Perceived cultural differences in healthcare for foreign patients visiting South Korea: tool development and measurement

South Korea is becoming a multicultural society. Thanks to the Policy for Attracting and Utilizing Oversea Talents and Employment Permit System, the number of migrant workers has risen steadily [1]. In addition, South Korea attracts so-called medical tourists who travel for the purposes of medical treatment and healthcare [2]. Medical tourism has been promoted by some Asian countries [3] including South Korea, generally because high-quality healthcare is available at moderate cost. South Korea created a legal basis for attracting foreign patients by revising its medical laws in 2009, and began to promote medical tourism with the aim of increasing economic prosperity [4]. A report from the Korea Institute for Industrial Economics and Trade [5] ranked South Korea as the 19th most competitive country in medical tourism among the member nations of the Organization for Economic Cooperation and Development (OECD). In 2017, 321,000 foreign patients visited South Korea for medical reasons, which represents an annual average increase of 23.3% compared with 2009 [6]. In 2017, 31.0% of patients were from China, 13.8% from the USA, 8.5% from Japan, 7.7% from Russia, and 4.3% from Mongolia.

As the number of foreign patients visiting South Korean hospitals has increased, their cultural backgrounds have diversified. This rapid transition to cultural diversity within an ethnically homogeneous country has made many South Koreans, including healthcare professionals, uncomfortable [7]. Although the South Korean government and medical institutions have devoted much effort to creating a culturally friendly environment for foreign patients, this change in social demographics has been challenging for most South Korean nurses because they have rarely experienced, or been educated about, cultural diversity. The cultural competency of South Korean nurses is lower than that of nurses in the United States of America (USA) and Canada, whose societies have long histories of multiculturalism [8]. Moreover, foreign patients visiting South Korean hospitals experience difficulties associated with cultural differences in healthcare between South Korea and their home countries, in terms of the healthcare system itself, the food provided by hospitals, and language barriers [4, 9].

Patients treated in foreign countries expect to encounter cultural differences. However, if such differences are perceived negatively, this may cause patient dissatisfaction, poor adherence to medication, and worse health outcomes [10‐12]. Thus, providing culturally competent nursing care to foreign patients requires that nurses first understand how patients view cultural similarities and differences [13], and then integrate patient values and preferences into their nursing care. As nurses become more knowledgeable about the cultural differences perceived by foreign patients, they will be able to understand the cultural beliefs of these patients and thus become better able to integrate patient values and preferences into their nursing care.

Previous studies in South Korea have considered only the nurses' point of views, measuring their cultural competence [8] and assessing their educational needs for cultural competence [14]. Few studies have explored whether foreign patients are satisfied with Korean healthcare services [15]. The available tools for measuring cultural issues in healthcare, such as the Cultural Self-Efficacy Scale [16], the Cultural Awareness Scale [17], the Cultural Competence Assessment [18], and the Cultural Knowledge Scale [19] measure only the cultural competence of nurses. No previous study has assessed how foreign patients perceive cultural differences in healthcare. This renders it impossible for nurses to understand how foreign patients experience differences in healthcare services, and the extent of such differences. In this study, we developed a tool measuring cultural differences perceived by foreign patients visiting South Korean hospitals.

We developed and validated a 41-item tool measuring cultural differences perceived by foreign patients who visited South Korea for medical treatment. We explored whether cultural differences perceived by foreign patients differ  between South Korean healthcare and that of their own countries, and compared perceived cultural differences by language group. The CVIs for all items were > 0.80, and the overall CVI of the tool was 0.97, indicating that all items were relevant. EFA revealed seven significant cultural factors: hospital care and services, food, the healthcare system, communication, the healthcare facility, religion, and cultural values. Each factor contained at least three items and no item evaluated multiple factors; all components were thus unidimensional. All factor loadings were all > 0.45, indicating that all grouped items were homogeneous [39].

The seven cultural factors covered six cultural phenomena of the Giger and Davidhizar model [22], with the exception of “time”. We did not include a “time” item because we sought to measure cultural differences perceived after patients had experienced the South Korean healthcare system. However, we believe that the seven factors well-reflect the cultural phenomena of the transcultural assessment model developed by the Giger and Davidhizar to teach nursing students how to view patient culture. That is, hospital care and services, the healthcare system, and the healthcare facility all refer to environmental control, which is related to how the healthcare environment affects patient health. The food factor refers to biological variation, which is in turn related to individual uniqueness, including nutritional preferences. The communication factor of course refers to verbal communication in space (the distance between communicating/interacting individuals). The religion and cultural items refer to social organization (cultural values derived from religious affiliation, gender and sexual orientation, geography, age, and life-cycle status).

The overall Cronbach’s alpha for the tool was 0.96, and the Cronbach's alpha for all seven cultural factors were ≥ 0.70. These values are acceptable [40] and show that our tool is internally consistent.

No prior tool assessing cultural differences from the patient viewpoint is available. Babiker, Cox, and Miller [41] developed a questionnaire for use by overseas students, measuring the cultural distance between the two cultures based on their social and physical attributes. Our study is similar to the cited work in that a tool measuring differences between the two cultures was developed by dividing the cultures into measurable components. Food, religion, and communication were included in both studies. The cultural distance questionnaire for overseas students additionally examined climate, clothes, educational level, material comfort, leisure, family structure, and courtship/marriage. We additionally evaluated hospital care and services, the healthcare system, and the healthcare facility.

We used our tool to measure the extent to which foreign patients perceive cultural differences in healthcare, and which cultural factors they perceived differently. Foreign patients perceived South Korean healthcare culture as significantly different from that of their home countries. In addition, the perceived cultural differences differed among those with diverse cultural backgrounds, particularly by language group. The results support our two hypotheses and confirm that the tool measures the intended construct appropriately, i.e., it assesses cultural differences in healthcare as perceived by foreign patients. Of these differences, hospital care and services, food, the healthcare system, and the healthcare facility were more greater than personal/interpersonal factors, including communication, religion, and cultural values. The Mongolian-and Russian-speaking groups were similar, perhaps reflecting active cultural exchanges between Mongolia and Russia given their geographical proximity and shared history of bilateral relationships and co-operation. The Arabic-speaking group perceived less cultural differences than did the other patient groups, perhaps because the government and hospitals have sought to make the South Korean healthcare system as Muslim-friendly as possible; the South Korean government seeks to attract Middle Eastern patients as evidenced by the signing of a memorandum of understanding with the UAE government in 2011. Also, Muslims tend to respond more moderately (“politely”) in surveys than do other groups [42]. However, the Arabic group perceived greater cultural differences in personal/interpersonal factors.

We found that foreign patients perceived the “cost of medical care” and “skill and competency of medical staff” of the “hospital care and services” factor more differently compared to their home countries; followed by “food aroma” and “food taste” of the “food” factor and “globalization of healthcare” of the “healthcare system” factor. Our findings are similar to those of a report on foreign patients’ satisfaction surveyed by the Korean Ministry of Health and Welfare [6]. Those who participated in the foreign patients’ satisfaction survey rated South Korean medical services as more advanced than those available in their own countries, but they were not satisfied with the food or cost of treatment. The “skill and competency of medical staff” and “the globalization of healthcare” were perceived to be very different from the study respondents’ home countries. This may be related to satisfaction with the advanced South Korean medical services that they were now able to access. The “food aroma”, “food taste”, and “cost of medical care” scores, also were perceived as very different from our study respondents’ home countries. This could be due to dissatisfaction with the food and cost of treatment they receive in Korea.

The tool developed in this study will help nurses to understand the cultural needs of foreign patients, and facilitate an understanding of different cultures. The strength of the study was that we obtained data from 256 patients from various countries, with this sample showing cultural  differences across the different language groups. Nurses can use the tool to assess patients from different cultures and respect cultural differences when caring for foreign patients. Nurses can distribute questionnaires to foreign patients, study the responses, and adjust their care accordingly. Patient-centered care and evidence-based nursing care will thus be achievable.

Our study had certain limitations. Although we measured perceived cultural differences, we did not measure the direction of such differences. In future study, the tool should include descriptive phrases to reveal the direction of differences (positive or negative), and thus to determine how such differences impact patient care. Second, participants were recruited from only three tertiary hospitals in Seoul, South Korea, which is the most advanced city in the country. Thus, additional data should be obtained from patients in other healthcare institutions in other parts of South Korea. Third, although we performed EFA and used Cronbach’s alpha to confirm the validity and reliability of the tool, further testing is required.

We developed a tool that measures cultural differences in healthcare perceived by foreign patients in South Korea. Healthcare providers can use the tool to measure the extent of such differences in particular healthcare domains. Nurses can use the tool to understand foreign patients and render their care more culturally competent.