sensitive topics other than the patient’s illness, such as political or religious issues.

Pleasant Environments

From the patient’s perspective, reasonable organization, necessary facilities, clear signs, clean and tidy environments, nicely flavored food, and a warm atmosphere are the most basic requirements. Some participants described that enabling views of nature and well organized facilities make them more relaxing and cause less anxiety, and comfortably built and homely environments play an important role in assisting them feel better:

International client NO6: I hope to see some fresh flowers or plants in the clinic, no awful smell when I walk in, which make me feel relaxed and happy. [Focus group 3].

International client NO3: I prefer to use a clean toilet and generally try not to go to the bathroom in the hospital. Because I always feel that the toilets in the hospital are not very clean. And I cannot use a squatting pot, it is wired. [Focus group 1].

International patient NO7: Children’s play areas and mother-infant rooms are too important because I always spent so much time in the hospital. As you know, children get bored easily and can start to get restless which may cause distress to other clients. [Focus group 3].

Nurse (N4): We have a separate unit here … We are equipped with sofa, tea table, drinking water, TV programs, newspapers and magazines in English and Chinese. I think these are perfect for clients to kill time when they have to wait for the results.

For others, the essence of a patient-friendly environment has more to do with the general atmosphere and feelings associated with being there, rather than what it looks like:

International client NO5: Everybody is very friendly, it is not too busy, and it is clam. I feel very comfortable here. I made an appointment by email first, then come to visit. It’s similar to we have at home, from UK. [Focus group 1].

International client NO2: This is the only international clinic I have been to, it looks beautiful, and people on WeChat, even say it is very trustful. Yes, it is very good. Like the sitting, decorations and the way you move people around, like this waiting area, very well organized. [Focus group 2].

International patient NO6: One of my friends recommended here [international outpatient clinic], it is a good choice. The facilities here are fine and the grounds adequate. The most important thing is I feel safe here. [Focus group 1].

Qualified Care and Procedures

The participants described that their main concern was to relieve pain and cure diseases, which led to the demand for high quality and professional skills of medical staff:

International client NO8: Doctors and nurses should be professional and qualified. I hope I can receive the same standard of service every time I come to the hospital. [Focus group 2].

International client NO8: Sometimes I feel I cannot trust the doctor, especially when he cannot answer my questions accurately. [Focus group 3].

Some clients described the importance of having specialists, more than just GP doctors. They hope to see the same doctor when they come back for follow-ups:

International client NO4: You have specialist doctors here, I have seen them couple times and then they are very good. [Focus group 3].

International patient NO1: It is very nice to have a specialist you can see. And it is nice to see the same doctor. [Focus group 1].

Others mentioned that well organized clinic visits and reasonable temporal planning can improve the healthcare experience:

International client NO3: My first experience here, everything went very smoothly, I contacted by email and by phone which was very easy. [Focus group 3].

International client NO4: The most important thing for me, do not wait for so long. In my country [German], when I made an appointment, I need to wait like half an hour. [Focus group 3].

Nurse (N3): The biggest challenge for me is how to deal with clients’ complain about “wasting of time”. People have to wait sometimes, blood test or CT scan, we always make appointments for clients first, but it still needs to take time for the results.

Respect

Some participants described the importance for clients to feel respected as the basis of healthcare work. This includes being recognized, being trusted, and having the right to refuse care and express preferences:

International patient NO4: I went to the general clinic once, their English are ok, but the doctor acted like “oh, foreigner”, which makes me so stressed and distrustful. [Focus group 1].

International client NO6: When they [nurses] need to copy my passport or get my signature, they always let me know the reasons and ask my permission first. [Focus group 1].

Nurse (N4): We need the patient’s permission for almost everything we do and we did the same thing for every patient. For example, when a patient’s family members wants to accompany with the patient, we ask the permission from the adult patient first.

Participants consistently reported a strong focus on informed consent, particularly relating to the right to say no to treatment:

International client NO5: If I do not like the doctor, I feel free to express my feeling, you[nurses] would be so nice to arrange another one for me. [Focus group 2.]

International client NO1: I do not like venous transfusion. I refuse them unless I have to. The doctor should respect my choice, I have the right to choose my treatment. [Focus group 3].

Some participants discussed that seeking information from health professionals about what is going on, how the medication would benefit them, and why they need to do the test is an important part of respect:

International client NO5: I hate the sentence “You don't need to know.” Sometimes, doctors do not like to explain what is going on, they prefer to tell me what I should do next. I would like to know why and how, not only “what”. [Focus group 3].

Doctor (N2): People have the right to know. Only when they are fully aware of their own situation can they make the right choices. What’s more, respect is the important foundation of our healthcare work.

Discussion

The strength of this study was in obtaining opinions from both the clients’ focus groups and the healthcare providers’ focus group, which enhanced the trustworthiness and the quality of the findings. The findings we obtained in this study provide a first-hand reference for the international service centers to meet the international clients’ expectations.

We found that international clients were more concerned about privacy protection than Chinese clients. The previous study reported that the Health Insurance Portability and Accountability Act (HIPPA) mentioned several key points for privacy protection in the American healthcare industry, including notification, authorization and consent, limited use and disclosure, auditing and accounting and access, but it does not meet all the expectations of clients.¹⁴ Faced with growing health care data, privacy protection issues are becoming more prominent. The problem of patient privacy leakage may cause identity theft with huge economic losses.¹⁵ It is necessary for healthcare agencies to protect the privacy of client’s data. In our study, the international clients also expected to see the doctors or receive examinations in a private room without any other unnecessary people around. The international clinic in the studied hospital is a relatively independent area and equipped with several consulting rooms, examination rooms, waiting rooms to ensure a private space for each client. However, the requirement for clients’ data protection and clients’ needs for the privacy protection reminded the healthcare organizations to set up the policy and clinical settings to facilitate in meeting the needs of privacy protection. Healthcare professionals working in the international clinic need to receive the knowledge and skills training on privacy protection to meet the needs of the clients.

Our study also found out that effective communication was extreme vital in the international clinics. Many situations can cause communication problems in a hospital, such as tension or sadness, language problems, unrealistic expectations and so on.¹⁶ Communication skills of the healthcare providers including physicians and nurses is a key to effective communication. Poor communication can cause negative emotions in clients and affect their health and may cause complaints or violence.¹⁷ In contrast, effective communication can reduce clients’ anxiety, depression and other emotions, which leads to fewer complaints and improved the clients and staff satisfaction. One study found that communication in medical care was highly correlated with better client adherence, and training physicians to communicate enhanced their clients’ adherence.¹⁸ Using communication skills to encourage clients to express their own ideas and opinions could also ease the client’s tension and enhance the pleasantness of clients’ experiences, and promote a harmonious relationship between doctors and clients.^19,20 Nevertheless, language and culture differences can cause the communication barriers and minimizes the effective communication. To resolve this issue, healthcare professionals are encouraged to develop language competencies when interacting with international clients. In this study, the client highly appreciated that the healthcare providers could speak fluent English in the international clinic in China. In fact, we added language competency and educational or working experiences abroad as one of the criteria in the selection of the professionals involved in international clinic service at SRRSH. Our experience provides a reference for the selection criteria and training of physicians and nurses working in other international clinic.

Pleasant environments were another expectation of the clients interviewed. Building pleasant hospital environment including physical environment and humanistic atmosphere can positively influence the healing process.²¹ It was reported that natural and urban environment could shorten recovery periods and reduce levels of anxiety and stress.^22,23 Moreover, improved positioning of furniture could increase social interaction and create a supportive and stabilized environment for clients, leading a decreased pathological behavior.^24–26 In addition, the planning and design of hospital circulation zones is related with the problems of wayfinding difficulties and spatial disorientation²⁷ Client friendly hospital signs provide clear directions for the clients, thus reducing their distress and anxiety. Our study also found that the clients expected to have a separate area for reception desk, waiting area, separate clinic and auxiliary examination area with distinct signs for easy access. Besides the above-mentioned elements, taking the clients’ privacy protection need into consideration while building a physical environment is also vital. Humanistic atmosphere is as important as the physical environment for the clients. Keeping clients in a healthy and peaceful psychological state and helping them establish harmonious interpersonal relationship in the hospital is an essential content²⁸ It is mainly the harmonious and friendly relationship between people and personal feelings, including the relationship between client and physicians, clients and nurses, and clients and clients. Our study confirmed the importance of above-mentioned physical environment and atmosphere created by the healthcare professionals. In addition, some international clients preferred to have a children’s playground in the clinic to meet their extra needs besides the health care needs. With this piece of information, organizations are encouraged to think beyond to set up exceptional healthcare services for the international clients to improve their hospital experience. For example, the international clinic of the studied hospital equipped the clinic with English newspapers, accurate English signs, Chinese decoration, coffee machine and mother’s room to provide services with sincerity, confidence and love.

The medical safety of the clients and high-quality services to ensure the efficient of treatment process are both required in the healthcare organizations.²⁹ The expertise of the healthcare professionals is fundamental to providing high-quality and safe service for the clients. The development of trust has a positive impact on nurse-patient relationships and patient care quality.³⁰ The professional competence and interpersonal caring attitudes of healthcare providers is particularly important for developing a trusting relationship.³¹ In the current study, healthcare professionals constantly expressed the importance of professional expertise and the caring attitudes which were in align of the above mentioned reports in the literature. We concluded that the international service clinic, just like other clinics, needs to have a professional and qualified team with skilled and experienced members to ensure the safe practice and high-quality service. Inefficient workflow and processes may cause increased wait times which is related to congestion, dissatisfaction and clients’ perceptions of treat experience.³²

Studies^33,34 have shown that when nurses understand and respect clients’ beliefs, cultures and related behaviors, clients can better cooperate with the treatment. The need for multicultural care is reflected in all aspects of the treatment of international clients. Nurses in the United States of America and Canada have higher levels of cultural competency, and these societies have long histories of multiculturalism.³⁵ Chinese healthcare professionals in the international clinics expect to encounter cultural differences of the international clients. Negative perception caused by healthcare professionals’ low cultural sensitivity may trigger clients’ dissatisfaction, poor adherence to medication, and worse health outcomes.^36–38 One study found that uncertainty was consistently the main concern that happened when nurses caring for clients from diverse cultural, ethnic and linguistic background. That means they may do nothing when they have no idea about how to meet patients’ needs in a cultural appropriate way.³⁹ When doubts about the treatment plan arise due to cultural differences or different medical concepts, the medical staff is responsible to make a detailed explanation, and to provide optimal treatment options for clients to choose. In our study, clients also mentioned the importance of being respected. Although, this is a basic need for every human being, in the hospital settings, this need sometimes is neglected while the healthcare professionals focusing on handling the physical needs of the patients. One study reported disrespectful behaviors, such as negligence, impoliteness, dismissal, inattentiveness and discrimination that threaten patient dignity. Nurses’ responsive, compassionate, communicative and attentive behaviors could promote clients’ perceived respectfulness from the healthcare professionals in cross-cultural healthcare settings.⁴⁰ Therefore, healthcare professionals should respect and trust international clients without any forms of discrimination or injustice. At the studied hospital, mutual respect between doctors, nurses and patients was emphasized to build a warm atmosphere and provide high-quality services. Our study implied that improving cultural awareness and sensitivity was a very important and basic agenda for international healthcare providers.

Limitations

Two potential limitations in the current study were identified. First, most participants interviewed visited hospitals in one province in China, thus, the representativeness of the findings may be minimized. Second, English was not the first language for both the moderators and some of the clients, therefore, some valuable information may be missed out. In a future study, we may involve clients who have gone to other medical institutions in different areas in China. Professional interpreters or people from non-English speaking countries with high English proficiency will be invited to gain more and accurate information.

Conclusion

The findings of this qualitative study provided important insight into international clients’ healthcare needs. Our study suggested that high quality of international medical services perceived by the clients included a safe and comfortable environment, standardized and professional medical services, effective communication, and culturally appropriate care with respect, privacy and confidentiality protection. The government regulators or administrators and managers for international clinics in China and other countries are encouraged to construct the relevant policies and protocols and integrate cultural competence, communication skills, and privacy and confidentiality protection into health professionals training program to ensure the quality services.