Health Care Related Issues in Latin American Immigrants in Saitama and Gunma Survey 1 2008
Institute of Medical Anthropology Waseda University
1
Index Introduction……………………………………………3 Material and Methods………………………………..6 Results Quantitative Data…………………………………….8 Qualitative Data……………………………………...47 Discussion……………………………………………..62 Conclusion……………………………………………..66 References……………………………………………..67 Summary………………………………………………69 Annex I.
Questionnaire over Health Care Issues in Saitama and Gunma Immigrants Workers in Spanish……………………………………………………71
II.
Questionnaire over Health Care Issues in Saitama and Gunma Immigrants Workers in English……………………………………………………..78
III.
Questionnaire over Health Care Issues in Saitama and Gunma Immigrants Workers in Portuguese…………………………………………………84
2
Health Care Related Issues in Latin American Immigrants in Saitama and Gunma
Introduction Since 1985 favored immigration visa for Japanese descendants from South America united with the critical socio economical situation of the South American countries and the increasing and growing need of overseas workers in Japan initiated the process of the “ethnicity-based immigration”. (1) This immigration process developed it gradually from South America and represents now 14% of the total amount of foreigners in Japan, being the second group in number of importance after Asians (2) Certain aspects of this immigration process related with the public policies regarding them also made them to be called Japan`s “Guest workers” (3). The awareness of the potential and real problems of these non-citizens workers has been raised during these 20 years of experienced migration. Even though these amount and kind of nationality migration wasn`t experienced before, local governments were able to cope with this ongoing process of adaptation creating new departments into the local governments to face the needs of these new migrants as in Hamamatsu, Kanagawa, Gifu, Gunma prefecture, to cite some. Based on human rights, three main aspects in which attention is needed and focused are labor and economic affair departments, boards of education and health and welfare departments(4) The right to access to health care and welfare is one of the basic human rights. Besides the cultural resettlement experiences these Japanese descendants are facing health issues that remains to be better understood and support. One of the facts related with the health care of the Latin American immigrants workers and the local governments are dealing with is the fact that only the 40 % of these immigrants achieve the health care insurance provided by the Japanese government (11-12). The main reason that intend to justify this problem is that the earned amount monthly doesn`t meet the family needs and the amount of the national insurance coverage is unaffordable to them.
3
Another reason stated is that “The idea of status segmentation was applied to their social system. Since 1990, according to a Directive of the Ministry of Health and Welfare, the Livelihood Protection Law covers only citizens, permanent residents, spouses or children of citizens, spouses or children of permanent residents and quasi-permanent residents. These persons are considered as full members of the welfare state. Other regular residents are partial members of the welfare state. Irregular residents can be members of occupational welfare. In fact, many newcomers are not included in the social welfare system, even if they are regular residents. Employers of small companies are reluctant to pay half of the insurance premium and unskilled foreign workers are also reluctant to pay half of it because they wish to return to their original countries in the future and the insurance premium and pension have to be paid simultaneously. The Japanese welfare state for newcomer immigrants is immature.”(6) In December 1991 a regulation of the Ministry of Health and Welfare denied the National Health Insurance to the undocumented immigrants. Under the “Treatment of Travelers Law” some local governments assumes part or all of the expenses done by immigrants for emergency care not covered by any insurance, but that means significant monetary loss to the hospitals, health care services and to the local governments itself.(4) In addition to the system improvement required to attend the health needs of this immigrant population, in terms of law, health insurance and welfare system, there are some other problems pointed out. Communication addressed as the access to the information itself as an obstacle to the health services and language barriers. Of course difference of culture, customs and religion affecting the medical-patient relationship in this setting remains to be study in deep, as highly influencing the satisfaction level in a health care encounter. (12-13) Recently, mental health as a health care issue in immigrant workers all over the world have been worthy of particular attention. “Fragmentation and erosion of identity, the loss associated with displacement from familiar contexts and support networks, the difficulties of settlement, and the pressures on accustomed family structures and relationships can increase vulnerability to mental illness…additional source of stress on immigrants is that host societies have generally failed to respond effectively to the reality of ethnic, cultural, and linguistic diversity.(15)
4
For having a better understanding of the culture and health care related issues of immigrants in order to contribute at the improvement in the use and access to health services, we decided to conduct this survey.
5
Material and Methods With the purpose to get inside the topic of health care in immigrant’s workers in Japan, we designed a pilot survey focused on health care issues. The area selected for the pilot survey was the Gunma and Saitama prefecture due to the increasing population of immigrant’s workers in these prefectures. (2,17) We conducted randomly interviews in that area during the period of January and February of 2008. We selected demographics variables as nationality, age, type of visa, living years in Japan, family dependants in Japan, number of children in Japan; variables related to health care as having or not health insurance in Japan, having or not health insurance in the country of origin, frequency of use of health insurance in Japan during a year, children access to health care using health insurance during a year, first time after arrival medical services were needed (in years), explanation for omittance of health insurance in Japan, diseases that required medical assistance, diseases treated at home, having a personal o family experience of hospitalization in Japan, reason for hospitalization in Japan and questions related with cultural and anthropological customs as, if they were able or not to see a traditional healer in Japan, which kind of medicines are they taking in Japan and the use and kind of traditional medicine in Japan. To evaluate the difficulties they have due to protection concerns, access to health and welfare and the resettlement experience, we chose the Postmigration Living Difficulties Checklist.(5) The Postmigration Living Difficulties Checklist contains 24 items of postmigration difficulties and is graduated in 5 degree scale from 1 to 5. 1. Not a problem at all 2. A bit of a problem 3. Moderately serious 4. A serious problem 5. A very serious problem The living difficulties that reached the 4th and 5th degree were considered living difficulties causing serious/very serious stress. The quantitative data analysis was made using the SPSS, version 13 (SPSS Inc, Chicago, Il, USA).
6
The qualitative data collected in the interviews on health care experiences and inputs about how to improve the health care services received in Japan were taken and summarized by cases. We had to reassure the anonymous mode of the questionnaire many times because of the bias in the answers due to the fear of the interviewed people regarding their visa status or the fact that their answers could be felt as criticism or protest.
7
Results Quantitative DATA We did 67 interviews. The statistics for each item of the questionnaire and the Postmigration Living Difficulties Checklist are shown with tables and graphics. Statistics and graphics of observed data Nationality Age Type of visa Living years in Japan Family dependants in Japan Number of children in Japan Health Insurance in Japan Health Insurance in the country of origin Frequency of use of health insurance in Japan Children`s frequency access to health care using health insurance First time after arrival medical services were needed Explanation for omittance of health insurance in Japan Diseases you required medical assistance Diseases you can treat at home Which kind of medicines are you taking in Japan Use of traditional medicine in Japan Experience of hospitalization in Japan Reason for hospitalization in Japan Living difficulties questionnaire
8
Statistics Nationality N
Valid Missing
67 0
Nationality Frequency Valid
Percent
Valid Percent
Cumulative Percent
Peruvian
55
82.1
82.1
82.1
Brazilian
7
10.4
10.4
92.5
Bolivian
2
3.0
3.0
95.5
Pakistani
1
1.5
1.5
97.0
Philippine
2
3.0
3.0
100.0
67
100.0
100.0
Total
9
10
Statistics Age N
Valid Missing
Mean Std. Deviation
67 0 37.69 11.524
Minimum
19
Maximum
66
11
12
Statistics Type of Visa N
Valid
66
Missing
1
Type of Visa Frequency Valid
Percent
Valid Percent
Cumulative Percent
Japanese descendant
25
37.3
37.9
37.9
Permanent resident
29
43.3
43.9
81.8
5
7.5
7.6
89.4
4
6.0
6.1
95.5
3
4.5
4.5
100.0
66
98.5
100.0
1
1.5
67
100.0
Nationality Spouse of Japanese National or Permanent Resident Short-term Stays Total Missing Total
System
13
14
Living Years in Japan N
Valid Missing
Median Variance
66 1 11.00 39.517
15
Statistics Family Dependants in Japan N
Valid
67
Missing
0
Family Dependants in Japan Frequency Valid
Percent
Valid Percent
Cumulative Percent
Yes
39
58.2
58.2
58.2
No
28
41.8
41.8
100.0
Total
67
100.0
100.0
16
17
Statistics Number of Children in Japan N
Valid Missing
67 0
Number of Children in Japan Frequency Valid
Percent
Valid Percent
Cumulative Percent
Without children
28
41.8
41.8
41.8
One child
10
14.9
14.9
56.7
Two children
20
29.9
29.9
86.6
Three children
8
11.9
11.9
98.5
More than three
1
1.5
1.5
100.0
67
100.0
100.0
Total
18
19
Statistics Health Insurance in Japan N
Valid
67
Missing
0
Health Insurance in Japan Frequency Valid
Percent
Valid Percent
Cumulative Percent
Yes
54
80.6
80.6
80.6
No
13
19.4
19.4
100.0
Total
67
100.0
100.0
20
21
Statistics Health Insurance in the Country of Origin N
Valid
67
Missing
0
Health Insurance in the Country of Origin Frequency Valid
Percent
Valid Percent
Cumulative Percent
Yes
10
14.9
14.9
14.9
No
57
85.1
85.1
100.0
Total
67
100.0
100.0
22
23
Statistics How Often Do You Children Access to
N
Use the Health
Health Care using
Insurance?
Health Insurance
Valid
62
33
5
34
Missing
How Often Do You Use the Health Insurance? Frequency Valid
Once a year
Missing
21.0
21.0
7
10.4
11.3
32.3
34
50.7
54.8
87.1
8
11.9
12.9
100.0
62
92.5
100.0
5
7.5
67
100.0
System
Total
Cumulative Percent
19.4
I don`t use it Total
Valid Percent
13
Three times a year More than three times a year
Percent
Children Access to Health Care using Health Insurance Frequency Valid
Three times a year
Cumulative Percent
6.0
12.1
12.1
24
35.8
72.7
84.8
5
7.5
15.2
100.0
Total
33
49.3
100.0
System
34
50.7
67
100.0
They don`t use
Total
Valid Percent
4
More than three times a year
Missing
Percent
24
25
26
Statistics First Time After Arrival Medical Services Were Needed N
Valid
54
Missing
13
Mean Std. Deviation
1.6944 2.28180
Minimum
.00
Maximum
10.00
27
28
Case Summary Cases Valid N $Whynota
Missing Percent
12
N
17.9%
Total
Percent 55
N
82.1%
Percent 67
100.0%
a. Group
$Whynot Frequencies Responses N Why nota
Percent
Percent of Cases
We are in the process to get it
3
20.0%
25.0%
Cultural or Language Difficulties
2
13.3%
16.7%
2
13.3%
16.7%
It is very expensive
5
33.3%
41.7%
Other
1
6.7%
8.3%
I don`t need it
2
13.3%
16.7%
15
100.0%
125.0%
We
don`t
have
enough
information
Total a. Group
29
30
Case Summary Cases Valid N $Doctordisea
Missing Percent
61
91.0%
N
Total
Percent 6
N
9.0%
Percent 67
100.0%
a. Group
$Doctordise Frequencies Responses N Doctordiseaa
Total
Flu
Percent
Percent of Cases
39
48.8%
63.9%
Work Accident
7
8.8%
11.5%
Gynecological/ Obstetrical Cause
4
5.0%
6.6%
Allergy
6
7.5%
9.8%
Don`t use medical services
5
6.2%
8.2%
Hypertension / Diabetes
6
7.5%
9.8%
Pediatric Care
1
1.2%
1.6%
Dyspepsia / Diarrhea
7
8.8%
11.5%
Pain
2
2.5%
3.3%
Dental Care
3
3.8%
4.9%
80
100.0%
131.1%
a. Group
31
32
Case Summary Cases Valid N $treathoma
Missing Percent
58
N
Total
Percent
86.6%
9
N
13.4%
Percent 67
100.0%
a. Group
$treathom Frequencies Responses N treathomea
Percent of Cases
None
21
27.6%
36.2%
Flu
28
36.8%
48.3%
2
2.6%
3.4%
12
15.8%
20.7%
Allergy
4
5.3%
6.9%
Diarrhea / Stomachache
7
9.2%
12.1%
Stress
2
2.6%
3.4%
76
100.0%
131.0%
Dysmenorrhea Headache
Total
Percent
a. Group
33
34
Statistics Have You Ever Seen a Traditional Healer in Japan? N
Valid Missing
63 4
Have You Ever Seen a Traditional Healer in Japan? Frequency Valid
Missing Total
Percent
Valid Percent
Cumulative Percent
Yes
2
3.0
3.2
3.2
No
61
91.0
96.8
100.0
Total
63
94.0
100.0
4
6.0
67
100.0
System
35
36
Case Summary Cases Valid N $Medicinea
Missing Percent
62
N
Total
Percent
92.5%
5
N
7.5%
Percent 67
100.0%
a. Group
$Medicine Frequencies Responses N Medicinea
Traditional
Medicine
Percent
Percent of Cases
Imported 6
7.7%
9.7%
29
37.2%
46.8%
41
52.6%
66.1%
2
2.6%
3.2%
78
100.0%
125.8%
From My Country Medicines I Carried From My Country Over the Counter Medicine From Japanese Drugstores Prescribed Medicines in Japan Clinics Total a. Group
37
38
Case Summary Cases Valid N
Missing Percent
$spemeda
36
N
53.7%
Total
Percent 31
N
46.3%
Percent 67
100.0%
a. Group
$spemed Frequencies Responses N spemeda
Infusion
(Extract
Tea)
Chamomille,
Lemon
Verbena,
Percent
Percent of Cases
6
15.0%
16.7%
Coca Tea
1
2.5%
2.8%
Cat`s Claw
3
7.5%
8.3%
1
2.5%
2.8%
18
45.0%
50.0%
1
2.5%
2.8%
Vitamins
5
12.5%
13.9%
Flu Remedy
3
7.5%
8.3%
Chanca Piedra (Break-stone)
2
5.0%
5.6%
40
100.0%
111.1%
Anise
Sangre
de
Grado
(Chroton
Lechleri) Do not use Flour
of
Maracuya
(Passion
Fruit), Linaza, Maca Root
Total a. Group
39
40
Statistics Have
You
Ever
Experienced
Hospitalization in Japan? N
Valid
66
Missing
1
Have You Ever Experienced Hospitalization in Japan? Frequency Valid
Missing Total
Percent
Valid Percent
Cumulative Percent
Yes
30
44.8
45.5
45.5
No
36
53.7
54.5
100.0
Total
66
98.5
100.0
1
1.5
67
100.0
System
41
42
Case Summary Cases Valid N $reashospa
Missing Percent
30
44.8%
N
Total
Percent 37
N
55.2%
Percent 67
100.0%
a. Group
$reashosp Frequencies Responses N reasohospa
Childbirth,
Percent
Percent of Cases
Other Gynecologic 11
32.4%
36.7%
Cardiovascular Disease
1
2.9%
3.3%
Accident
4
11.8%
13.3%
Pulmonary Disease
3
8.8%
10.0%
Cerebrovascular disease
2
5.9%
6.7%
Cancer
3
8.8%
10.0%
Surgery
8
23.5%
26.7%
Hepatitis
1
2.9%
3.3%
Medical Checkup
1
2.9%
3.3%
34
100.0%
113.3%
Reason
Total a. Group
43
44
Living difficulties causing serious/very serious stress A Serious
A Very Serious
Problem
Problem Subtotal Table
Table Valid N %
Table Valid N % Valid N %
Communication Difficulties
3.03
6.06
9.1%
Discrimination
6.06
6.06
12.1%
Separation from Family
3.03
10.61
13.6%
Worries About Family Back at Home
3.03
15.15
18.2%
Unable to Return Home in Emergency
1.52
4.55
6.1%
0
0
.0%
Not Being Able to Find Work
1.52
1.52
3.0%
Bad Job Conditions.
3.03
4.55
7.6%
Being in Detention
0
0
.0%
Interviews by Immigration
0
0
.0%
Delays in Processing Your Application
3.03
0
3.0%
Conflict with Immigration Officials
1.52
0
1.5%
0
1.52
1.5%
Worries About Not Getting Treatment for Health Problems
6.06
3.03
9.1%
Poor Access to Emergency Medical Care
1.52
6.06
7.6%
Poor Access to Long Term Medical Care
1.52
3.03
4.5%
Poor Access to Dentistry Care
3.03
4.55
7.6%
Poor Access to Counselling Services
4.55
7.58
12.1%
Little Goverment Help with Welfare
1.54
3.08
4.6%
Little Help with Welfare from Charities
3.03
0
3.0%
Poverty
3.03
0
3.0%
Loneliness and Boredom
6.15
1.54
7.7%
Isolation
3.08
1.54
4.6%
0
1.52
1.5%
No Permission to Work
Fears of Being Sent Home
Poor Access to the Foods You Like
45
Living difficulties causing serious/very serious stress A Serious
A Very Serious
Problem
Problem Subtotal Table
Table Valid N %
Table Valid N % Valid N %
Communication Difficulties
3.03
6.06
9.1%
Discrimination
6.06
6.06
12.1%
Separation from Family
3.03
10.61
13.6%
Worries About Family Back at Home
3.03
15.15
18.2%
Unable to Return Home in Emergency
1.52
4.55
6.1%
0
0
.0%
Not Being Able to Find Work
1.52
1.52
3.0%
Bad Job Conditions.
3.03
4.55
7.6%
Being in Detention
0
0
.0%
Interviews by Immigration
0
0
.0%
Delays in Processing Your Application
3.03
0
3.0%
Conflict with Immigration Officials
1.52
0
1.5%
0
1.52
1.5%
Worries About Not Getting Treatment for Health Problems
6.06
3.03
9.1%
Poor Access to Emergency Medical Care
1.52
6.06
7.6%
Poor Access to Long Term Medical Care
1.52
3.03
4.5%
Poor Access to Dentistry Care
3.03
4.55
7.6%
Poor Access to Counselling Services
4.55
7.58
12.1%
Little Goverment Help with Welfare
1.54
3.08
4.6%
Little Help with Welfare from Charities
3.03
0
3.0%
Poverty
3.03
0
3.0%
Loneliness and Boredom
6.15
1.54
7.7%
Isolation
3.08
1.54
4.6%
0
1.52
1.5%
No Permission to Work
Fears of Being Sent Home
Poor Access to the Foods You Like Survey 1: Saitama - Gunma 2008 Institute of Medical Anthropology
46
Qualitative DATA The experiences in getting health care in Japan and comments or suggestions received while the questionnaire was filled, were collected and summarize. In addition we interviewed a medical doctor with emergency health care experience with immigrants. His comments expressed the view of the difficulties experienced by the side of the health workers.
47
Case 1: Peruvian, 45 years old, 16 years living in Japan The following case is a successful case of a Peruvian family settled down 16 years ago in Honjo, Saitama. 16 years ago, Mr. X, with a sansei descendant visa came to Japan. The way of coming was through a contractor. He paid to him 2000 dollars for the expenses of the paperwork and for finding him a job in Japan.
He wasn`t provided any health
insurance, but any work accident, or medical expense was covered completely by the contractor. He didn`t participate in the yearly medical checkup at the factory. One year after his wife came. Then they started to pay the health insurance, which was around 40 000 yen a year. They had to pay it separately, because they both worked. After his wife got pregnant they decided to return to Peru. The boss of the company then invited him to be employed directly to the factory not through the contractor, getting the benefits of being employed in Japan. They decided to settle down in Japan and started paying at that time the shakai hoken. This insurance costs 40 000 yen monthly and additional 9000 yen for each child. Inside it has the coverage for unemployment, the retirement coverage and the health insurance in the same package. The head of the family in addition now is paying a life insurance for him in order to protect his wife and his three daughters in case of a severe disease or death. He has 45 years. Yearly he and all the workers in the factory have medical checkups. He said that the workers who are engaged through the contractor do not receive any medical checkup. At 50 years old, the medical checkup includes in addition being hospitalized two days for general checkup. They don`t have any health insurance in Peru. They use to go to a private Japanese medical doctor near home since the time they arrived at Honjo. He said he usually goes to the doctor once a year and his children and wife three times a year. They have use the medical service for colds and child bearing. The medicines they are using are Japanese medicine. Time to time they brought some traditional herbs as anis and mate de coca from Peru. They haven`t heard about the possibility of seeing a healer in Japan. The first time he needed medical care was two months since he arrived.
His wife
had the experience of being hospitalized in Japan for child bearing three times for cesarean section. The wife didn`t have any problem she could remember and she could communicate with the doctor through a Brazilian translator in a Saitama 48
hospital. They said this translator attracted many immigrants to the services of this hospital near Honjo but some immigrants were used to go and run with the medication without paying either the services or the medication. Subsequently, the services which suffer these abuses finally were closed progressively. The first one was gynecology. In the questionnaire about living difficulties, they feel just a little bit nostalgic by the separation and worries about of the family they left in Peru. Dental care does not cover aesthetic procedures as orthodontics and because one of their children needs it they are thinking about the way to afford it. They feel very grateful for the opportunities they have got to live and raise their children in Japan. The biggest inconvenience for them is still the language but even with this difficulty they have managed to be integrated in the Japanese community in Honjo and actively participate in communal activities. Case 2:
Peruvian, 32 years old, 2 years living in Japan This is a Peruvian Japanese descendant with long-term resident visa. She is 32 years old and is working in Japan two years ago. She didn`t have family dependants in Japan neither children. She is paying the national health insurance in Japan, starting 6 months after having a work related accident, for which she received attention through the Red Cross. She has no health insurance in Peru. She is not paying the shakai hoken because she wants to return to Peru in the next three years. Before the accident she didn`t have the health insurance because she wasn`t informed about it and was employed through a contractor. She usually goes to the doctor once a year. At home she solved medical problems as colds and diarrhea, headache using medicines brought from Peru. She uses traditional medicines from Peru as Cat`s Claw, Lemon Verbena, Chamomille, sangre de grado (Chroton Lechieri). She has not being able to see a traditional healer in Japan. She had no inpatient experience in Japan. In the living questionnaire, she considered a moderate problem communication difficulties and being unable to return home in case of emergency, poor access to emergency medical care and long term medical care and getting help from welfare and charities. She considered very serious problems discrimination, separation from family, worries about her family in Peru, bad conditions in work and isolation. A bit of a 49
problem were considered poor access to dentistry care and little government help with welfare.
Case 3 Peruvian, 26 years old, 8 years living in Japan This is a case from a Bolivian Japanese descendant, 26 years old, living in Japan 8 years ago. She has a long-term visa.
She has 2 children, but 10 months ago she
sent them back to Bolivia to her mother care. She is paying the national health insurance in Japan and at the same time she has the government health insurance in Bolivia. She goes to the doctor once a year, not frequently, in fact the inpatient experiences of child bearing were the main encounters with the medical services in japan and she did not experience difficulties because she is fluently in Japanese. She hasn`t heard about any traditional healer from Bolivia in Japan. She uses medicine from Japanese drugstores for colds and headaches. She is not using traditional herbs. In the living difficulties questionnaire, being separated from her family and worries about them is a moderate problem. Case 4 Peruvian, 57 years old, 30 years living in Japan This is a Japanese citizen, but who was raised in Peru. He is 57 years old and is living 30 years in Japan. He is the owner of a Peruvian restaurant. He has three children not dependent on him. He is enrolled in the national health insurance, and the private American express insurance and a life insurance. He said the American express insurance is covering the retirement and the unemployment possibility. He has not enrolled the social insurance because if he does it all his workers should be enrolled in the same plan, but because they don`t want to settle down in Japan they are joined to the national health insurance or any other private health insurance. The ones joined to private insurance as American Express can be covered also in their countries of residences in case they wanted to return to their countries to received their treatments there. He said if someone paying the social insurance wants to come back to his country of residence can take back as much as three years of contribution. He said he doesn`t use the medical services. His wife used to go to the very cheap medical checkups organized by NGOs. That medical checkup can cost 1000-2000yen or can be free. 50
He has no heard about a traditional healer in Japan. He uses over the counter Japanese medicines. He had an inpatient bad experience of malpractice in his sister`s grandniece. In the living difficulties he expressed his worries about the separation with his parents living in Peru as a very serious problem. Case 5 Peruvian, 30 years old, 10 years living in Japan This is a Brazilian Japanese descendant. He has his wife and two children dependent of him in Japan. They don`t have health insurance either in Japan or in Brazil. They said they are now in the process of getting it but before they weren`t able to have it because it was very expensive. They used to go to the doctor at leat once a year due to colds. They can solve at home problems as allergy or diarrhea for which they use medicine brought from Brazil. They haven`t being able to go to a traditional healer. They don`t use traditional medicine. They haven`t experienced being inpatient in Japan. In the living questionnaire he experienced as very serious problem discrimination and little government help with welfare. As moderately serious problem they found difficulties for communication, worries about not getting treatment for health problems, poor access to dentistry care and counseling services. He considered a bit of a problem interviews by immigration. Case 6 Peruvian, 28 years old, living 18 years in Japan, No family dependents yet in Japan. He has joined the national health insurance, but not the social insurance. He said he doesn`t know yet if he wants to settle down in Japan. He used to go to the doctor three times a year, mainly by colds. He doesn`t know about traditional healers in Japan. He uses over the counter Japanese medicine. He doesn`t use any traditional medicine and hasn`t been hospitalized in Japan. In the living difficulties he doesn`t considered any of the items a problem for him.
51
Case 7 Brazilian, 39 years old, 16 years living in Japan She has the national health insurance in Japan and in Brazil. She used to go once a year to the doctor and 1 or 2 times a month with his child who has asthma. The first contact she had with health system was at her first year of residence, because of an accident. She had experience being hospitalized two times in Japan, because of the accident and childbirth. She said she received good care at that time in Hiroshima, because the foreigners were few and they received better care and attention, after that she experienced the attention in the hospital was not so careful. She said the main difficulty in receiving health care is language. The expenses for paying an interpreter to accompanying her to the hospital could be around 5000 yen and she felt sometimes insecure about the translation. She said there is a need of translators in the hospitals. She saw how during these past years in Ota, Japanese medical doctors have learned medical terms in Portuguese as Papanicolau and that practical medical terms has improved the communication with doctors. She said now even his child is translating to her in medical appointments. The diseases for which she usually goes to the doctor are colds and bronchitis. She has not being able to contact a traditional healer in Japan. She uses Japanese medicine but she said they only relieve but do not cure the disease. She doesn`t take traditional herbs. Medical expenses as dental care she waits until going for visits to Brazil to go to the dentistry. In the living difficulties questionnaire she considered a bit of a problem the access to
dental
care
and
psychological
assistance,
communication
difficulties,
discrimination, and worries about family back at home. Case 8 Brazilian, 46 years old, 12 years living in Japan He lives with his wife and three children. He and his family has joined the national health insurance. He said he had not join the social insurance because it wasn`t offered by the company, but it seems to be implemented very soon in his factory for all workers. They are not paying social insurance in Brazil. He used to go three times a year to the doctor in Japan but his children more frequently. The diseases for which they usually go are colds and allergy. They have not heard about traditional healers from Brazil in Japan. They use over the counter Japanese medicine
and the ones that the doctor prescript. 52
They are not using traditional medicine. His wife experience two times childbirth in Japan without any problem, with help of translator. In the living difficulties questionnaire they only considered now a bit of a problem communication difficulties and worries about the family left in Brazil. They feel grateful to Japan and the medical assistance they had received, they don`t want to complain and they don`t have anything to complain about it. They said the first care they take for prevention for diseases is to eat well. Case 9 Brazilian, 26 years old, 10 years living in Japan She doesn`t have family dependants. She doesn`t want to pay neither health insurance nor social insurance.
She said she did at the beginning but after she
experienced the difficulties in communication, felt as indifferent medical attitude to her suffering she decided not paying for this service. She thinks there are better medical doctors in Tokyo than in Ota. If she would have children she would pay because the children are the ones who require more frequently health consultation. She is paying a private health insurance in Brazil and goes there for medical and dentistry care and health checkup. The first time she had to go to the doctor in Japan was two years after coming. The disease she solves at home are cold and stress with acupuncture. She is taking medicine brought from Brazil. She said a long time ago there were more accessible Brazilian medicine over the counter but now if she wants to take Brazilian medicine is the one she brought for her from Brazil. She is not using traditional herbs, but she is thinking to go to the paranormal doctor from Brazil that comes every year to visit Brazilian people. She has not experienced hospitalization in Japan. In the living questionnaire, she experienced as very serious problem poor access to dental care; as serious problem discrimination, bad work conditions; as moderate problems worries to get treatment for health problems, poor access to emergency care, communication difficulties, separation of the family and worries about her family in Brazil. A bit of a problem would be being unable to return home in Emergency. She introduced me a free line for health questions in Portuguese (0120-050062). This is a service for Brazilians offered without cost by the consulate of Brazil in Nagoya who offered contact with Brazilian doctors in Japan or help in translation for Japanese medical doctors attending Brazilians. 53
Case 10 Pakistani 38 years old, 20 years living in Japan His visa is as spouse of a Japanese woman. He doesn`t have any family dependents. He doesn`t have neither health insurance nor social insurance. He said he prefer to go to the doctor in Pakistan. He thinks Japanese medicine is weak, and he usually is healthy with the exception of dandruff. He didn`t go for colds to the doctor, and he hasn`t heard
about traditional healers from Pakistan, but there are medical
doctors from Pakistan and India in Hiroo and Sakai Machi, but it is too far from his living place that he prefers to go to the doctor in his country. He said they have mosque in Ota and in Sakai Machi, and they use to go there for spiritual care because they are Muslims. He has not experienced being hospitalized in Japan. He said none of the issues of the living difficulties questionnaire is even a bit of a problem for him. Case 18 Peruvian 19 years old,3 years living in Japan. She was hospitalized by childbirth and deep vein thrombosis. “Sometimes foreigners do have difficulties for communication, we look for a translator, but the date of the medical appointment they can`t go with you and then you lost appointments or if you go, you don`t understand, remaining without knowing what is happening to you, is hard, I know because I have had experienced.” Case 23 Peruvian 28 years old, 6 years living in Japan with two children. “It would be very helpful for those who have children, either infants or adolescent to solve the language difficulty.
Foreigners do need stronger medicine in higher doses.
Even though I feel grateful for the service I am receiving.” Case 25 Peruvian 28 years old, 6 years living in Japan “The dentist care is long but of good quality. If you have the insurance you could afford it. I use to go to the medical checkup given by the government”.
54
Case 27 Peruvian 60 years old, 12 years living in Japan “The big work for the dentistry I am use to do it in Peru. Here in Japan I just do the details. Until now the only medicine I keep bringing from Peru is one that I take for migraine.” Case 28 Peruvian 37 years old, 10 years living in Japan. He had previously the social insurance. “In my factory the medical checkup is given to all workers even if they don`t have the social insurance. I don`t have it know. I do think there would be more information about the health insurance in Japan” Case 29 Peruvian 36 years old, 8 years living in Japan. Industrial engineer now factory worker. “The Social Insurance cost is around 40,000 to 60,000 yen monthly; annual medical checkup depends of the company. My friend was going to the doctor for dyspepsia for a long time. Finally they discovered stomach cancer at last stage. Generally take many appointments to reach a diagnosis. Even though the insurance cover the 70% for us the medical care is expensive. We would like to have a Spanish-Japanese medical manual. In the company they have a first-aid kit. From there I have received sometimes pills for headache and stomaches.” Case30 Peruvian, 50 years old, 11 years living in Japan laboratory clinical analyst, factory worker “I am going regularly to be checked because of high blood pressure, but the doctor didn`t say anything about salt or tobacco. I smoke. I read and get knowledge about it in internet, but I would like to receive this information from the doctor. However my blood pressure is in good control. I have at home a vademecum, which I brought from Peru for being aware of the content of the medicines I am taking now. With that book I also can compare the medicines I used to take in Peru and I could get over the counter in Japan. What I really considered a big problem is the psychological care because it is impossible to get it in Spanish. My sister in law had to return to Peru because of this.”
55
Case 31 Peruvian, 36 years old, 17 years living in Japan “I really appreciate this initiative, because I think it would be helpful to express ourselves as persons and not only to receive information about health” Case 33 Peruvian 59 years old, 15 years living in Japan He was hospitalized one month for an stroke last year. The hospitalization even with the insurance was expensive, but he was able to pay in parts. Then he returned to Peru and did all the exams again to understand better what he had and from Peru he is receiving his medicine. In Japan he doesn`t go to the doctor because he doesn`t understand the explanation well. He didn`t go even for the control of his blood pressure.” Case 34 Peruvian, 23 years old, 2 years living in Japan She prefers to do medical checkup in Peru in spite of paying health insurance in Japan. Case38 Peruvian 21 years old, 2 years living in Japan She doesn¨t pay health insurance because she will return back to Peru in one year to continue with her university studies. Case 40 Peruvian 25 years old, 8 years living in Japan “I went to the emergency room with a renal colic. Because of the pain I had my clothes and face soaking wet. I didn`t paid my health insurance and they told me, you can`t be hospitalized. They gave me 5 suppositories for the pain, one each day for five days. The pain I had was so strong that I used 3 that night. Although I had a strong pain I was making line in the emergency room to get something for the pain. The first time I had this colic, I was paying my health insurance, I was brought by ambulance to the hospital but they don`t give anything for the pain, they kept telling to resist until reaching the emergency room. That is why the second time I decided to go by myself because I knew it would be the same. The first time they told me you can stay in the hospital if you decide to have surgery for this renal colic, if you don`t agree with the surgery you won`t 56
stay. For what I should have this surgery? Do you want to earn more money, or do you want to make me to pay more? I think it is the same paying or not paying, I will receive the same bad health care. My parents got a virus or something and they proceeded with expensive medical exams for that, those exams cost 600 000 yen. Their results went to a clinical consultation in a big hospital in Tokyo, for what? No use. They make them to do a very risky procedure, they had to sign a form of exoneration of responsibility and at the end there was a small blood vessel that was causing the bloody sputum.” Case 41 Peruvian 30 years old, 17 years living in Japan She had a work accident occurred during transportation to the work. She did a lawsuit and she won, but she considered the amount of compensation she received is not enough for the expenses she did. “After the accident I was going many times to the doctor because of back and leg pain with relief. One day I was hit again on the back accidentally by a coworker and the back pain was increased. The day after I couldn`t even get out of the bed and one fried called an ambulance which took me to the hospital. In the hospital they told me because you don`t have health insurance you can`t stay here, Gambate! They put me a suppository for the pain and I was forced to get out of the bed. The back pain remained and I was unable to work. I went to another doctor who told me you have a slipped disk and he made another diagnosis on me and wrote a note to my previous doctor. I have that copy. All I want is to get well soon, work without pain, dance, before I taught folk dance, now I can`t because of the pain. Look these are the pills I am taking daily, I brought from Peru because those from here are not strong enough..After all I considered myself as lucky, there is a Chilean woman who lost her hand in a work accident, she got also compensation and is working now driving taxi.” Case 42 Peruvian 42 years old, 16 years living in Japan with 3 children “ I would like to have the translation at least of the clinical laboratory analysis of blood and urine to know WHAT is GOOD in the results of my children, just that, in addition to that I think everything is fine.”
57
Case 47 Peruvian 50 years old, 17 years living in Japan “Those who are recently settled have the bigger problems. Now the translation for going to the doctor can be done by my children, but it causes them inconveniences, because they have to request permission in their factories for going with me to the doctor”. Case 50 Peruvian 35 years old, 16 years living in Japan “We, peruvians, are a colony growing and getting stronger. This initiative serves as an example to our children about the things that remains to be done”. Case 54 Peruvian 45 years old, 17 years living in Japan “I would like to get more help during the explanation of the diseases at the time we could have them and I would like to request the Japanese doctors more patience and willingness in taking care of us. Thank you.” Case 55 Peruvian 52 years old, 18 years living in Japan “In Japan there is advanced medical technology, but the medical doctors don`t have enough medical knowledge and or they think patients shouldn`t ask questions because they don`t have the knowledge or studies they had. Case 56 Peruvian 44 years old, 15 years living in Japan “Why I don`t have health insurance in Japan? Because it is very expensive. In 1992 I wanted to enroll the National Health Insurance in Oyama (Tochigi). They denied me the access telling me it was reserved only for those with very low income. When I came to Isesaki and I wanted to enroll it again they wanted to charged me the whole amount since I came to Japan which is unaffordable to me. My father had pneumonia two times in Japan, finally lung cancer and died in 1998, here in Japan. My mother had colon cancer. She had surgery in 2004 in Japan and I think she didn`t have an appropriate post surgery treatment because she a metastatic hepatic disease in June 2006. This time we sent her to Peru and she started chemotherapy in 58
July 2006. After that she recovered with treatment there.” Case 57 Peruvian 54 years old, 17 years living in Japan “I want to congratulate you for this help you are given us, the support we need as a foreign community. God bless you all. Case58 Peruvian 38 years old, 6 years living in Japan “Your help is most appreciated for us as being immigrants in this country. I am a person who was really needed of medical consultation and support, overall in psychology because my father had depression and I couldn`t help him.” Case 60 Peruvian 45 years old, 18 years living in Japan “The treatment is impersonal. After many years I went to a medical checkup without translation available” Case 61 Peruvian 28 years, 6 years living in Japan “In Fukujima hospital they can speak Spanish. Once I went to the dentist and they forgot to give me the pill for the pain.” Case 63 Peruvian 55 years old, 17 years living in Japan “My daughter has been trained recently in a program developed and given by the Gunma prefecture for being a medical translator.” Case 64 Peruvian 32 years old, 6 years living in Japan “I don`t go frequently to the doctor not only because of the language but because of the trust.” She has a first aid kit of over the counter medicine at the school, with explanation in Spanish, provided by a Japanese company (048 644-3240/ 0495(21)8392). Every two months a worker of the company check the kit and receive the payment of what has been used. She is a director of a Peruvian-school in Japan. She found some difficulties for getting things as alcohol for the experiments in the school. She said 59
around 25% of the students are asthmatics and require nebulizers and the psychological care in Spanish is needed for the students and is not available at the Japanese schools. Case 65 Peruvian 35 years old, 13 years living in Japan “His father had stomach cancer and had curative surgery but died three years after in Japan. She didn`t received a clear explanation of the cause of dead. She and her husband recall the doctor said many times tabun..at the beginning of any explanation he said. They were told to wait, to resist, gambate, but none of those answers were satisfactory. They are paying a familiar health insurance valid only in Peru. Case 66 Peruvian 39 years old, 7 years living in Japan He doesn`t have the National Health Insurance nor the social insurance but he is paying a private health insurance that would cover his eventual need of hospitalization, burial and pay to him the same amount of salary he is receiving during the time the hospitalization lasts. This private health insurance costs him 5000 yen monthly and he knew about it because his Japanese friends were visited at the factory for being offered that kind of convenient insurance. He suffers from gout but is not receiving any regular control. “Not understanding the medical consultation creates distrust. One problem I see is stress. Because of the misunderstandings at work sometimes they yell, ,not to me , but I have seen that. And then you keep the impotence of not being able to communicate to reply. Some of those who had these stress problems finally are talking to themselves on the street. I have not participate in the City hall medical checkups because of lack of time and the others organized by the NGOs because I didn`t know.”
Interview with Dr Manabu Sugita (05/02/2008) He is the director of the Department of Emergency Care in Juntendo University Nerima Hospital. He said his experiences with foreign patients has been with repatriation of people who wants to return to their countries after getting sick in Japan and helping with big disasters in other countries as a member of the Japan Medical Team for Medical Disaster Relief. He learned Spanish by himself in one month training in San Salvador. Because of his knowledge of Spanish he has been requested to take care and examined foreign patients in Japan. He does this service for emergency care of patient who don`t have health insurance and are brought to 60
the emergency care settle. He said the hospitals don`t like to have this patients because they can`t pay. So they don`t publicize that they are able to attend foreign people in different languages. There is none network for attending foreign people working in the Red Cross Hospital or any other hospital in Saitama as far as he knows. He told me about a French guy with an expired visa who intended to commit suicide. After taking care of the poisoning he knew he needed further psychiatric evaluation and hospitalization, but because he did not afford to pay the hospitalization neither the French embassy nor his mother in Switzerland could help him, he returned home where he finally committed suicide. He said in addition that the psychologically and psychiatrist evaluation he had was not well performed because that kind of evaluation is even more difficult than physical because of the language. Another experience with work accidents was a guy without insurance who came with his cut finger to the emergency care. He said his finger couldn`t be rejoined because of the time and the kind of the lesion. He helped him as he usually does, but after that the account management department took care of the payment. He thinks the main problem of foreign workers is they don`t have the health insurance. He recommends them to use the 119 line to request an ambulance in case of emergency and he showed me a phone number which provides medical information service offered by the Tokyo Government (03-5285-8181) in English, Chinese, Korean, Thailandese and Spanish.
61
Discussion The mean age of the participants was 37 years having a mean of 11 years living in Japan, so they came to work since they were 25 years old, investing the best years of their productive life in Japan. The time they have been living in Japan could be considered enough to adapt and adjust to the overall experiences of resettlement, including health care access in a foreign country. Also the type of visa they carried were mostly a very stable one, named as Japanese descendant, permanent resident, nationality or spouse of Japanese national or permanent resident. Just 5% carried a short term stay visa. Almost 2/3 of the interviewed people had relatives economically dependent on them in Japan, as well as children in Japan. It can be said that being established they have decided to settle their family here, as corresponding to their visa status. Health insurance 80% of the interview people had any kind of health insurance in Japan, the National Health Insurance, Welfare health insurance or private health insurance. In comparison with the prevalence of the data we got from the Saitama City Hall officer of 40% of immigrants having either the national health insurance or the social security and the results of Tamura (11) about 42% of Brazilians immigrants having any kind of health insurance, our results doubled the expected prevalence of having any kind of health insurance in Japan. These results could be due to the longer stay in Japan of the interviewed people and the increased consciousness of the need of health care services owing to the fact that they have family dependents and children living with them. Regarding the welfare health insurance, in the qualitative data we got experiences of people who wanted to have it because they think it is worthy even though they don’t know how long they will stay in Japan. Those people who thought in that way were informed through friends that, after paying they could get back part of their contribution in case they would decide to return to Peru. There were many persons who knowing that desired to have it but it wasn`t offer by the employer. That could explain the low rate of enrollment to the Welfare Health system found in Brazilian immigrant workers of 15 %.( 11)
62
At the same time near 15% of the interviewed people is currently having private or public health insurance in their country of residence. That could be due to the preference of being treated and having medical checkup in their country of residence for communication and cultural reasons. They said “I just understand that everything is right...” “The doctor don`t examines by touch...” “I don`t feel they put interest on me…” “I don`t feel like been cured...” Some others had the experience of having someone very sick at the family, illness as cancer, which they prefer to have the treatment and support surrounded by their relatives at their homeland with their families. Within the reasons for not having the health insurance in Japan, the cost remains as the first cause, followed by those who are in the process of getting it. There was a case of someone who couldn’t pay since the beginning of his stay in Japan and now for enrolling she has to pay the whole amount since she came to Japan. She said, the first time she wasn`t able to enroll because they said she should have welfare health insurance because she was working, but the employers didn`t provide her that, and even now she doesn`t have the possibility to have it at work and the National Health Insurance is tremendously onerous to her, Those who don`t have any kind of health insurance because of lack of information are 13% the same amount of those who don`t have it because of language and cultural difficulties. The quantity and quality of the information regarding health care given to the immigrants in their own language is the first step to surpass these obstacles to the health care access. The efforts of some prefectures and consulates to provided accurate health information to the foreigners can be exemplified by the medical guide for foreign people granted for free in some prefecture websites (7, 8) and the detailed website of the Brazilian consulate in Nagoya (10) which contains experienced counseling regarding health insurance and medical care, offering a 24 hours free telephone line to attend the Brazilians immigrants. The counseling on the website includes considering to maintain the health care insurance in their country of residence. Language and cultural difficulties represents a great challenge in the process of health care reform all over the world. Canadian Health system with a well earned experienced gained in many years of multicultural and multilanguage immigration is discussing that given for granted the accessibility to a qualified translator in the health care settings available for anyone who required it, even more they are considering that the system itself need to be modified taking into account the cultural view of the patients. 63
(14, 16) Translation should be done through a qualified translator. The cost of the translation, with the exception of the places where translation has been implemented and granted for free to the immigrants, increments considerably the cost of the health care itself even for those who are paying health insurance. Regarding translation efforts by some prefectures, Gunma prefecture is giving courses to prepare proficient medical translators. To prevent these misunderstandings, medical errors and lawsuits due to inaccurate translation in health care settings since 2000 in US Medicare and Medicaid can cover the expenses needed by medical translation (18) Those who don`t have health insurance because they think they don`t need it represents a challenge anywhere in the world. This population cannot be reach easily because of the lack of consciousness of disease and prevention. Fortunately they are only a small percentage in this pilot survey. Diseases requiring medical assistance Diseases requiring medical assistance after flu, following in importance were work accidents and the gynecological/ obstetrical care. Regarding workers’ accident compensation, the law doesn`t make a difference between the Japanese, foreigners and undocumented migrants. (3) The coverage would allow them to be compensated even if they were deported or decide to return to their countries. This legislation wasn`t know since the beginning of the immigration. As soon as the immigrants took knowledge of this issue the number of work accident compensation lawsuit was yearly increased. (9) However, I did find miserable cases in Gunma prefecture of persons that having lost arms or hands, they did not request their compensation being afraid of deportation. Kind of medicine taking in Japan The regular consumption of medicines is divided by half in medicines brought from Peru and medicines they got in Japan even thought they have a medium of 10 years living in Japan. The reason could be the cost, the quantity of dose, the trust to the drug itself or again language and cultural difficulties. The dose of the drugs available in Japanese drugstores is ordinarily half of the dose available in other countries because of the difference in the speed of drugs degradation of the Japanese enzyme system. 64
More than the half of the interview people is taking traditional medicine from Peru, sometimes available in Peruvian stores. Hospitalization in Japan Almost half of the interview people themselves or their relatives have experienced hospitalization in Japan, mainly due to childbirth, surgery or accident. That maybe could explain why these people having experienced the cost of hospitalization in Japan considered worthy to be enrolled in any kind of health insurance. Living difficulties causing serious/very serious stress In comparison with a group of 67 Persian-speakers settled with permanent protection visa in Australia(5) even though they encountered 54% of communication difficulties they felt only 1% of serious/very serious stress regarding worries about not getting medical treatment. Our group had only 9% of serious/very serious difficulties in communication but the serious/very serious worries about not getting treatment for health problems were 9%.
Poor mental health access (12%) was the first difficulty felt,
followed by dentistry (7.6%) and emergency medical care(7.6%). Migrants face a broad range of stressors in their process of migration. Some causes and precipitants of mental disorders in migrants are premigration factors as traumatic events or lack of preparation, cultural factors as minority status and acculturation stresses, social factors as social isolation and the loss of social network, family factors as the partial or total absence of the family, psychological factors as life changes events or homesickness or even biological factors as growing old (16) Evaluation for mental diseases in immigrants requires a high proficient translation level and a broad cultural understanding. The access to mental health for migrants in this pilot survey is the biggest worry regarding health care in Japan the immigrants have. This topic deserves carefully attention and subsequent research.
65
Conclusion In this pilot survey we concluded that health care access even for those who have health insurance continues to be a problem in spite of long time of residence and permanent visa status. There are language difficulties but cultural differences in the outpatient and inpatient settings that deserve to be noticed to improve to satisfaction level of the medical-patient relationship. Lack of health insurance was due to high cost as well as insufficient information and cultural and languages difficulties. Within the worries about getting treatment for health problems, mental health is the first one named by the immigrants and in a preventive approach needs to be taking into account.
66
References 1. Paradoxes of Ethnicity-based immigration: Peruvian and Japanese-Peruvian migrants in Japan. Ayumi Takenaka. In Global Japan The experience of japan`s new immigrants and overseas communities Goodman R, Peach C, Takenaka A, White P. 2003 2. http://www.stat.go.jp/english/data/kokusei/1995/1518.htm
Last
time
accessed
08/04/24 3. Shimada H.Japan`s “Guest Workers” Issues and Public Policies.1994. University of Tokyo Press. 4. Tegtmeyer Pak K. Outsiders moving in: Identity and institutions in Japanese responses to international migration. The University of Chicago. December 1998. Master Thesis. 5. Momartin S, Steel Z, Coello M, Aroche J, Silove D, Brooks R. A comparison of the mental health of refugees with temporary versus permanent protection visas MJA 2006; 185:357-361 6. Kondo A. Managing Immigration in Japan and comparison with western countries. International Symposium Migration and Integration Japan in a comparative perspective 2007/10/23-24 DIJ-GSAPS 7. www.pref.saitama.lg.jp/A12/BF00/lib/04guide%20EN.pdf
Saitama
prefecture
medical guidebook. Last time accessed: 2008/04/27 8. www.city.kawasaki.jp/Guideforforeigner/HP/HP/Medical%20Guide%20(E).pdf Kawasaki prefecture medical guidebook. Last time accessed: 2008/04/27 9. Del Castillo A. Los peruanos en Japón. Tokyo, Japón : Gendaikikakushitsu Publishers, 1999.ISBN 4-7738-9918-2 C0087 10. http://www.consuladonagoya.org/cgnagoya/index.php?option=com_content&task=bl ogsection&id=4&Itemid=50 Servicio de información de salud del Consulado de Brasil en Nagoya. Last time accessed: 2008/04/27 11. Tamura, C. (2005). Arbeitsmigration und gesellschaftliche Entwicklung in Japan: unter
besonderer
Berücksichtigung
der
Integrationsperspektiven
von
brasilianischen Arbeitnehmern in der Kleinstadt Mitsukaido. Bonn: Bier`sche Verlagsanstalt. 12. Herrera L. 日本で医療通問題 The 22nd Annual Meeting of Japan Association for International Health (JAIH) Journal of International Health Vol.22 Supplement October 2007 pag 31.
67
13. Tsuchida M, Bandres M, Guevara X. General satisfaction level and analysis of the doctor-patient relationship among doctors in training at internal medicine wards, , Rev Med Hered 2003, Volume 14, Pages 175-180. 14. Anderson J, Tang S, Blue C. Health Care Reform and the Paradox of Efficiency: "Writing In" Culture International Journal of Health Services Volume 37, Number 2/2007 Pages: 291-320 15. Bhugra D, Iraklis HM. Mental health and global movement of people. The Lancet. Sep 29- Oct 5, 2007. Vol. 370, Iss.9593; pg.1109, 3 pgs. 16. MacLachlan M. Culture and Health.1997. John Wiley & Sons Ltd. England. 17. Maternal and child health statistics of Japan. 2005 Mothers`& Children`s Health & Welfare Association. 18. Flores G. Languages barriers to health care in the United States. NEJM 355:3 229-231
68
Summary Objetive: To review cultural and health care related issues and living difficulties of immigrants in Saitama and Gunma prefectures.
Materials and Methods: Cross-sectional study with 67 interviews in Saitama and Gunma prefectures, during January and February 2008. The Living difficulty questionnaire was applied to evaluate the level and kind of experienced difficulties by immigrants in Japan. The demographic and clinical variables selected were : nationality, age, type of visa, living years in Japan, family dependants in Japan, number of children in Japan, health insurance in Japan, health insurance in the country of origin, frequency of use of health services, children access to health care, first time after arrival medical services were needed, reason for omittance of health insurance in Japan, diseases you required medical assistance, diseases you treat at home, kind of medicines used in Japan, use of traditional medicine in Japan, need of hospitalization in Japan and reason for being hospitalized.
Results: The average age of participants was 37 years, 82% were Peruvian, and 43% have a Japanese descendant type of visa. The average time living in Japan was 11 years， 58% have family dependants in Japan, 42% don`t have children, 80% have health insurance in Japan, 14% have health insurance in the country of origin, 55% use medical services more than three times a year, 73% of the children use health services more than three times a year. The mean first time medical services were needed after arrival was 1.7 years, 33% of those who don`t have health insurance in Japan it is because it is expensive. Diseases that required medical assistance 49% was flu, 37% treat flu at home, 52% used over the counter medicine from Japanese stores, 55% use any kind of tradicional medicine, 45% had experience of hospitalization in Japan, 35% were hospitalized because of childbirth or other gynecologic cause. Among the living difficulties causing serious/very serious stress were worries about not getting treatment for health problems 9.1%, poor access to counseling services 12.1%, poor access to emergency medical care 7.6%, poor access to dentistry care 7.6%, poor access to long term medical care 4.5%.
Conclusion: Health care access continues to be a problem in spite of long time of residence and permanent visa status. There are language difficulties but cultural differences in the outpatient and inpatient settings. Lack of health insurance was due to high cost as well as insufficient information and cultural and languages difficulties. 69
Annex IV.
Questionnaire over Health Care Issues in Saitama and Gunma Immigrants Workers in Spanish
V.
Questionnaire over Health Care Issues in Saitama and Gunma Immigrants Workers in English
VI.
Questionnaire over Health Care Issues in Saitama and Gunma Immigrants Workers in Portuguese
70
Cuestionario sobre los servicios de salud de los inmigrantes en Saitama Este cuestionario es parte de un proyecto de investigación del Instituto de Antropología Médica de la Universidad de Waseda. Este proyecto se propone mejorar la comprensión y el conocimiento de la realidad de la atención de salud que los trabajadores inmigrantes afrontan en su adaptación a la sociedad japonesa. Nos comprometemos a garantizar la privacidad de las respuestas que recolectemos. Nuestro base de datos será usada para un análisis estadístico, sirviendo como un valioso medio para evaluar y mejorar la asistencia y políticas de salud que los trabajadores inmigrantes reciben en Japón. Este cuestionario no tiene ninguna vinculación con las oficinas de la policia, inmigración o tributación. Les agradecemos su participación y gentil colaboración. Al responder este cuestionario, por favor considere las siguientes indicaciones: z
No necesita identificarse
z
Ponga una letra (X) o llene los recuadros donde se indique.
z
Cualquier duda y/o
pregunta se puede dirigir a:
Instituto de Antropología Médica Universidad de Waseda Marisa Tsuchida Tel.03-5286-1733.
[email protected]
71
1.Nacionalidad 2.Edad 3.Tipo de visa 4.Tiempo de permanencia en Japón: 5.Familiares dependientes en Japón: 6.Niños: No ( 1(
)
(años) Si (
)
No
(
)
)
2(
)
3(
)
Más de tres
(
)
7.¿Usted y su familia están cubiertos por algun tipo de seguro de salud en Japón: En Japón:
Si (
)
No (
)
En su pais de residencia:
Si (
)
No (
)
8.Si no tienen ningún seguro de salud en Japón, ¿Por qué no lo tienen? 1. (
)
Estamos en el proceso de conseguirlo
2. (
)
No tenemos el derecho de acceder a él
3. (
)
Dificultades en los procedimientos administrativos o burocráticos
4. (
)
Dificultades culturales o del idioma
5. (
) Falta de información suficiente al respecto
6. (
)
Es muy caro
7. (
)
Otra…………………………………………………………………………………….
9. Si usted tiene el seguro nacional de salud o un seguro privado, ¿Con qué frecuencia lo utiliza? 1. Una vez al año
(
)
2. Tres veces al año
(
)
3. Más de tres veces al año ( 4. No lo utiliza
(
)
)
10.¿Con qué frecuencia sus hijos lo usan? 1. Una vez al año
(
2. Tres veces al año
) (
)
3. Más de tres veces al año ( 4.No lo utiliza
(
)
) 72
11. ¿Cuánto tiempo después de su llegada a Japón usted o su familia requirió algún servicio de salud?
12. ¿Cuáles son las principales enfermedades que le llevan a requerir asistencia médica para usted o su familia?
13. ¿Cuáles son las enfermedades que puede solucionar en casa sin recurrir a los servicios de salud?
14. Para las enfermedades en las que usted y su familia no requieren asistencia médica, le es posible visitar a un curandero en Japón? Si
(
)
No (
)
15.Para las enfermedades en las que usted y su familia no requieren asistencia médica, ¿Qué tipo de medicina tradicional utiliza? 1. (
) Medicina tradicional importada de mi pais de residencia
2. (
) Medicina traida de mi pais de residencia
3. (
) Medicinas de venta libre disponibles en las farmacias japonesas
4. (
) Otras…………………………………………………………………………………
73
16. Para alguna medicina tradicional que utilice por favor explique sus razones
17. ¿Alguna vez Ud o algún miembro de su familia ha sido hospitalizado en Japón? Si (
)
No (
)
18. Si es asi, por favor cuéntenos el motivo de su internamiento
74
CUESTIONARIO DE LAS DIFICULTADES DE VIDA Debajo hay una lista de dificultades de vida que han experiementado algunas veces los solicitantes de asilo que han llegado a Australia. Durante los ultimos 12 meses ¿Alguna de estas dificultades ha sido un problema para usted en Japón? Ningún
Algún
Problema
problema
problema
moderado
Problema Problema serio
muy serio
1. Dificultades para comunicarse. 2. Discriminación. 3. Separación de la familia. 4. Preocupación por la familia en su país de origen. 5. Imposibilidad de volver a casa en caso de una emergencia. 6. No tener permiso para trabajar. 7. No poder encontrar trabajo. 8. Malas condiciones laborales. 9. Ha estado detenido. 10. Entrevistas por el personal de inmigración. 11. Retrasos en el proceso de su solicitud (a). 12. Conflicto con funcionarios de inmigración. 75
Ningún
Algún
Problema
problema
problema
moderado
Problema Problema serio
muy serio
13. Miedo de ser enviado a su país(b). 14. Preocupación por no conseguir tratamiento para los problemas de salud. 15. Poco acceso a la asistencia sanitaria de urgencia. 16. Poco acceso a la asistencia sanitaria a largo plazo. 17. Poco acceso a la asistencia dental. 18. Poco acceso a servicios psicológicos. 19. Escasa ayuda del gobierno para su bienestar. 20. Escasa ayuda benéfica para su bienestar (ej. de Cruz Roja, etc.). 21. Pobreza. 22. Soledad y aburrimiento. 23. Aislamiento. 24. Poco acceso a los alimentos que le gustan (c). (a) solicitud de asilo o de permiso de estadia (b) miedo de tener que dejar el país (c) en el sentido de alimentos tradicionales, propios de su cultura. 76
Le agradecemos por el tiempo que se ha tomado en participar en la encuesta respondiendo las preguntas de este cuestionario. Sus comentarios y sugerencias son gratamente bienvenidos, si desea puede escribirlos en el recuadro inferior.
77
Questionnaire over Health Care Issues in Saitama Immigrants Workers The present questionnaire is part of a research project of the Institute of Medical Anthropology in Waseda University, which intends to improve the understanding and knowledge about the health care related facts immigrants workers are facing in their integration to the Japanese society. We commit to guaranty the privacy of the personal answers we would gather. Our data base would be used for statistical analysis, serving as an important instrument to evaluate and improve the health care related issues and policies the immigrants workers are dealing with in Japan. This questionnaire has not links to the police, immigration or tribute office. We would really welcome and appreciate your collaboration.
In answering this questionnaire, please follow the following instructions: z
No need to put their behalf.
z
Check with an (X) a letter or fill in the form in appropriate locations.
z
Doubts or questions should be directed to:
Institute of Medical Anthropology, Waseda University Marisa Tsuchida Tel.03-5286-1733.
78
1.Nationality
2.Age
3.Visa type 4.Time spent in Japan:
(years)
5.Family members dependents in Japan:
(
)
6.Children: 1(
)
2(
)
3(
)
More than three
(
)
7.Are you and your family covered by any health insurance: In Japan:
Yes (
)
No (
)
In your country of residence:
Yes (
)
No (
)
8.If you or your family doesn`t have any health insurance in Japan, why don`t you have it? 1. (
)
We are in the process of getting it
2. (
)
We don`t have the right to access to it
3. (
)
Difficulty on administrative, bureaucracy processes
4. (
)
Cultural, languages difficulties
5. (
)
Not enough information about it provided
6. (
)
It is too expensive
7. (
)
Other……………………………………………………….
9. If you have national health insurance or private health insurance, how often do you use it? 1. Once a year
(
)
2. Three times a year
(
3. More than three times 4. Don`t use
(
) (
)
)
10. How often do your children use it? 1. Once a year
(
)
2. Three times a year
(
3. More than three times
) (
)
4. Don`t use 79
11. How long after your arrival in Japan, you or your family required to receive any health service?
12. Which are the main diseases your family or you are requiring medical assistance?
13. Which are the diseases you can resolve at home without using health care services?
14. For the diseases you and your family don`t require medical assistance, are you able to visit a healer in Japan? Yes (
)
No (
)
15.For the diseases you and your family don`t require medical assistance, what kind of folk medicine are you applying? 1. (
) Imported folk medicine from my country of residence
2. (
) Medicine brought from my country of residence
3. (
) Medicines available in Japanese drugstores on free sale
4. (
) Others……
80
16. For any of your folk`s medicine choice, detail your reason
19. Have you or any member of your family, ever been hospitalized in Japan? Yes (
)
No (
)
20. If yes, please tell us the reason
81
LIVING DIFFICULTIES QUESTIONNAIRE Below is a list of living difficulties that asylum seekers who have arrived in Australia sometimes experience. During the past 12 months have any of the difficulties listed below been a problem for you in Japan? No
A bit
Moderate
A serious
A very
problem
of a
ly
problem
serious
at all
problem
serious
problem
1. Communication difficulties. 2. Discrimination. 3. Separation from family. 4. Worries about family back at home. 5. Unable to return home in Emergency. 6. No permission to work 7. Not being able to find work. 8. Bad job conditions. 9. Being in detention. 10. Interviews by immigration. 11. Delays in processing your application. 12. Conflict with immigration officials. 13. Fears of being sent home. 14. Worries about not getting treatment for health problems. 15. Poor access to emergency medical care. 16. Poor access to long term Medical care. 17. Poor access to dentistry care 18. Poor access to counselling services. 19. Little Government help with welfare 20. Little help with welfare from Charities (eg. Red Cross, St Vincent de Paul, etc) 21. Poverty 22. Loneliness and Boredom.
23. Isolation. 24. Poor access to the foods you like. 82
Thank you very much for taking part of your time answering this questionnaire. Any comments or suggestions are welcome, and you could write them down.
83
Questionário sobre os serviços de saúde para os trabalhadores imigrantes em Saitama O presente questionário é parte de um projeto de investigação do Instituto de Antropologia Médica na Universidade Waseda, que pretende melhorar a compreensão e conhecimentos sobre a atenção à saúde que os imigrantes trabalhadores enfrentam na sua integração à sociedade japonesa. Comprometemo-nos a garantir a privacidade das pessoas que nos oferecem essas respostas. Nossa base de dados será utilizada para a análise estatística, servindo como um importante instrumento para avaliar a assistência e as políticas de saúde que os trabalhadores imigrantes recebem no Japão. Este questionário não tem ligações com a polícia, a imigração ou tributação. Agradecemos-lhe pela sua participação e gentil colaboração.
Para responder a esta questionário, siga as seguintes instruções: z
Não é necessário identificar-se.
z
Marque com um (X) ou preencha o formulário nos lugares apropriados.
z
Qualquer dúvida ou pergunta deve ser enviada ao seguinte endereço:
Instituto Médico de Antropologia Universidade de Waseda Marisa Tsuchida Tel. 03 - 5286 - 1733.
84
1. Nacionalidade: 2. Idade: 3. Tipo de visto: 4. Quanto tempo faz que está no Japão: (anos) 5. Familiares dependentes no Japão: (
)
6. Crianças: 1(
)
2(
)
3(
)
Mais de três (
)
7. Você e a sua família têm algum seguro de saúde: No Japão:
Sim (
)
Não ( )
No seu país de residência:
Sim (
)
Não ( )
8. Se você ou sua família não têm nenhum seguro de saúde no Japão. Por que não o tem? 1. (
) Estamos no processo para obtê-lo
2. (
) Não temos direito de tê-lo
3. (
) Dificuldade nos processos administrativos e/ou burocráticos
4. (
) Dificuldades culturais ou pelo idioma
5. (
) Não há informação suficiente sobre o tema
6. (
) É muito caro
7. (
) Outros……………………………………………………….
9. Se você tiver seguro nacional de saúde ou seguro de saúde privado, com que freqüência você o usa? 1. Uma vez por ano ( ) 2. Três vezes por ano ( ) 3. Mais de três vezes ( ) 4. Não usa
(
)
10. Com que freqüência seus filhos o usam? 1. Uma vez por ano ( ) 2. Três vezes por ano ( ) 3. Mais de três vezes ( ) 4. Não usa
(
) 85
11. Quanto tempo depois da sua chegada no Japão você ou sua família precisaram receber algum serviço de saúde?
12. Quais são as principais doenças que fazem que você e a sua família precisem de assistência médica?
13. Quais são as doenças que você pode resolver em casa sem usar os serviços de saúde?
14. É possível visitar um curandeiro no Japão para curar os problemas de saúde seu e da sua família que não requerem assistência médica? Sim
(
)
Não (
)
15. Para as doenças que você e a sua família não necessitam assistência médica, que tipo de remédios tradicionais você usa? 1. (
) Remédios tradicionais importados do meu país de residência
2. (
) Remédios trazidos do meu país de residência
3. (
) Remédios disponíveis em venda livre nas drogarias japonesas
4. (
) Outros……
86
16. Para um dos seus remédios tradicionais que você ou a sua família usam, explique os motivos:
17. Você ou alguém da sua família esteve internado alguma vez em um hospital no Japão? Sim (
)
Não (
)
18. Se sim, por favor, diga-nos o motivo
87
QUESTIONÁRIO DAS DIFICULDADES DA VIDA Abaixo há uma lista de dificuldades que alguns solicitantes de asilo tiveram quando chegaram à Austrália. Você teve alguma dessas dificuldades durantes os últimos 12 meses no Japão? Nenhum
Algum
Problema
problema
problema
moderado
Problema Problema sério
muito sério
1. Dificuldades para se comunicar. 2. Discriminação. 3. Separação da família. 4. Preocupação pela família no seu país de origem. 5. Impossibilidade de voltar para casa em caso de emergência. 6. . Sem permissão para trabalhar 7. Não poder encontrar trabalho. 8. Más condições laborais. 9. Esteve preso. 10. 11. Entrevistas pelo pessoal de imigração. 12. Atrasos no processo da sua solicitude. (a) 13. Conflito com funcionários de imigração.
88
Nenhum
Algum
Problema
problema
problema
moderado
Problema Problema sério
muito sério
14. Medo de ser enviado ao seu país(b). 15. Preocupação por não conseguir tratamento para os problemas de saúde. 16. Pouco acesso à assistência sanitária de urgência. 17. Pouco acesso à assistência sanitária a largo prazo. 18. Pouco acesso à assistência dental. 19. Pouco acesso aos serviços psicológicos. 20. Escassa ajuda do governo para o seu bem-estar. 21. Escassa ajuda benéfica para seu bem-estar (ex. da Cruz Vermelha, etc.). 22. Pobreza. 23. Solidão e tédio. 24. Isolamento. 25. Pouco acesso aos alimentos que você gosta (c). (d) solicitude de asilo ou de permissão de estadia (e) medo de ter que deixar o país (f) no sentido de alimentos tradicionais, próprios da sua cultura. 89
Agradecemos-lhe pelo tempo que você utilizou para participar dessa pesquisa respondendo as perguntas desse questionário. Seus comentários e sugestões serão bem-vindos, se deseja pode escrevê-los no quadro abaixo.
90