Multiculturalism is highly valued in Canadian society. In the Province of British Columbia (BC), there are more than 200 ethnic groups reported in Greater Vancouver based on Statistics Canada (2016).1 About 42% of the population is made up of visible minorities.2 The uprising immigration pattern brings challenges as well as opportunities to Canada. Their health beliefs, healthcare needs, and service utilization behaviors could be different from the mainstream population.
In 2015, the BC Ministry of Health announced that the province will strive to deliver healthcare as a service built around the individual, not the provider and administration. The framework is designed to build on existing efforts and accelerate the adoption of patient-centered care practices in BC. It emphasizes the care for all individuals residing in BC, including visible minorities. The shared vision for patient-centered care is to put patients at the forefront of their health and care, ensure that they retain control over their own choices, help them make informed decisions, and support a partnership between individuals, families, and healthcare services providers. The following components are keys to patient-centered care in BC3:
- shared and informed decision-making;
- an enhanced experience of healthcare;
- improved information and understanding;
- the advancement of prevention and health promotion activities.
Can these components apply to all individuals in BC? The Chinese-speaking immigrants residing in BC have unique healthcare and preventative care beliefs and practices embedded in their culture for better patient-centered care outcomes. Unfortunately, their culture has not yet blended into mainstream healthcare services.
1.1 Health beliefs and health behaviors
First of all, understanding health beliefs and health behaviors is essentially important. According to Cukor et al,4 “Health beliefs, particularly feelings of self-efficacy, relate to an individual’s perceived ability to perform a certain behavior. These perceptions of self-efficacy may influence whether individuals will attempt certain behaviors and how the behaviors will be carried out.”
Furthermore, a Health Belief Model (HBM) was developed in the early 1950s by social scientists at the U.S. Public Health Service5 to understand the failure of people to adopt disease prevention strategies or screening tests for the early detection of disease. Later uses of HBM were for patients’ responses to symptoms and compliance with medical treatments. The HBM suggests that a person’s belief in a personal threat of an illness or disease, together with patients’ responses and compliance, can predict the effectiveness of the health behavior recommended by healthcare providers.6
The HBM derives from psychological and behavioral theory with the foundation that the two components of health-related behavior are 1) the desire to avoid illness, or conversely, get well if already ill and 2) the belief that a specific health action will prevent or cure illness. An individual’s course of action often depends on the perceptions of the benefits and barriers related to health behavior. There are six constructs of the HBM. The first four constructs were developed as the original tenets of the HBM. The last two were added as research about the HBM evolved.7
- 1) Perceived susceptibility. This refers to subjective perception of the risk of acquiring an illness or disease. There is wide variation in feelings of personal vulnerability to an illness or disease.
- 2) Perceived severity. This refers to feelings on the seriousness of contracting an illness or disease (or leaving the illness or disease untreated). There is wide variation in feelings of severity, and often a person considers medical consequences (eg, death, disability) and social consequences (eg, family life, social relationships) when evaluating the severity.
- 3) Perceived benefits. This refers to perception of the effectiveness of various actions available to reduce the threat of illness or disease (or to cure illness or disease). The course of action taken in preventing (or curing) illness or disease relies on consideration and evaluation of both perceived susceptibility and perceived benefit, so that the person would accept the recommended health action if it is perceived as beneficial.
- 4) Perceived barriers. This refers to feelings about the obstacles to performing a recommended health action. There is wide variation in feelings of barriers, or impediments, which leads to a cost and benefit analysis. The person weighs the effectiveness of the actions against the perceptions that it may be expensive, dangerous (e.g., side effects), unpleasant (e.g., painful), time-consuming, or inconvenient.
- 5) Cue to action. This is the stimulus needed to trigger the decision-making process to accept a recommended health action. These cues can be internal (e.g., chest pains, wheezing, etc) or external (e.g., advice from others, illness of a family member, newspaper article, etc).
- 6) Self-efficacy. This refers to the level of confidence in the ability to successfully perform a behavior. This construct was added to the model most recently in the mid-1980s. Self-efficacy is a construct in many behavioral theories as it directly relates to whether a person performs the desired behavior.
1.2 Impact of culture on health beliefs and health behaviors
APA Dictionary of Psychology defines culture as “the distinctive customs, values, beliefs, knowledge, art, and language of a society or a community. These values and concepts are passed on from generation to generation, and they are the basis for everyday behaviors and practices.”8
Furthermore, culture is a hidden and obvious influential factor in behavior. Usually, culture can be described as an iceberg, with its most influential components hidden under the ocean, for example, one’s values and ethics, beliefs, communication style, and handling one’s emotions.
In Canada, different cultural groups have diverse belief systems regarding health behaviors and healing. These belief systems may include different disease models, wellness and illness paradigms (e.g., traditional Chinese medicine), various culturally specific diseases and disorders, feelings about healthcare providers, their perception in seeking Westernized healthcare, and the use of traditional healthcare practices and approaches.
Health belief and health behavior are cultural concepts because culture frames and shapes how we perceive the world and our experiences. Along with other determinants of health and disease, culture helps to define the following9:
- How patients and healthcare providers view health and illness.
- What do patients and healthcare providers believe about the causes of disease?
- Which diseases or conditions are stigmatized and why? In many cultures, depression is a common stigma, and seeing a psychiatrist means a person is “crazy.”
- What types of health promotion activities are practiced, recommended, or insured? In some cultures, being “strong” (or what the Canadians would consider “overweight”) means having a store of energy against famine, and “strong” women are desirable and healthy.
- How illness and pain are experienced and expressed. In some cultures, stoicism is the norm, even in the face of severe pain. In other cultures, people openly express moderately painful feelings. The degree to which pain should be investigated or treated may differ.
- Where do patients seek help, how do they ask for help, and, when do they make their first approach. Some cultures tend to consult allied healthcare providers first, saving a visit to the doctor when a problem becomes severe.
- Patients’ interaction with healthcare providers. For example, not making direct eye contact is a sign of respect in many cultures, but a care provider may wonder if the same behavior means that his/her patient is depressed.
- The degree of understanding and compliance with treatment options recommended by healthcare providers who do not share their cultural beliefs. Some patients believe that a physician who doesn’t give an injection may not take their symptoms seriously.
- How patients and providers perceive chronic disease and various treatment options.
Culture also affects healthcare in other ways, such as:
- Acceptance of a diagnosis, including who should be told, when, and how.
- Acceptance of preventive or health promotion measures (e.g., vaccines, prenatal care, birth control, screening tests).
- Perception of the number of individuals in preventing getting the disease and monitoring the progression of the disease.
- Perceptions of death, dying and who should be involved.
- Use of direct or indirect communication. Making or avoiding eye contact can be viewed as rude or polite, depending on the culture.
- Willingness to discuss symptoms with a healthcare provider when an interpreter is present or not.
- Influence of family dynamics, including traditional gender roles, filial responsibilities, and patterns of support among family members.
- Perceptions of youth and aging.
- Accessibility and function of the health system.
1.3 Traditional Chinese medicine
The participants of this study are Chinese-speaking immigrants residing in BC. They encounter challenges and opportunities when using Canadian healthcare services. Their Chinese perspectives on health and their health practice could be considerably different from mainstream Western perspectives, including most of the Canadian healthcare providers. They bring with them a combination of philosophical, cultural, and religious beliefs, as well as values, symbols, rituals, and practices consciously and unconsciously influenced by a syncretic blending of Confucianism, Buddhism, and Daoism. Concepts such as the qi and yin-yang are unique features of the Chinese views of health.10 According to traditional Chinese medicine (TCM), weak, stagnant, and imbalanced yin-yang and qi give rise to health problems. From the Chinese perspective, humans are regarded as an integrated part of nature, and therefore, protecting and maintaining the integrity of the human-nature unity is fundamental to health and health practices.
The Western medicine perspective of illness is different from that of the Chinese. It focuses on abnormalities in the structure and function of organs and body systems.10,11 For example, Western perspectives on health beliefs and behaviors are divided into two categories, health-enhancing or health-compromising. In Canada, Western healthcare providers regularly recommend their patients for health-enhancing behaviors such as doing exercise, eating healthy, and sleeping well. Those behaviors may require special skills, knowledge, equipment, and allocation of time to activate the health-enhancing behaviors. The likelihood of performing health behaviors is attributed to predisposing health beliefs. The other category is health-compromising beliefs and behaviors in Western medicine. They could be smoking and drinking behaviors that are harmful to health. The common practice has been challenged in terms of its ability to predict the effectiveness of healthy behavior, and the extent to which they reflect the cognitive processes that influence one’s health-related choices.
On the contrary, Chinese culture does not distinguish clearly between health-related and other forms of behavior. Instead, everyday conduct is directed toward maintaining the yin-yang balance and the qi flow in the body. When an imbalance arises, there are some courses of action that may restore the balance which could involve activities considered to be healthy behaviors and also activities related to social, work, finances, and relationships. The Chinese are firm believers in balancing the yin and yang with food for better health.12
TCM focuses on healing the root causes of disease in addition to treating symptoms. TCM encompasses nutrition, acupuncture, herbal medicine, mind-body exercise, and Tui Na (推拿). The TCM food study includes how specific foods relate to the seasons, the five elements, and health.13 Within TCM, each “organ” is not just the actual and individual organ, but rather a whole system unto itself that regulates many aspects and functions of the body. There is a close relationship among these organ systems, the five flavors of food, and the five elements. The practice of Chinese dietary therapy comprises choosing specific foods to cause the desired change in health. For example, pungent or spicy foods tend to increase circulation and sweet foods tend to nourish the body.14
1.4 Healthcare needs of Chinese-speaking immigrants
There are general cultural differences between the culture of Chinese-speaking immigrants and the mainstream culture in Canada.10 Although the general differences can be instructive, the inter-relationship between the two needs to be taken into consideration. As the interaction between the two cultures increases, there is the possibility of mutual influence. Health beliefs and behaviors, cultural values, and healthcare needs could be integrated. The term researchers used to describe the process is “assimilation” or “acculturation.” However, the Chinese immigrants also tend to be resistant to this process. They continue to maintain their traditional culture while adopting some aspects of the mainstream culture. It is the reason why many Chinese Canadians participate successfully in everyday Canadian life, but do not necessarily see themselves as part of the mainstream culture. In summary, they still maintain their unique needs when seeking healthcare services. They may need some healthcare service accommodation from Canadian society.
The diversity and inclusion movement during the coronavirus disease 2019 (COVID-19) pandemic calls for diversity, equity, and inclusion (DEI) in healthcare services as well.15 In this approach, a more in-depth understanding of Chinese-speaking immigrants’ healthcare needs and the relevant issues and concepts is necessary.
To address the healthcare needs of Chinese-speaking immigrants in BC, this research study was conducted in 2020–2022 to provide a more in-depth understanding of their TCM health beliefs and behaviors. The Research Human Ethics Board (RHEB) process was approved by the Human Research Ethics Board of Trinity Western University (File #: 20F04) for 2020–2022. This study has obtained informed consent from all participants.
2.1 Data collection
Quantitative method and qualitative methods were applied to the study. In total, 314 participants were recruited for the 1st stage quantitative study to cross-validate an instrument tool for the study [i.e., Patient Reported Outcome Measures (PROM)], followed by 20 participants selected out of the 314 participants in the 2nd stage using stratified random sampling based on gender, language preference, and age variables for in-depth qualitative interviews (Table 1). The average time for each interview is 40 to 60 minutes. Data collected for each stage was designed for a specific research purpose. The TCM-related concepts and use are only included in the second stage of data collection process to gain an in-depth understanding of the selected participants. The purpose and findings of the two stages were not related, but unique in their own ways.
Table 1 -
||Mandarin and English
||Cantonese and English
The semi-structured qualitative in-depth interview was created by the research team, and interview questions were refined based on questions from the instrument tool validated in the first stage and in collaboration with two retired medical doctors, who acted as the patient partners for the research project. Interview questions included an inquiry into experiences of taking a specific healthcare outcome instrument online and past encounters with the Canadian healthcare system. To explore healthcare needs and outcomes, the interviewer asked questions such as: “Could you tell me a story about your health outcomes and how these relate to your quality of life?”or “Could you talk about how your healthcare needs are being met, or not met?.” In addition, the interviewer probed further by asking questions about the extent to which these needs and outcomes were reflected in the healthcare outcome instrument (ie, PROM questions). The interviews that occurred in the Greater Vancouver area were conducted by a Chinese-speaking professional specializing in qualitative inquiry. Out of 20 interviews, eight were completed in traditional Mandarin (TRM), and 12 were completed in simplified Mandarin (SM). Each interview was recorded and transcribed verbatim using a professional transcription service from Chinese into English for backward and forward cross-validation purposes.
2.2 Data analysis
Storytelling, or narrative, is a useful tool for exploring and documenting the cultural contexts of health, which can be defined as the practices and behaviors that groups of individuals who share the same language, customs, and geography.16 Healthcare issues experienced by culturally distinct groups can be articulated through a narrative process,17 where detailed and nuanced stories could help illuminate subjective issues on healthcare utilization and health outcomes. A narrative research approach and thematic analysis were conducted to offer a deep understanding of the healthcare needs and outcomes perceived by Chinese-speaking immigrants and to determine the extent to which Chinese-speaking immigrants see their needs and desired outcomes reflected in the PROM questions.
Before formal data analysis, each transcript was read by two independent coders. The transcript of the 20 Chinese interviews were first reviewed by the Chinese-speaking researcher who conducted the interviews. The same transcripts were then translated into English and reviewed by a second non-Chinese speaking coder. This initial process was conducted to perform a narrative overview of each participant’s story expressed through their interview. Data analysis was conducted using NVivo 12 data analysis software. The first coder was the same researcher who conducted the interviews. Validation was performed by the second non-Chinese speaking qualitative analyst (coder) based on the 20 transcripts directly translated into English.
The analysis of data includes the following four basic elements: categories (e.g., problem with health), codes (words of significance to the indicated problem, e.g., issue and difficulties), patterns (e.g., having problems in specific health area), and themes (identification of a major element, e.g., TCM practice, health needs, priority in health services) in a coherent manner. The research team examined raw data and performed thematic analysis to produce narratives. In addition, multiple coding processes occurred with knowledge users and patient partners to find a word or short phrase that could be attributed to a portion of the data. Then, relationships between similar categories and codes were found and combined to create a pattern. Themes emerged as patterns formed in each category and code until saturation was achieved without new patterns forming. The research team conducted an initial coding process and a cross-validation coding process until theme saturation occurred and no new themes emerged from the analysis.
From 2021 to 2022, two follow-up Zoom meetings were scheduled to validate the findings with the participants from the above analysis.
3.1 Experience of Chinese immigrants using health services in BC
3.1.1 Language barrier
Dimensions of a cultural group include language, communication style, customs, beliefs, rituals, and roles which may be carried on by subsequent generations.18 Participant stories highlighted several important cultural features related to their health. Though acculturation was observed in some accounts, it often occurred among younger generations compared to older generations of Chinese immigrants. Therefore, there may be significant impacts due to the presence of cultural differences between patients and care providers, preventing optimal quality of care.
The fear of misdiagnosis appeared due to language barriers. The following example illustrated the potential impact of language barriers on patients’ healthcare outcomes:
“…they also get nervous because they are afraid that inaccurate English communication will make [them] misdiagnosed. So that’s why [they] would also be worried and [they] would want to be able to communicate more accurately with the doctor or the professional”. (SM46)
3.1.2 Communication differences
Differences in communication extend beyond spoken languages at medical appointments. There are differences between Chinese culture and Western culture in describing and understanding medical symptoms.17 When communicating symptoms, it is common for Chinese-speaking immigrants to describe them using terminology found within TCM.17 Health issues are often expressed as yin (cold) or yang (heat), with the experience of having an excess or deficiency of either aspect.17 In the case of one young male participant, the concept of balancing yin and yang for health maintenance was explained to his peers at work:
“…I just explain to them…that what you drink, and then diet, and then those aspects, and then the temperature of it, and then being closer to your body’s temperature and then it’s going to be better for your digestive system and stuff like that. If it’s too cold, then it’s more likely to irritate the head”. (SM12)
In addition to language barriers, participants also expressed their experiences of waiting too long for medical appointments and procedures as well as high medical costs among those who were not yet eligible for Medical Services Plan (MSP) in Canada.
3.2 Demand for culturally competent family physicians
In BC, there are too few physicians who integrate Chinese medical therapies into their practice due to their Western medicine-focused training. One participant expressed the need for family physicians to be familiar with TCM practices:
“…if they have some understanding of traditional Chinese medicine, maybe to the patient some, before the history, and then the usual and so on, and then will be [clearer]”. (SM12)
Some concepts related to maintaining qi and meridians found within the body are not often instilled into medical practices. Chinese-speaking patients who valued TCM felt a lack of connection to and understanding from their physicians. Participants also noted the focus of treatment over prevention in Western medicine, where medications were readily prescribed for various ailments which might have been targeted differently using TCM. A notable deficiency of TCM in Western medical settings extends beyond the need for holistic health-promoting herbs and therapies, such as acupuncture and acupressure. In palliative care settings, there was a contrast between Eastern and Western medical philosophies on what information ought to be shared with patients at the end of their lives. In this context, preserving dignity at the end of life is an important value in Chinese culture19:
“In fact, I think it is not only a language communication but also in the culture to enable them to have some learning I am also in the learning process because we are after all a background over, Chinese culture is not too willing to talk about death this thing”. (SM46)
Many participants expressed frustration when seeking a family physician, particularly one who is an effective communicator, who is bilingual, and who understands the philosophy behind TCM. Due to the limited time provided for each patient visit, language barriers may also prevent the physician from taking the necessary time to adequately assess patients’ needs:
“After looking for a family doctor, it is not easy to find, and the family doctor, he is always in rush is he will not be very careful to listen…”. (SM262)
Participants described their own pursuit of TCM therapies, such as acupuncture, to complement therapies and medicines offered through Western medical practices. If needs were not sufficiently met, patients would seek out-of-pocket TCM therapies and herbs:
“…you have to kind of jump through to get access to what you need, and then by the end of the day, I think a lot of Chinese people probably [say], “oh well, I’m just going to go to the herbalist down the street”. (TRM47)
Physicians who are knowledgeable in Western medical practices and TCM were identified as important for enhancing the quality of care. Cultural competence is practiced through the “development of processes by which the individual examines his or her cultural principles, awareness, and understanding, and works toward developing a level of competence when working with diverse groups”.18 Culturally competent physicians who understand their patients (including spoken languages) would ensure the optimized quality of care for Chinese patients, as illustrated by this participant:
“…he wants to find a doctor who can understand what he is saying, who can understand what he is saying, so that the quality of his medical treatment will be very high. The problem is now you have to find someone who can understand what you’re saying and listen to what you’re saying, so hard”. (SM133)
4.1 Improving healthcare for Chinese-speaking immigrants
The practice of TCM among the Chinese-speaking immigrants residing in BC is examined in this qualitative research project. When integrating TCM with common available Western medical practices, “cultural capital” could be established and more service choices could be available by combining the two. The results could provide more options for health and disease management for the community.17 Integrating TCM into Western medical practices could diversify the spectrum of services available for all Canadians. In Eastern countries, patients and caregivers often use Western medicine to treat acute conditions, yet TCM plays an important role in treating chronic ailments, particularly when Western medicine is not effective or leads to unwanted side effects.19 However, literature also shows its utility in treating acute conditions, including some acute illnesses and strokes.19 Chinese medicinal herbs could also be used as alternative medicine to promote better health outcomes for various acute illnesses.19 Therefore, effective strategies used to target disease may not only be offered through medication or conventional medical intervention, but also by appropriate alternative medicine used in TCM.
Chinese immigrants residing in Canada have unique healthcare needs and beliefs that may differ from mainstream Canadians as well as the Chinese living in Asia,20 thus requiring specialized healthcare services. A set of congruent behaviors, attitudes, and policies need to come together and work effectively in cross-cultural situations.21,22 The demand for culturally appropriate communication in healthcare settings and its impacts on healthcare outcomes are evident in the literature. The recognition of different perspectives between patients, families, and healthcare providers is critical in providing quality cross-cultural care.19
As family physicians act as initial contacts for care, or “gatekeepers”17 providing referrals to specialist services and necessary treatments, there is a need to address language barriers at this entry point as this affects the trajectory of care received by patients. The need for greater access to bilingual or Chinese-speaking physicians in Canada is also present in other parts of Canada. Similar to the findings of the current qualitative study, Chinese immigrants prefer to receive care from Chinese-speaking family physicians in Toronto.17 Therefore, Canadian cities with multi-ethnic populations should increase the number of culturally competent physicians, especially family physicians in order to offer intervention and care in those cities.
4.2 Community call to action
Healthcare access, including navigating the Canadian healthcare system when seeking primary care, is difficult for immigrants, particularly for the elderly.23 Lai and Chappell24 recognized that social support was an enabling factor for Chinese immigrants to seek TCM. Therefore, a health network community should be created, particularly for the elderly, to promote access to existing resources including linkages to culturally competent and bilingual family physicians.
Health champions are people within the community who have the experience, enthusiasm, and skills to encourage and support other individuals and communities to engage in health promotion activities.25 Among the Chinese diaspora in Vancouver, key community champions could be identified to host educational sessions, create knowledge translation materials, and build an online platform (i.e., website) for networking. This health-promoting network could be able to offer information for key Chinese sub-groups, such as non-English speaking Chinese immigrants, elderly immigrants with limited resources, new immigrants, and international Chinese students.
5 Limitations and recommendation
There are several limitations to consider when interpreting the results of this study. Though the initial analysis was performed using the original Chinese transcripts by a Chinese researcher, the English-translated versions used for cross-validation may have lost some meaning during thematic analysis due to translational issues and grammatical errors. This prevented the capture of coherent narratives within each transcript due to key language elements lost in translation.
Further exploration into ethnic sub-groups within the interviewed participants is recommended to assess the differences in their healthcare needs. These groups include those using Traditional Mandarin and Simplified Mandarin, and new immigrants (<10 years) and immigrants who have been living in BC for over 10 years. By doing so, it could discover the differences within and between those sub-groups to have a more in-depth understanding of the factors that impact the healthcare needs of the Chinese-speaking immigrants residing in BC of Canada.
This research project entitled “Cross-cultural Validation Methods for Generic PROMS” (PCM-010) was funded for 2020–2022 by the BC Support Unit Methods Cluster under Michael Smith Health Research BC.
The Research Human Ethics Board process of this research project was approved for 2020–2022 by the Human Research Ethics Board of Trinity Western University (File # 20F04).
Tina Wu is the lead principal investigator of this research project and the sole contributor of this paper.
Conflicts of interest
The author declares no financial or other conflicts of interest.