Quantitative phase

1). Study design and setting

The cross-sectional study was carried out in Seville, the Southern Spain, to make a first contact with the Chinese immigrant population. Seville is the second province of Andalusia with the most Chinese immigrant population (24.6%).¹⁶ In the Spanish cities, there has been an influx of foreigners in recent years, which makes it difficult to socially assimilate immigration changes.¹⁸ Due to the difficulties in approaching these Chinese immigrants, such as language and cultural differences,¹⁹ a convenience sample and a “snowball sampling” procedure were used. All individuals signed an informed consent to participate.

Participants included were immigrants of Chinese origin living in Spain; emigrated to Seville; were between 19 and 44 years old; and were able to communicate in Mandarin Chinese, Spanish, or English. According to some authors, immigrant's age should be limited to avoid the influence of older adults on the analysis.^7,20 Although in some studies the age ranges from 19-60 years,^21,22 the majority of Chinese immigrants are between 20 and 55 years, due to the main reason for immigration is labor, which implies young people of active age.^23,24 This coincides with the average age proposed in our work and in others with an immigrant population.^25-29

2). Procedure

Data collection took place between September 2016 and January 2017. A total of 252 businesses (e.g. bazaars, restaurants, wholesale businesses) were visited, and 92 questionnaires were completed correctly (22.3%). In order to expand our sample, social media was used and 17 (4.5%) people completed the entire questionnaire. Finally, 134 Chinese from institutions (mostly educational institutions, Asian cultural centers, and health services) were also contacted and 24 questionnaires were completed (18%) (Fig. 1). Most participants were approached in their workplaces. Mainly, face-to-face surveys were conducted, taking 60minutes to complete its. Some participants requested to fill in the questionnaire later (due to work activity). Finally, people contacted through Facebook preferred to complete the survey online and then send them to the MR (via e-mail).

Figure 1.  Flow chart of the sampling procedure. 

Prior to use, a content validation of the tool by a group of experts in health promotion (n=6) and a pilot with 30 participants were carried out.²⁶ After the pilot, a new content validation was carried out by a group of Chinese native speakers (n=3) who have been living in Spain for more than 10 years. For the cross-cultural adaptation of the tool, a Spanish-Chinese translation was carried out by Chinese natives (n=3), and a Chinese-Spanish back-translation by other Chinese native (n=1) as well as by a translation company.

3). Variables

The present survey was based on the National Health Survey of Spain.³⁰ The variables were:

Demographic variables. Independent variable was sex (male and female). Other were marital status (single, married, living with partner and divorced), level of education (secondary or lower and vocational or university), employment status (employed or unemployed). Continuous variables were age and length of residence in Spain.

Accessibility to health services. Visits to the doctor, use of emergency services and hospitalization, main reasons for visit (acute health problems, check-ups, accidents and sick leaves or discharges), place of the last visit (public primary care centers, public emergency services, and private health centers), type of emergency services used (public hospital, private hospital, and public primary care center), other special health services used (radiology, dentistry, and homeopathy, naturopathy, and acupuncture), reason not to receive healthcare (long waiting time and lack of personal time). Continuous variables were days of hospitalization, and number of visits to emergency services.

4). Statistical methods

Descriptive analysis was carried out using absolute and relative frequencies, as well as mean, median, and standard deviation. Inferential analysis was performed using chi-squared tests, odds ratios or Mann-Whitney tests depending on the nature of the variable (categorical, ordinal or continuous). Normality was checked using the Kolmogorov-Smirnov test and, based on the result, the tests were selected as independent t-tests or Mann-Whitney tests. Analyses were performed using the SPSS statistical package (version 23.0). In addition, a p <0.05 was considered to be significant.

Qualitative phase

1). Design and sampling

A phenomenological approach was used with semi-structured interviews. The sampling was intentional and was carried out using saturation criteria. Relevant key informants from the Chinese community were indicated by members of the Chinese community in Seville and selected based on their relationships, roles, and knowledge regarding the Chinese immigrant population. A total of seven interviews with key informants were conducted between January and March 2017 (Table 1). We strove for a sample of participants reflecting diversity in, age, jobs, and experience living in Spain. The intention was to increase the credibility of our findings and their transferability to other Andalusia areas. Exceptionally, the inclusion of second-generation people (n=2), and Spanish one (n=2) with strong ties with the Chinese community was accepted. A field diary was also kept through the continuous and cumulative recording of everything that happened during the research and the informal conversations that were held with Chinese immigrants while filling out the survey in the quantitative phase.

2). Instruments

The interview script was adapted from the theoretical framework of the quantitative questionnaire. The interview included questions such as: What services do Chinese immigrants use when they have a health problem? What are the reasons and barriers for using the Spanish health services? How would they define the concept of “health” in the Chinese context? What type of services and resources do they have in China? What are the differences between healthcare in China and Spain? Is another type of treatment or medication used? How do they think the local health system could adapt to meet the needs of the Chinese community?

3). Data analysis

The qualitative analysis was carried out following these steps: familiarization with the data; generation of categories; search, review, and definition of themes; and final report.

The data obtained was captured through audio recording, and the use of a field diary. Transcription, literal reading, and theoretical manual categorization were performed. The coded data from each participant were examined and compared with the data from all the other participants to develop categories of meanings. Three main themes were then defined to reflect all of these categories: “Use of health services”, “Contrast between the Chinese and Spanish health systems”, and “Improvements in the Spanish health services to increase their use”. A final report was prepared with the statements of the key informants indicated by “key informant number” and the participant's informal conversations “C-questionnaire number, sex, age”.

Quantitative phase

1). Sample characteristics

The sample consisted of 133 Chinese immigrants, of whom 61.7% were women with a mean age of 30.7 years and an average length of residence in Spain of 11.3 years. The majority of participants (78.3%) were from Zhejiang Province, China; 61.7% were married and had secondary education (71%) (Table 2).

2). Use of health services

Table 3 shows the use of the health system. Most of the participants had health coverage at the time of the study, public (87.2%) and/or private (31.7%), and only 2.3% had no health insurance. In the previous year, 51.1% had visited a doctor, 33.8% had visited the emergency department, and 8.3% had been hospitalized. The main reasons for hospitalization were pregnancy (37.5%) and surgery (25%). However, 20% of the sample reported that they had never visited a doctor since living in Spain. In the previous month, 23.3% had visited a doctor, mainly due to acute health problems (58%) and routine check-ups (32.3%). The visit to the doctor took place in public primary care centers (37%), private health centers (37%), and public emergency services (26%).

As for the inferential analysis, visiting the doctor during the previous year was not associated with sex or length of residence in Spain, but with age (U=951.5; p=.02). Younger immigrants (M=29.8 years; SD=7.5) visited the doctor more frequently than older immigrants (M=33.6 years; SD=7.6).

In terms of the healthcare received, 99.2% reported that they had not received specialized healthcare (i.e. home-based care, domestic help, or special transport services) and 8% stated that they had not received healthcare despite needing it. Lack of time was the main reason for not receiving healthcare, followed by the long waiting time.

It was found that there was no sex difference in the relationship between waiting hours and not receiving medical care in general. However, when considered separately, lack of time due to work was associated with medical care (χ² (1)=7.9; p=0.005) in men (odds ratio [OR]=7.7; 95% confidence interval [95%CI]: 1.67-35.5), whereas lack of time due to childcare was associated with medical care (χ² (1)=6.6; p=0.01) in women (OR=12; 95%CI: 1.6-91.1).

Qualitative phase

Table 4 shows the main ideas included in the verbatim quotations. Regarding “Use of health services”, the key informants and the informal conversations of the participants showed that, among the Chinese community, employed immigrants frequently use public emergency services, whereas students and self-employed workers use private insurance.

However, all of the informants agreed that Chinese immigrants should not be considered frequent users of the public health system in Spain. Most Chinese immigrants, older adults in particular, prefer to use traditional Chinese medicine as their first treatment rather than visiting a doctor.

Interestingly, during the interviews, immigrants offered several traditional medicines to the interviewer with labels in Chinese. It demonstrates the familiarity and confidence this population has in traditional Chinese medicine compared to Western medicine. In “Contrast between the Chinese and Spanish health systems”, they consider Western medicine to be curative and very symptom-centered, which differs from the preventive nature of traditional Chinese medicine.

“Improvements in the Spanish health services” includes the accessibility barriers, such as the incompatibility of schedules with the resources offered. Chinese immigrants prioritized their duty to work as a primary necessity over regular medical care. Because of the intense working hours this group is subjected to, they tend to regard visiting the doctor for health reasons as a “waste of time”.

It was easy to see that these immigrants spent most of their time in their businesses working and had little time for other things such as seeing a doctor. A Chinese immigrant (conversation 86, woman, 44 years) had a fibular fracture a couple of months earlier, remaining in pain and having difficulty standing. Despite these constraints, he continued to work and, because of his work, was unable to go to rehabilitation.

Their statements also reflect another element that hinders access to health services: language barriers, so that the community itself establishing its own resources, such as having children or young people accompany adults to facilitate the translation and understanding of health information (conversation 113, woman, 29 years; conversation 120, man 19 years).

The trips to China in order to use the Chinese healthcare system are common among adults (conversation 66, woman, 37 years; 101, woman, 44 years) and those who do not have access to healthcare (conversation 127, man, 40 years).

In all statements, communication and waiting times are highlighted as major barriers to accessing health services.

It was also noted that some form of information campaign targeting the Chinese community was an important strategy to minimize the lack of accessibility. Some information examples were how the service works, where they have to go, which doctor is responsible for them (key informant 4), as well as other more specific aspects, such as adapting rooms for them and fitting them with kettles, since the Chinese population consumes mainly hot water (conversation 85, man, 37 years).

The proposals to improve health services are undoubtedly an attempt to resolve or eliminate the factors that hinder access and generate unequal use of resources by the Chinese population. However, most informants acknowledge that health professionals still pay little attention to these cultural differences.