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• To familiarise yourself with the healthcare needs of overseas Chinese students
• To understand the barriers experienced by overseas Chinese students when accessing UK student primary healthcare
• To enhance your knowledge of strategies to increase access to healthcare services for this population
Individuals from China comprise the largest cohort of international students in the UK, making up almost one quarter of those coming to the country to study. The large Chinese student population at UK universities means there are considerable numbers each year who require access to student primary healthcare.
This article describes a literature and narrative review that aimed to critically review the evidence concerning whether the primary healthcare needs of overseas Chinese students studying at UK universities are being met. Three themes were identified: primary healthcare accessibility and potential barriers for overseas Chinese students; health-seeking behaviour and health needs; and cultural and spiritual foundations of health needs and trusted health-seeking frameworks.
Primary Health Care. 31, 6, 25-30. doi: 10.7748/phc.2021.e1731
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondencemrscharlotteporter@yahoo.co.uk
Conflict of interestNone declared
Porter CL (2021) Meeting the healthcare needs of overseas Chinese students at UK universities. Primary Health Care. doi: 10.7748/phc.2021.e1731
AcknowledgmentsI wish to acknowledge the help provided by my primary care colleagues at University Health Service, The University of Sheffield, particularly Dr Mike Jakubovic, Ben Hallsworth and Emma de Chenu
Published: 29 November 2021
Published online: 25 August 2021
The UK is a popular destination among international students undertaking their undergraduate and postgraduate studies at UK higher education (HE) institutions. Nearly half a million overseas students enrolled at universities in the UK between 2018 and 2019 (Universities UK 2021). Individuals from China studying in the UK comprised the largest cohort, making up almost one quarter of all overseas students (UK Universities 2021).
Student primary healthcare is an important service that is provided to university students who are living away from their family home. Many students will have accessed healthcare at one family practice before starting at university, and may find it challenging to maintain their health as they move back and forth between university and home (Hagell 2017). In addition to challenges with obtaining healthcare, international students experience additional stressors when studying abroad compared to home students, such as integrating academically and language issues (Cao et al 2016, Cao et al 2018, Cheng et al 2019).
The large overseas Chinese student population at UK universities means there are considerable numbers each year who require access to student primary healthcare. Meeting the needs of this population is the responsibility of professionals working in education, public health and primary care. This article describes a literature review and subsequent narrative review that investigated whether the primary healthcare needs of overseas Chinese students are being met.
• Student primary healthcare is a service provided to university students who are living away from their family home
• English language proficiency is a frequent barrier to overseas Chinese students accessing primary healthcare
• The healthcare needs of overseas Chinese students are influenced by their cultural and social norms, and some will prefer to access traditional Chinese medicine
• The results of this literature review suggested that the healthcare needs of overseas Chinese students may not be met in the UK
The following databases were used to search for literature related to the healthcare needs of overseas Chinese students at UK universities: Medline, Cumulative Index to Nursing and Allied Health Literature, JSTOR, PubMed, Scopus, ProQuest and Internurse.
The terms ‘Chinese students’ AND ‘(international OR overseas)’ AND ‘health needs’ were used to search the databases. This ensured that the search yielded literature that discussed undergraduate and postgraduate students from mainland China, Hong Kong, Taiwan, and in some cases, ethnically Chinese students from Singapore, Malaysia and the wider South East Asian region. Literature featuring Chinese students from these countries was included as these countries contributed tens of thousands of overseas students in the UK in 2018 (UNESCO 2021) and excluding this literature would significantly reduce the total number of articles included and reduce the data pool.
Studies were included in the literature review if they:
• Were written in the English language.
• Were published between 1 January 2015 and 4 June 2020, to ensure contemporality, and in keeping with a period of time where there was a growth in the population of overseas Chinese students at UK universities (UK Universities 2021). Additionally, the five-year period ensured that there was enough time for the researchers to thoroughly review the literature for anomalies and variations, while ensuring that the search remained current (Caruana and Roman 2015).
• Incorporated primary health data on:
• The whole UK student population, including Chinese students.
• International students studying in the UK.
• Chinese students studying in the UK or other English-speaking countries, such as New Zealand, Australia and the US.
• Ethnically Chinese people’s health needs in the UK.
• How Western and traditional Chinese medicine is used by student populations globally.
• University students in China, both international and home, and health-related quality of life.
• Influences on mental health in Chinese culture.
• UK mental health services for Chinese service users.
Papers were excluded depending on how relatable the subject matter was to Chinese students studying in the UK. For example, some papers discussed issues to do with specific host countries, such as US papers that featured incidents of students being required to pay for healthcare at the point of use. Papers such as these were excluded. Papers with a low-transferability value to overseas Chinese students in the UK were also excluded.
The search yielded 270 articles, of which 80 were excluded after evaluating their title. A further 40 were removed as they were duplicates, leaving 150 papers to be evaluated by reading the abstract. Evaluation of the abstracts led to 111 more papers being removed. The remaining 39 papers were read in their entirety, with a final total of 22 papers being found suitable for the literature review.
A thematic narrative review strategy was used to provide some context to the data that had been yielded from the standard literature review. The purpose was to identify, analyse and interpret patterns and themes or meaning from the data captured by a different, less formal literature search, but which still had merit.
The rationale for conducting an additional narrative review was to more clearly understand the wider narrative, and specifically to expand the search to include grey literature such as the health needs assessments that are specifically undertaken on student populations in the UK. Narrative reviews explore the most significant and central aspects of the current knowledge on a topic (Onwuegbuzie and Frels 2016), whereas literature reviews tend to be simply descriptive rather than incorporating a critical dimension to the analysis (Pati and Lorusso 2018).
For the narrative review, the search methods applied were the same as those described for the literature review, except that Google and Google Scholar were used in addition to the databases already outlined. Inclusion criteria was the same for the populations and types of data already discussed, but the scope was widened to include papers published over the previous ten years, newspaper articles, student health needs assessments and book chapters. The exclusion criteria comprised papers that were not written in English, and papers published more than ten years ago. Hand searching also excluded work where no new themes were described, and that had not already been captured in the original literature search.
Within the remit of the narrative review, where peer reviewing was not present, data was collected from sources where authors were able to describe their methodologies, aims, objectives and disclose any potential conflicts that might have biased the results from their work.
Box 1 demonstrates the final themes and sub-themes extracted from the literature.
Primary healthcare accessibility and potential barriers for overseas Chinese students:
• Language issues
• General understanding of primary healthcare services
• Inconvenient or untimely appointments and concerns about not receiving adequate attention
• Embarrassment discussing certain health and well-being concerns
Health-seeking behaviour and health needs:
• Seeking out trusted family and close friends for health advice
• Using specific social media channels for seeking health information
• Using Western medicine and traditional Chinese medicine
Cultural and spiritual foundations of health needs, and trusted health-seeking frameworks:
To access primary healthcare in the UK, overseas Chinese students simply need to register with a GP surgery when they arrive (UK Council for International Student Affairs 2020). However, the literature review discovered several sub-themes related to the issue of access.
The studies that analysed acculturative barriers for overseas Chinese students all cited language issues as a major barrier (Chang et al 2015, Chunfeng Wang et al 2015, Wang et al 2015, Cao et al 2016, Wang 2017, Cheng et al 2019, Lian et al 2020). Wang (2017) collected primary quantitative data from overseas Chinese students and found that language barriers impeded them from accessing NHS services.
The study cites individual examples of Chinese students who found it challenging to make themselves understood when attempting to converse in English with their GP, and that this impaired the treatment they received. Li et al (2014) found that English language proficiency was closely associated with East Asian students’ psychological well-being when studying abroad.
Misinterpreting what local health services can and cannot offer was a significant theme found in the review (Chang et al 2015, Gao et al 2016, Wang 2017, Chen et al 2020). Wang (2017) revealed that some overseas Chinese students attended GP surgeries for issues that could have been dealt with by dental or ophthalmic services, for example toothache.
Issues such as untimely appointments are particularly challenging for some overseas Chinese students (Wang 2017). There was a reported difference in the time taken for some international students to be seen by the GP compared to home students. Data from the narrative review suggests that 60% of home students reported seeing a GP within three days compared to 49% of international students (O’Neill 2012). Wang (2017) suggested that some overseas Chinese students may exaggerate the seriousness of their conditions to receive adequate attention from GPs. Wang (2017) also suggested that some overseas Chinese students may be concerned that they are not seeing a doctor when they think they should, while others were concerned at the level of skill of the practitioner that attended to them at their GP practice.
The attitudes of overseas Chinese students to sexual health are largely informed by their home culture, and as such may be challenging for them to discuss (Gao et al 2016). For example, overseas Chinese students tended to obtain their health information related to human papillomavirus (HPV) vaccination on social media platforms and social networks (Gao et al 2016).
Overseas Chinese students use their friends and family support networks extensively for advice on health and wellbeing, often instead of seeking support from a healthcare professional (Chang et al 2015, Cao et al 2016, Chen et al 2020).
Overseas Chinese students frequently reported using an extended social media network for health advice (Gao et al 2016). This was because it linked them to peers that hold similar opinions and experiences of health needs and beliefs on well-being. The ‘instant information’ provided by social media networks, such as Weibo and WeChat, was seen as an advantage and meant these sites were widely used and trusted among overseas Chinese students (Gao et al 2016, Wang 2017).
Evidence suggested a highly pragmatic approach to medical treatment (Zhang et al 2015), with overseas Chinese students using both Western medicine and traditional Chinese medicine simultaneously (Wang 2017).
The findings identified multifactorial themes pertaining to only child status, high expectations for overseas Chinese students, and spirituality and beliefs.
Chu et al (2015) suggested that university students globally experience several challenges, which affect their levels of perceived stress and life satisfaction. For example, Chinese children with siblings reported lower levels of life satisfaction than only children. This was compared to non-Chinese children who showed no difference in life satisfaction whether they were an only child or not. This reduced life satisfaction among children with siblings may be important when they go on to attend university and have to share homes and study time with other students. For example, reduced life satisfaction may affect these students’ general health and health needs.
The literature review and narrative review raised the theme of personal ambition, personal and family pride, shame, and the value placed on academic and employment success. This is said to lead to a hard-working ethos that overseas Chinese students continue to demonstrate during their studies abroad (Cao et al 2017). How this relates exactly to the health and well-being and the health needs of overseas Chinese students is not extensively developed in the literature. One study suggested that not achieving personal, academic and family goals causes psychological distress for overseas Chinese students (Law 2016).
While pressure may be felt from academia, friends or family, these may also be where students can receive trust and support. Wang (2017) mentioned examples of overseas Chinese students attending local church groups and shared interest groups where they could discuss peer-support and health and well-being.
Overseas Chinese students place high value on academic success, but the learning styles encountered while at UK universities are significantly different from their past educational experiences. The literature revealed that overseas Chinese students do not generally wish to contribute when in large student groups (Cao et al 2016), and that their former education has taught them to listen to the teacher, and not ask questions (Wang 2017). When they study at UK universities, overseas Chinese students experience an environment where open discussion is encouraged, and through acculturalisation this becomes easier to participate in (Cheng et al 2019). However, initially, the new culture may prove to be stressful and can negatively affect a student’s mood, in turn potentially affecting their health needs.
The literature suggested that overseas Chinese students can view their health as a balance between humanity and nature, but also more individually as a balance between the body, mind and spirit. This concept is often described as Yin and Yang, a holistic philosophy that may determine the health needs and health-seeking behaviour of this population. Wang (2017) suggested that there is a view among overseas Chinese students that the concepts of balance and dualism, both of which are features of Yin and Yang, can complement a biomedical approach to health.
The literature revealed that English language proficiency was a significant factor in how effectively overseas Chinese students are able to access and understand primary healthcare services. English language proficiency in the UK is tested by the International English Language Testing System (University of Sheffield 2021). However, despite the generally high scores required to be accepted onto university undergraduate courses, the literature found that there are still communication issues present when students attempt to access healthcare services. Studies in other populations have produced similar findings on language barriers and uptake of healthcare (Abdullahi et al 2009, Greenwood et al 2015). Research has suggested that this could be alleviated through an increased use of interpreters. Gerrish et al (2004) found that the use of interpreters by nurses working in primary care was varied, with a lack of training cited as a reason.
A health needs assessment conducted in the North East of England showed a small gap in satisfaction with GP services between home and international students, with 83% of home students satisfied, compared with 73% of international students (O’Neill 2012). Potentially, this gap could be reduced by addressing the barriers to access caused by communication and language issues. Satisfaction with GP services may also be addressed by improving the untimely GP access experienced by international students compared with home students. However, if overseas Chinese students’ satisfaction with receiving timely access is dependent on their ability to obtain a face-to-face appointment with a GP, then their expectations of what constitutes access may be higher than that of a home student who may be happy to speak to a nurse practitioner over the telephone.
The literature review found that the use of traditional Chinese medicine was a recurring theme, with students either using it alongside or to replace Western medicine (Wang 2017).
Research also suggested that there is a disparity between the health needs and health-seeking behaviours of international students as perceived by health service providers such as primary care and universities, and their health needs as perceived by a universal student health needs assessment approach (O’Neill 2012). The student population is incredibly diverse, and a one-size-fits-all approach may leave health needs unmet in the overseas Chinese student population if health service providers do not account for potential differences.
Acculturalisation to university life is a commonly accepted experience for overseas Chinese students. However, they may not have anticipated that they also have to navigate a different healthcare service, which may be distressing if their expectations are not managed.
There is a common belief in Chinese society that ill-health is caused by an imbalance of Yin and Yang (Bellaimey 2013). It has traditionally been accepted that ill-health can be addressed by eating certain foods; administering herbs and traditional Chinese medicine; using physical therapy such as acupuncture, massage and cupping; and undertaking meditation and physical activity.
When asked about health and practices that can enhance well-being, many overseas Chinese students stated that they used traditions that are rooted in the theory of dualism and traditional Chinese medicine. These traditional practices are often used alongside Western medicine, suggesting that overseas Chinese students believe the two approaches can be used in unison for optimum health (Wang 2017).
The following practices have been shown to be popular with overseas Chinese students:
• Seasonal influence on health (Bellaimey 2013, Ma 2015, Wang, 2017) – in traditional Chinese culture, as in Western culture, it is recognised that food consumed in the normal growing season will be the most nutritious and have maximum benefits for optimal health and balance (Ma 2015). Seasonal influence is pertinent because ill-health can be attributed to natural conditions such as cold, wet, windy, or dry and hot weather (Wang 2017). These natural conditions are often thought to be intrinsically linked to human emotions (Wang 2017); therefore, seasonal influence may affect an individual’s perception of their health and well-being, and in turn their health needs.
• Culturally guided dietary intake during illness or a medical procedure – for example routine vaccinations and the consumption of hot and cold foods thereafter (Ma 2015, Gao et al 2016). In Chinese medicine, a medical procedure or treatment, such as a vaccination, is seen as an imbalance, and to rectify this imbalance the consumption of specific foods that are viewed as hot or cold are sometimes recommended. Overseas Chinese students may seek explanations regarding certain treatments for the purpose of planning a personal routine that follows cultural traditions. This may include the meal they eat immediately after a treatment, whether they can smoke or drink alcohol, and whether they can undertake exercise.
Future research into the healthcare needs of international students is required from a UK perspective, and should involve seeking the views of the overseas Chinese student community and primary healthcare staff.
Nurses should consider Chinese students’ proficiency in the English language and make required adjustments.
Surgeries could consider operating dedicated ‘fresher clinics’, whereby students, including international students, have space to discuss common issues such as sexual health and vaccinations.
Having a basic understanding of some of the principles of traditional Chinese medicine may support nurses to understand the health needs of patients from the overseas Chinese student community.
This literature review featured minimal UK data specifically related to the primary healthcare needs of overseas Chinese students. In addition, there are some aspects of primary healthcare needs that were not available in the literature as standalone data related to overseas Chinese students, for example healthy eating, obesity and smoking. As a result, the review featured international literature from other countries, such as the US and Australia, and the experiences of overseas Chinese students in these countries may not apply to those in the UK.
The review extrapolated findings from studies investigating international students in general, because specific data for Chinese students was not always available. However, these findings were still useful for identifying the potential primary healthcare needs of overseas Chinese students.
It is important to acknowledge that various individuals from a given country will not have identical health needs.
This literature review considered the extent to which the primary healthcare needs of overseas Chinese students studying at UK universities are being met. The findings suggest that in some areas such as access to services, the healthcare provided to this population is suboptimal. English language proficiency, cultural influences on health-seeking behaviours and misunderstandings regarding what services should be provided are among the perceived barriers to achieving equitable primary healthcare for overseas Chinese students.
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