Search strategy

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:

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.

Search results

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.

Search strategy

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.

Search results

The literature search for the narrative review yielded an additional nine pieces of literature: three cross-sectional studies, one book chapter, one longitudinal cohort study, three newspaper articles and one systematic review.

Language issues

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.

General understanding of primary healthcare services

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.

Inconvenient or untimely appointments and concerns of not receiving adequate attention

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.

Embarrassment discussing certain health and well-being concerns

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).

Seeking out trusted family and close friends for health advice

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).

Using specific social media channels for seeking health information

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).

Using Western medicine and traditional Chinese medicine

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).

Family background, such as only child status

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.

High expectations for overseas Chinese students

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.

Spirituality and beliefs

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.