2022 SOS Public Health Needs Assessment of International Residents in Korea

The following, extensive blog post presents the findings of the 2022 SOS Public Health Needs Assessment. Such an assessment reflects South of Seoul’s commitment to improving information and research regarding the public of health of the international community living in South Korea.

A pdf version of this needs assessment is available to download at the end of this blog post.

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Introduction

Graduate student Olivia Bowman conducted this needs assessment. Mrs. Bowman completed this assessment as part of her practicum with SOS Public Health (SOSPH) in the Fall of 2022.  This needs assessment examines healthcare information access among the multinational English-speaking community living in South Korea with a focus on the role that cultural dissonance may play in such access.

Cultural dissonance is the “potential confusion, uncomfortableness, and/or disagreement experienced by someone in a novel cultural environment” (IGI Global, 2022). This assessment aims to inform the community of ways to overcome the confusion and uncomfortableness associated with accessing healthcare in a novel environment.  

Data for this needs assessment comes from two main sources:

1. The 2021 SOS Public Health Foundational Survey
2. A key informant interview with FedMedi, conducted by Mrs. Bowman.

The results of this assessment may inform continued research and the construction of initiatives that address cultural challenges in access to healthcare.   

Foreign Population Background

As of 2022, 51.63 million people live in Korea, with long-term foreigners making up approximately 3.1% (1.6 million) of the population (Kim, 2022). Despite not yet being officially classified as a multicultural society by most academic standards (having a percentage of foreigners greater than 5%), the number of foreigners in Korea has greatly increased over the last few decades (Yonhap News, 2020). Twenty-five times more foreigners now live in Korea compared to the early 1980’s (Marrinan, 2022). 

From 2020 to 2021, Korea’s foreign population dropped due to travel restrictions during the COVID-19 pandemic. Despite a slight decline, projections estimate the foreign population continuing its growth. The foreign population estimates a climb to 2.16 million (or 4.3% of the population) by 2040 (Population projections, 2022). 

The vast majority of foreigners residing in Korea come from China, followed by Vietnam, Thailand, the United States, and Uzbekistan (Wikimedia Foundation, 2022). These varying cultural backgrounds may influence individual perceptions of healthcare access. Culture affects not only perceptions of health, but also “perceptions of illness and death, beliefs about causes of disease, approaches to health promotion, how illness and pain are experienced and expressed, where patients seek help, and the types of treatment patients prefer” (Mayhew, n.d.). These differing perceptions may lead to unique cultural challenges for foreigners accessing healthcare in Korea depending on one’s country of origin. 

Language Background

The multinational community in Korea speaks various languages, as indicated in the 2021 SOS Public Health Foundational Survey. 2021 SOSPHFS respondents reported speaking 17 different first languages. Approximately 18% of respondents reported no Korean language proficiency, and 31.2% reported an elementary proficiency (Figure 3). Not speaking the local language may create a language barrier. Language barriers have been shown to disadvantage patients in access to healthcare services as well as in terms of health outcomes (Shamsi et al., 2022).

Although the multinational community in Korea speaks various languages, SOS Public Health focused mainly on the English-speaking community. Among the 2021 SOSPHFS respondents, 83% of respondents reported native/bilingual English proficiency. 14.3% of respondents reported full professional English proficiency, and 2.7% reported professional working proficiency. See respondents’ English proficiency levels in Figure 1. 

Figure 1

Cultural Background

In addition to language barriers posing a challenge to healthcare access among foreigners in Korea, cultural challenges may prove to be just as challenging. Developing cultural competence is often seen as a way for medical professionals to provide quality care to individuals regardless of their cultural background (St. George’s University, 2022). However, the foreign population in Korea encompasses cultures from a multitude of countries. Such diversity can make cultural competence training from the medical providers’ perspective a complex challenge to overcome alone. 

Therefore, this needs assessment examines cultural dissonance as it relates to patients’ perspectives. Improving cultural competence surrounding the patients’ perspective may allow individuals to advocate for themselves more effectively as they access the Korean healthcare system. 

Methodology

SOSPH graduate student researcher, Mrs. Bowman, utilized both primary and secondary data sources for this needs assessment.  Mrs. Bowman chose data sources based on their ability to shed light on healthcare information access among the multinational community. Mrs. Bowman analyzed survey data from the previously administered 2021 SOS Public Health Foundational Survey and conducted a key informant interview to collect additional data. The survey provided input directly from the community of interest. The key informant interview provided a unique perspective on healthcare access challenges for foreigners through the eyes of healthcare support organizations. 

2021 SOS Public Health Foundational Survey (2021 SOSPHFS)

Lisa Peck (2021), SOSPH founder, conducted the 2021 SOS Public Health Foundational Survey to assess the multinational community’s general access to primary medical care in Korea. The survey aimed to reach the English-speaking multinational population living in Korea. This population includes migrants, immigrants, students, religious missionaries, and United States military-affiliated individuals and families. The survey consisted of 84 questions. The questions covered the following sections: demographics, social support and social integration, personal cultural competencies, comparison of healthcare access between the home country and Korea, equity and inclusion, and language barriers (Peck, 2021). One hundred and twelve individuals from varying backgrounds participated in the 2021 SOSPHFS. For the purpose of this needs assessment, Mrs. Bowman analyzed several sections of the 2021 SOSPHF Survey including demographics, personal cultural competencies, and language barriers. 

SOS Public Health’s Key Informant Interview with FedMedi

Mrs. Bowman conducted a key informant interview with an employee of FedMedi in November 2022. FedMedi is a Korean company that employs multinational, multilingual staff members to provide medical case management for international residents living in Korea who use foreign health insurance (Rivers-Woods, 2022). In the summer of 2022, FedMedi collaborated with SOS Public Health (SOSPH). The two organizations created and currently manage the Health and Wellness in Korea Facebook Group. This group provides a safe space for multinational residents in Korea to have their health care access questions answered openly or anonymously. 

Mrs. Bowman interviewed FedMedi in order to better understand the experiences of the multinational community when accessing health care services in Korea. FedMedi staff provided insight on the experiences and perceptions of the multinational community’s access to healthcare in Korea, both as a service provider and an international resident accessing health care. The interview explored the role that cultural differences can play in such experiences and perceptions. This interview also touched on possible ways to overcome cultural challenges. Additionally, FedMedi provided input on the ways that organizations serving the multinational community may struggle when trying to provide support in light of such cultural differences. 

SOS Public Health Needs Assessment Limitations

This needs assessment identified three main limitations in the research:

1. limited sample size
2. online distribution method
3. time constraints

SOS Public Health Foundational Survey Limited Sample Size

The 2021 SOSPHFS had 112 respondents. With small sample sizes, results are less generalizable. Within such data, the confidence level of the study decreases and the margin of error increases. This means results are more likely to deviate from the statistical mean, and less likely to reflect true population parameters (Deziel, 2022).

SOS Public Health Online Distribution Method

Online survey distribution presents several limitations to research in terms of sampling. Sampling bias can occur when some members of a population are more likely to be chosen to participate in a survey than other members (Andrade, 2020). In the case of the 2021 SOSPHFS, only individuals who had access to the internet and South of Seoul’s online platforms could participate, thus excluding the portion of the population that did not have this access.

Secondly, for voluntary surveys, individuals with strong opinions on the subject matter may choose to participate at a higher rate compared to those without such strong feelings. When individuals with biases select themselves into the sample by participating at a higher rate, the survey results may be skewed (Andrade, 2020). 

Time Constraints

Due to time constraints, SOSPH only conducted one key informant interview for this project. Two hospitals with international clinics declined SOSPH’s request for an interview. A larger array of interviewees would have broadened the scope of information and perspectives obtained for this needs assessment. 

Mrs. Bowman kept these limitations in mind during the production of this needs assessment with an understanding that further, in-depth, research is required to gain a broader understanding of the cultural challenges to healthcare access. The results below provide a starting point for potential community improvement efforts rather than definitive answers and solutions. 

Results

SOS Public Health Foundational Survey Results

This section highlights select results from the 2021 SOSPHFS, including community demographics, language proficiencies, and cultural competencies. 

Demographics:

• Of the 112 survey respondents, 91 identified as female, 19 as male, and 2 as non-binary. 
• Respondents originate from over 20 countries, as displayed in Figure 2. 

Figure 2

Source: https://blog.southofseoul.net/3-important-differences-between-primary-healthcare-in-south-korea-and-the-u-s/ 

Language:

• Respondents identified 17 different languages as their first language. A majority of respondents reported English as their first language (79.5%), followed by German (3.6% of respondents) and French (2.7% of respondents). 
• The survey asked respondents to rate their Korean language proficiency. Almost half of the respondents (49.2%) described their Korean language proficiency as “elementary” or “none” (Figure 3). 

Figure 3

Culture: 

The 2021 SOS Public Health Foundational Survey looked at several factors that may affect respondent’s confidence in accessing primary care in South Korea. Such factors included:

• amount of time respondent’s lived in Korea and
• respondents confidence in regard to their knowledge of South Korean customs, culture, and etiquette.

Results for these inquiries are shown in Figures 4 and 5.

Figure 4

Figure 5

The 2021 SOSPHFS found a small, positive correlation between respondents’ confidence level in regard to their knowledge of South Korean customs, cultures, and etiquette, and their confidence in accessing primary medical care in South Korea (Pearson’s r=0.329, p-value=<.001, BF₁₀=57.2.)  The alternative hypothesis predicts the data 57.2 times better than the null. In other words, increased cultural confidence is correlated with higher access to healthcare. However, due to the small sample size, the statistical significance of this correlation is limited (see Limited Sample Size). 

The total number of years that respondents spent living in South Korea ranged from 1 year to 24 years. The average respondent lived in Korea for 5.7 years (2021 SOSPHFS). SOSPH found a small, positive correlation between respondents’ total number of years having lived in South Korea and their confidence in accessing primary medical care in South Korea (Pearson’s r=0.289, p-value=0.002, BF₁₀=13.2). The alternative hypothesis predicts the data 13.2 times better than the null. This means more time spent living in South Korea is correlated with being more confident in accessing primary medical care in Korea. Like the result above, this correlation is not considered statistically significant due to the small sample size (see Limited Sample Size). 

FedMedi Key Informant Interview Results

This section contains select results from Mrs. Bowman’s key informant interview with FedMedi from the following sections:

1. Demographics of FedMedi’s clientele
2. Cultural challenges for FedMedi’s clients
3. Cultural challenges for FedMedi 

Demographics:

• FedMedi’s clients primarily come from the United States, with some clients from Japan. FedMedi also serves Koreans who have moved overseas and no longer have National Health Insurance (NHIS). 
• Approximately 90% of the clientele do not speak Korean.
• Clients most commonly speak English as their first language.  
• A majority of clients seek care at FedMedi with their families. 
• Clients include United States Forces Korea (USFK) members and their families, diplomats, and medical tourists. 
• Most clients use FedMedi for primary care medical exams and check-ups. 

Cultural Challenges for FedMedi’s Clients:

In order to examine possible sources of cultural dissonance, Mrs. Bowman asked FedMedi to think about cultural challenges they observed in their clients’ experiences when accessing healthcare services in Korea. FedMedi identified two challenge areas experienced by their clients:

1. Healthcare system differences
2. Language barrier

Cultural challenges for FedMedi’s clients due to Healthcare System Differences

FedMedi reported that clients had difficulty coping with differences between their home country’s and Korea’s healthcare systems. For example, FedMedi described how one of their clients became frustrated when their scheduled hospital appointment was pushed back to accommodate a more urgent patient. The client was accustomed to being seen in the order they were scheduled in their home country. As a result, the client was unprepared for this difference in Korea. When speaking of the way some clients handle these unexpected differences, FedMedi stated the following:

“At first [the clients] get frustrated, but after time they get used to [the cultural differences]…over time they get used to this way it’s done in Korea, and become more accepting that things are different, that it’s just the way it’s done here.”

FedMedi Employee

As a foreigner themself, the FedMedi employee stated the following about their own experience with the Korean healthcare system: 

“Once I learned how the system and healthcare system functioned, I no longer got frustrated and stressed. [Foreigners] have to understand and incorporate cultural differences. If you just want it to be the system of your country, you’ll be frustrated.”

FedMedi Employee

Cultural challenges for FedMedi’s clients due to the Language Barrier

The language barrier poses another potential cultural challenge for English-speaking residents seeking care in Korea. FedMedi noted that using an interpreter during medical appointments may cause a “gap” in the information communicated between doctor and patient due to misunderstandings, mistranslations, or omissions by the interpreter. As such, FedMedi tries to schedule their clients with English-speaking doctors whenever possible. This largely eliminates the need for an interpreter, though FedMedi does stand by to help clarify as needed. 

Cultural challenges for FedMedi:

Support organizations, like FedMedi, may also face cultural challenges when working with clientele due to:

1. A language barrier
2. Healthcare system differences

Cultural challenges for FedMedi due to the Language Barrier

Despite providing multilingual, including English, support for the international community, FedMedi employees may not share the same native language as their clients. When two parties do not share the same native language, misunderstandings can still occur and satisfaction can decline for both involved parties (Al Shamsi et al., 2020). Such misunderstandings between individuals who speak the same language can happen due to differences in technical vocabularies, such as knowledge of medical terminology, or differences in language proficiency (Gurmentor, 2021).

Cultural challenges for FedMedi due to Healthcare System Differences

In speaking about a patient transitioning care from their home country to Korea, FedMedi stated the following:

“[The client] needs to understand we’re dealing with a new healthcare system, so they need to follow guidelines here. [The client] was reluctant at first, so we explained the system and that the doctor always wants what’s best for the patient. It can be hard to explain the differences to them, but over time it gets easier.”

FedMedi Employee

While organizations like FedMedi work to support the international community living in Korea, they must also cope with cultural dissonance. Like the challenges their clients face from being unfamiliar with the Korean healthcare system, organizations can themselves experience challenges from being unfamiliar with the healthcare system of their client’s home country. Such cultural dissonance may cause a disconnect between the client and the support organization when the support organization tries to act as a go-between for the client and the Korean healthcare system. If the organizations have different countries of origin from their clients, they may have difficulties anticipating unfamiliar aspects of the Korean healthcare system for the client (Zapf, 1991). Organizations may then struggle to effectively communicate and prepare their clients for these differences. 

Discussion

This needs assessment examined possible sources of cultural dissonance among the community that may contribute to healthcare information accessibility. The 2021 SOSPH Foundational Survey and the FedMedi key informant interview provided insight into some of the cultural challenges faced by the multinational community living in Korea. The following sections will discuss the implications of such cultural challenges.

Language Barrier

SOSPH examined the language barrier that can occur between the English-speaking international population and healthcare resources in Korea as one possible source of cultural dissonance. 

Language Barrier between Groups of People

Language barriers commonly occur between two groups when they do not share a native language. They can result in miscommunication and misunderstandings, even if both groups speak the same language, due to differences in technical knowledge or proficiency levels. While seeking care in South Korea, foreigners may encounter language barriers at multiple stages of the process. In healthcare, language barriers between medical providers and patients have been shown to reduce satisfaction for both involved parties, while also decreasing the quality of healthcare delivery and patient safety (Al Shamsi et al., 2020). English-speaking foreigners and the organizations aimed at supporting them through their healthcare journey in Korea may also encounter such language barriers. 

There are several steps individuals can take that may help decrease the language barrier between them and another individual. One option is to work on increasing proficiency in the target language through online language learning technology or in-person language courses. Individuals who have some proficiency in the target language are encouraged to focus on using simple, non-technical language. Furthermore, individuals should pay attention to non-verbal modes of communication such as hand gestures and facial expressions. Introducing cultural context, which can be accomplished through living in the country where the language is spoken, can also be beneficial to overcoming language barriers (Gurmentor, 2021).

Language Barrier between Individuals and Information

Language barriers can occur between foreigners and healthcare information, whether online or in print. When healthcare information, such as hospital websites or locations of pharmacies, are only available in Korean, the English-speaking community faces a potential challenge. Translation mobile applications and web browser extensions can be used in many of these instances. However, inaccurate translations may make navigating these sites difficult (Patil & Davies, 2014). 

To help overcome this barrier to healthcare information, foreigners can utilize 1330, the free Korean Tourism phone number that offers multilingual support for foreigners in Korea (South of Seoul, 2021). 1330 can answer a variety of questions for foreigners that may help improve healthcare access. For example, if individuals struggle to find the hours for a clinic on a Korean website, they can contact 1330 to connect with a multilingual operator who can help find the needed information.

Cultural Differences

Cultural differences between support organizations and foreigners can also inhibit the types of support that the organization provides for foreigners. For example, if two groups do not have the same country of origin, the organization may struggle to anticipate and prepare the client for what will be unfamiliar for them (Zapf, 1991). 

Unfamiliarity with the Korean healthcare system may cause discomfort when accessing healthcare in Korea. As evidenced in the FedMedi key informant interview results, individuals may become frustrated if they do not understand the differences between processes in their home country versus in Korea. This frustration has the potential to increase dramatically when combined with culture shock (Zapf, 1991). Culture shock occurs “when a person goes into a state of emotional shock when trying to deal with all the new information and rules associated with a new culture” (Rivers-Woods, 2018). 

One tip for overcoming culture shock includes seeking out knowledge about the new culture. Seeking knowledge can reduce the amount of unknown information the brain needs to try and process (Rivers-Woods, 2018). The 2021 SOS Public Health Foundational Survey results also demonstrate the importance of knowledge: a small correlation exists between being confident about one’s knowledge of South Korean customs, culture, and etiquette and being confident about accessing primary care in South Korea. 

Previous work by SOSPH has found that putting effort into developing cultural competence may improve one’s perception of their healthcare in South Korea (Peck, 2021). Cultural competence requires:

“knowing and reflecting on one’s own cultural values and world view and their implications for making respectful, reflective, and reasoned choices, including the capacity to imagine and collaborate in cross cultural contexts. Cultural competence is ultimately about valuing diversity for the richness and creativity it brings to society.”

University of Sydney, n.d.

When the international community living in Korea actively develops this cultural competence, they cultivate the ability to participate “ethically and effectively” in intercultural settings such as the Korean healthcare system (University of Sydney, n.d.).

Resources

To help overcome potential frustration caused by healthcare access barriers, SOS Public Health strives to provide relevant, accurate, and thorough healthcare information for the English-speaking community. SOSPH also provides education on how the community can improve their comfort and advocate for their healthcare needs in an international setting (Peck, 2021).

Organizations that work as mediators between foreigners and the Korean health care system, such as Fed Medi, serve as another possible healthcare access resource for the international English-speaking community in Korea. Such organizations aim to provide independent medical care management support for international residents that use non-Korean (international) insurance (Rivers-Woods, 2022). Additionally, organizations that mediate between patients and doctors help support foreigners through the unknowns associated with seeking care in Korea. Such unknowns include locating hospitals, scheduling appointments, transportation to and from appointments, translating and interpreting, and filing international insurance claims. 

Next Steps for SOS Public Health

Further research and ongoing support are needed in order to most effectively meet the healthcare access needs of the multinational English-speaking community residing in South Korea. There are three ways listed below to expand the research presented in this needs assessment. 

1. Firstly, SOSPH plans to continue its work analyzing the 2021 SOSPHFS and disseminating the survey results to the community. These ongoing efforts may provide additional insight on the needs and perceptions of the community. 

2. Conducting another survey on healthcare information access, with the goal of increasing the sample size to include a larger number of respondents, would help increase the statistical significance and generalizability of the results to the larger international community living in South Korea. 
3. Conducting interviews with a broader range of key informants could further explore the diverse perspectives of community members, healthcare facilities, medical providers, and support organizations with regard to healthcare information access among the community. 

Download the 2022 SOS Public Health Needs Assessment

Access the pdf version of the 2022 SOS Public Health Needs Assessment for the English-Speaking Multinational Population in South Korea below.

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