The Obstacle to Health Care of Foreign Residents in Japan

To shed a light on problems and areas of needs in health care services for foreign residents, this research focuses on identifying these problem areas that affect health care provision to foreign residents. This study was conducted in cooperation with an organization that provided everyday life support consultation to foreign resides in multiple languages at a Center for International Exchange. An analysis on contents of multi-lingual consultations provided by a foreign resident support organization in a major urban area identified these issues which are chosen from records of health related consultation cases which were selected from all everyday life support consultation records dating from April 2004 to March 2010. There were, in total, fifty-one health related consultation cases. Thirty one consultations were carried out in Japanese, issues that were caused by language barriers and cultural differences: communication problems, lack of information on health services and welfare services, difficulty in applying for benefits which resulted in the inability to pay medical costs and stress from unfamiliar work and life environment. Two elements of health service improvement would be “revised ways of information provision for the foreign residents” and “awareness of the multicultural society”. *Corresponding author: Sakiko Kanbara, Faculty of Nursing, University of Kochi, 2751-1 Ike Kochi, Japan, Tel: +81-88-847-8700; Fax: +81-88-847-8670; E-mail: kanbara@cc.u-kochi.ac.jp Received February 07, 2013; Accepted April 30, 2013; Published May 06, 2013 Citation: Kanbara S, Susa K (2013) The Obstacle to Health Care of Foreign Residents in Japan. J Nurs Care S5: 009. doi: 10.4172/2167-1168.S5-009 Copyright: © 2013 Kanbara S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
In recent years, migration of people has become more rapid and speedy around the world, and there is an increase in foreign residents in Japan as well. The number of registered foreign residents in Japan amounted to over two million at the end of 2009. This is a sharp increase from 1,550,000, the figure from ten years before. The number of permanent residents was 943,037 (43.1%) and non-permanent residents were 1,243,084 (56.9%). The current trend in migration is an increasing number of permanent residents [1]. Japan needs to respond to this rapid globalizing of its society; however, there are elements of infrastructure that are poorly equipped to meet the needs. As a result, social issues, such as instability and inequalities in employment, problems in schooling for children and crime rates among foreigners are on the rise [2]. Medical services to foreign residents are no exceptions. Many researches have been conducted and reported problems that stem from language and cultural differences which result in hindrance to accessing medical services. However, problems related to stages before accessing medical services have not yet been clarified.
Himeji City is a core city located in the industrial area of western Japan with a population size of approximately 530,000 (as of September 1, 2009) [3]. About 11,000 foreign residents are registered [4]. The city has a world heritage site and an increasing number of overseas travelers visit the area [4,5]. Himeji City has a history of assisting 5 foreigners with language acquisition, health management and employment, due to the presence of a former refugee settlement foster center (established in 1979 and closed in 1996) that received refugees mainly from Indochina and Vietnam [6]. In its new comprehensive city plan, Himeji is promoting urban planning with a global perspective [7] and has already been providing health services to its foreign residents. To implement an improved urban environment in which foreign residents' health can thrive, it is crucial to identify hindering factors in medical provision. This research focuses on identifying these problem areas that affect health care provision to foreign residents.
This study was conducted in cooperation with an organization that provided everyday life support consultation to foreign residents in multiple languages at the Center for International Exchange. The aim of the research was to discover the kinds of necessary actions to health care and to learn about the kinds of support the volunteer helpers at the organization actually provided. Data analysis was conducted to elicit health service related problems which were identified from a survey by the foreign residents of Himeji City and its surrounding areas.

Methods
The study was conducted with an approval by the University of KinDAI Himeji and the Himeji city government. Data collection period for this analysis research was from September to December 2010. Data set for this article was chosen from records of health related consultation cases which were selected from all everyday life support consultation records dating from April 2004 to March 2010. The everyday life support consultations have been catalogued by volunteers at the center. The records were reviewed by three volunteers and one faculty member in public health nursing. All data were carefully analyzed to identify the above mentioned issues.

Characteristics of the study subjects
There were, in total, fifty-one health-related consultation cases. Twelve cases were records from follow-up sessions from the previous consultations, and thirty nine cases were new consultation cases. Subjects of the consultation were nineteen males, nineteen females, and one unrecorded. There were eighteen Brazilians, which accounted for the largest group (46.2%), followed by nine Peruvians (23.1%) and four Vietnamese (10.3%) ( Table 1).

Languages of the clients
Among the fifty-one health related consultations, thirty one consultations were conducted in Japanese. This means that approximately 60% of the consultations were carried out in Japanese (

Contents of the consultations
The contents of the consultations were categorized into eleven groups (Table 3). Each case was not necessarily put into only one category but was counted for two if the case satisfied more than one category. Therefore, the ratio of the contents was indicated in percentage rather than in total number of cases. These eleven categories are: Hospital referral (11 cases, 21.6%): Seven consultations were done during the time of the H1N1 influenza epidemic for advice on hospital referrals for their children and family members who were showing flulike symptoms. One person requested for accompaniment to hospital. Two cases were requests from community leaders for information. Other cases included a woman inquiring about a clinic which is staffed with a female doctor and others asking about information on suitable hospitals for specific conditions. Need for interpreters (11 cases, 21.6%): Ten foreign residents requested for interpreters for going to a hospital as outpatients, being admitted to and discharged from the hospital, and communicating to doctors and nurses at the time of an emergency. Hospital staff requested interpreting services as well in two cases.
Medical expenses (7 cases, 13.7%): There were cases that showed difficulties with paying for medical fees due to financial hardship and late payments for health insurance contributions. In some cases, they were discharged form the hospital due to their inability to pay. These consultation clients sought advice on medical expenses for services and support for for the disabled, medical insurance, identification booklet for the physically disabled, and welfare benefits. There were six cases of clients without any kind of health insurance. Some were behind with payment for health insurance due to unemployment.

Report on progress (7 cases, 13.7%):
The clients in follow-up consultations reported their progress with application for some kind of welfare benefits, current life situations and medical conditions. Health related anxiety (5 cases, 9.8%): One client was concerned about health check at his workplace while another felt anxious about his/her ill health and unemployment to the point that he contemplated committing suicide. Due to stress at work place, some developed psychiatric illness and came for consultation.
Request for a companion (5 cases, 9.8%): There were requests for a companion who can assist them at such times as health examination, with discharge explanation, transfer to another hospital, and payment at hospitals.
Occupational health (5 cases, 9.8%): Three cases were about mental health problems that resulted from an injury or stress at their workplaces. The clients had lost their jobs due to poor health, and they were in need of support to reduce health related anxiety and to apply for welfare.
Family problems (4 cases, 7.8%): These were financial difficulties that were caused by illness, unemployment, and a greater financial burden on the family.
Complaints about hospitals (2 cases, 3.9%): Some felt dissatisfied with diagnosis and treatments they received from doctors. They expressed distrust towards the hospitals to consultants.
Information gathering (2 cases, 3.9%): Two people visited the Center to gather information about H1N1 influenza. They were both prominent people in their community. One of them was from a church and the other was from a restaurant where they had regular contacts with members of foreign communities.
Liaising with other support groups (7 cases, 13.7%): In Himeji City, there were services such as the Citizen Center in the municipal office and the consultation service at the International Exchange Center. At the citizen center, a counseling service for daily life was provided by trained staff from the FWEAP (Foundation for the Welfare and Education of Asian People), Refugee Assistance Headquarters, Kansai Branch for Indo-Chinese Refugees. The counseling services    were available in Portuguese, Spanish and Chinese. The International Exchange Center provided information in English to foreign residents, and consultation services in multiple languages were offered by other support organizations [8,9].

Post consultation support activities by volunteers
Support activities which were actually carried out were classified into 13 categories ( Table 4). Some of the cases were classified in more than one category of support activities. In such cases, both categories were counted. Therefore, the ratio of support activities was indicated in percentage. The following summaries are not necessarily in the order of these 13 categories but they are roughly divided.
Interpretation (15 cases, 29.4%): Volunteers accompanied clients as interpreters to hospitals and municipals office for application procedures.
Filing applications (12 cases, 15.4%): In response to consultation requests about medical fees that hindered the clients from going to a hospital, volunteers provided information on installment payment plans for health insurance, social welfare benefits and medical tickets to clients. This was followed by helping with filing applications for these financial services.
Providing information (12 cases, 23.5%): Information about social security provisions, such as the health insurance and welfare benefits that were offered by Himeji City was provided. Information on H1N1 influenza was also provided. Some clients were given information about hospitals where staff could speak the client's language or hospitals that were recommended by medical practitioners. Of the eight cases of hospital referral requests, four clients were actually introduced to hospitals with staff with language abilities or an appropriate clinical department for the client. One volunteer was introduced when H1N1 influenza information was inquired. A client in one case did not specifically ask for a hospital referral; however, the client was referred to one due to his symptoms.
Accompanying to hospitals (9 cases, 11.5%): There were two cases where the clients requested for a chaperone when feeling anxious to go to hospital. Three requested interpreters for a hospital visit, two requested for help with administrative procedures such as getting a medical certificate, paying for medical fees and retrieving discharge information. One requested translation of a patient referral and another for a visitor who came to see the client at the hospital. There were also two cases where the clients requested for help with application process for welfare benefit and health insurance.
Liaising with other support groups (7 cases, 13.7%): Volunteers introduced other organizations, NPOs and medical professionals. Seven cases were referred to the Center for Foreign Residents of the Prefecture (Hiroshima International Center). One case requested for cooperation from another organization, and another request was made to a medical professional.
Follow-up (6 cases, 11.8%): Follow-up consultations monitored the clients' progresses in the previously consulted areas in life and work. Volunteers provided directions for further progress and offered necessary information.
Listening and advice (5 cases, 9.8%): Some clients voiced their anxiety about poor health, stress from work, family and financial difficulties. Some cases only required an attentive listening to clients rather than providing practical advice. The volunteers listened to the clients, shared their feelings, and offered advice.

Consulting doctor (4 cases, 5.1%) and consulting health centers (3 cases, 3.8%):
The volunteers consulted doctors and health center staff to get advice in order to refer clients to appropriate hospitals or to provide accurate information. The volunteers were not medical professionals, so they sought professional advice.
Translating documents (1 case, 2.0%): One client who was an inpatient needed to be transferred to a hospital in his country of origin. He had requested a referral letter from his doctor to be translated into his native language.

Discussion
This study aimed to shed a light on problems and areas of needs in health care services for foreign residents. An analysis on contents of multi-lingual consultations provided by a foreign resident support organization in a major urban area identifies these issues.
The foreign residents of Hiimeji City, where the supporting organization is located, consist of Koreans (including North Koreans) 56%, Chinese 16%, Vietnamese 15% and Brazilians 3% [10] . The ratio of nationalities of the clients in this study differed from the demographic ratio of the city, as Brazilians and Peruvians made up the most clients, followed by Vietnamese. One of the reasons for such difference was because the support organization had volunteers who were fluent in Portuguese and Spanish. There was a strong connection with Brazilian communities and people knew about the organization, and such information was spread through a word of mouth. Out of South Koreans, North Koreans, and Chinese residents who account for 70% of the foreign residents of Himeji City, there was only one Chinese client. The reason for that is due to the fact that these are "old timers" Koreans, North Koreans and Chinese who are the second or third generation living in Japan. They do not have language problems and they have established their own communities and issues are solved within the community.
Thirty one consultations were carried out in Japanese. This made up 60% of all cases. However, the level of Japanese language ability varied, and this number includes the consultations that were conducted in very basic Japanese. Forty percent of the clients spoke in a mix of their mother tongue and Japanese. The contents of the consultation areas were not only about specific illnesses but also about hospital referrals, medical translations, and welfare benefits. Many clients did not seek out just for information about available support. Rather, they asked for assistance in practical matters such as how to fill out applications. It is suspected that necessary information such as health services and social security is not readily accessible to foreign residents. Even when they are capable  of communicating in Japanese in everyday settings, understanding written documents in Japanese and medical terminology is difficult. Therefore, much less information is available to foreign residents. This language barrier makes difficult for foreign residents to comprehend explanations and application processes for obtaining social benefits, such as payments or medical expenses for services and support for people with disabilities, health insurance and so on. It is inferred that foreign residents also struggle with understanding explanations from doctors and nurses. Under the current administration, application forms and explanatory documents that are written in multiple languages or easy Japanese are generally not available. It is essential to provide all citizens with information about social security and medical services to ensure good health care. This type of information should be made accessible to all members of the community. Such an effort will result in easy-to-understand information for Japanese speakers too.
Ten cases of consultation about H1N1 influenza were reported during its epidemic in 2009. The supporting organizations received phone calls day and night inquiring after information about this completely new type of influenza which confused Japanese people. H1N1 influenza appeared to be even more incomprehensible to foreign residents who lacked an understanding of the Japanese language. They experienced a panic by being kept ignorant. Watanabe and Kawashima stated that when a disaster occurs and there is a need for medical services, the greatest issue that foreign residents have is the "language barrier. " The foreign residents desired the "use of multiple languages in signage in hospitals" and "providing an interpreter for common languages" [11]. It is absolutely necessary to take measures not only for epidemic diseases but also for emergency cases such as disasters.
There were family members and leaders of foreign communities who visited the support service centers and requested information. Listening to the family members and community leaders led to further understanding of the issues faced by the local foreign residents. The community leaders may become an asset for information provision.
Problems caused by the language differences were not specifically recorded in the consultations. However, issues due to living in an unfamiliar environment and culture surfaced during the interviews. It was found that some people were suffering from psychiatric symptoms and others even contemplated committing suicide because of stress from work, family relationships and anxiety about sickness. Yamashita et al. stated that health service for foreigners is not such a unique matter; however, there are language barriers, differences in ways of thinking and differences in health service compared to their home country [12]. Some clients shared their dissatisfaction and distrust about the health service because of the lack of adequate explanation. Utagawa and Tanno [13] reported that where there were language problems, mothers giving birth and raising children experienced increased anxiety. Language barriers make the foreign residents feel more dissatisfied, more distrusting and more anxious. Medical staff ought to take these feelings that are due to language differences into consideration. While the world is increasingly globalizing, work places, communities and staff in health services should be aware that it is becoming commonplace for people to speak different languages and have different ways of thinking. There is a clear need to support the foreign residents in the community. It is hoped that wider communities and all involved in health services become aware of the current situations and issues and explore ways of understanding different cultures and living together as a society. In order to tackle such a challenge, foreign communities, supporters, universities and the government need to identify what they can contribute and then cooperate.

Conclusions
As a result of the content analysis of the consultations, issues that were caused by language barriers and cultural difference were: communication problems, lack of information on health services and welfare services, difficulty in applying for benefits which resulted in the inability to pay medical costs and stress from unfamiliar work and life environment. Two elements of health service improvement would be "revised ways of information provision for the foreign residents" and "awareness of the multicultural society".

Limitations and Challenges
This study analyzed only the contents of the consultations that were initiated by the clients who came to the support services; therefore it is not a reflection of health related issues held by all the foreign residents of Himeji city. It is suspected that there are other issues that are not reflected in the study.
The results were the contents of consultations that the trusted volunteers sorted then retrieved during the interview about health services carried out by the researchers of this study. Issues that the clients had shared may not be the actual cause of the problems they were facing. It was also found that some consultations were given without being officially recorded.

Publishing and Pass-on (reduction) of the Study Results
This study was part of the subsidized project of Himeji city policy research of 2010 titled "Review the modalities of health services in the globalizing society: the current situation of nursing the foreign residents and the potential of medical sightseeing" [9]. The results of this study were presented in a meeting where all the subsidized projects of Himeji City policy research were gathered and then returned to the city.