Barriers and Facilitating Factors to Healthcare Accessibility among Nepalese Migrants during COVID-19 Crisis in Japan: An Exploratory Sequential Mixed Methods Study

doi:10.21203/rs.3.rs-2633701/v1

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Research Article

Barriers and Facilitating Factors to Healthcare Accessibility among Nepalese Migrants during COVID-19 Crisis in Japan: An Exploratory Sequential Mixed Methods Study

https://doi.org/10.21203/rs.3.rs-2633701/v1

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Journal Publication

published 24 Jun, 2023

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Background

The COVID-19 pandemic has highlighted the need for global unity and timely access to healthcare for all including multilingual and intercultural societies. This study aimed to identify barriers to healthcare access due to the COVID-19 crisis among Nepalese migrants in Japan and explore ways to counter these barriers, both in routine and crisis situations.

Methods

This study used an exploratory sequential mixed-methods study design. The researchers conducted 11 focus group discussions including 89 participants and an online survey involving 937 respondents. The integration of focus group discussions and logistic regression analysis from the survey was reported via a ‘joint display’.

Results

26 themes on barriers to and six on facilitators of healthcare accessibility were identified by the focus group discussions among which 17 barriers like lack of knowledge of health insurance, limited operating hours of hospitals, language barriers, fear of catching the virus, fear of discrimination etc. had significant association in our logistic regression analysis after adjusting for all confounders. Similarly, the only facilitator that had a significant impact, according to the multivariable logistic regression analysis, was receiving health information from Nepali healthcare professionals (OR = 1.36, 95% CI= (1.01–1.82), p-value < 0.05).

Conclusion

The study suggests the need for a crisis information hub which could be coordinated by the Nepal embassy or concerned authorities, flexible policies for active deployment of Nepalese health workers and volunteers, accessible hotlines in the Nepali language, and incorporation of Nepali telehealth services in Japan.

barriers

facilitators

COVID-19

healthcare access

migrants

mixed methods

Nepalese

Japan

The COVID-19 pandemic has highlighted the need for global unity and timely access to healthcare for all including multilingual and intercultural societies. (1, 2, 3, 4) Migrant workers are often particularly vulnerable, (5, 6, 7) and this vulnerability is heightened during disasters. (8, 9, 10, 11) The COVID-19 pandemic has exacerbated the vulnerabilities of the migrants, (12) and in many countries they have been wrongly accused of spreading the virus and are subject to stigmatization. (8, 13, 14, 15) Barriers to healthcare access for migrants during the COVID-19 pandemic include language barriers; (16, 17, 18) unwillingness to ask for assistance due to fear of arrest and/or stigmatization, (19, 20, 21, 22) privacy concerns and cultural barriers. (23) These barriers were significant even before the pandemic, (24, 25) but have been detrimental during the crisis.

In Japan, the healthcare system is built upon a universal health insurance program that mandates enrollment of all residents, both citizens and foreign residents, in either Employee Health Insurance (EHI) or National Health Insurance (NHI) plans. (26) Those under 69 years old are responsible for paying 30% of the medical expenses, while the government covers the remaining 70%. The healthcare system also does not clearly differentiate between primary and secondary care and does not have a gate-keeper system that allows individuals the freedom to select their preferred medical facilities, which has resulted in shortages of general practitioners. (27) Foreign residents often face barriers to accessing healthcare, as the country's healthcare system are generally structured without considering the needs of non-Japanese patients. (28, 29) These barriers can include language hurdles, cultural differences, lack of information on health and welfare services, and difficulty in applying for benefits. (30, 31) This can be particularly problematic during emergencies or disasters, when timely access to healthcare becomes even more critical. Additionally, the number of migrants in Japan has been increasing rapidly, with Chinese, Korean, Vietnamese, Filipino, Brazilian, and Nepalese people making up the largest number of migrants. (32) Nepalese are the largest South Asian community in Japan and have seen a significant increase in their rate of migration over the past decade. (33) These migrants, particularly those with low proficiency in English or Japanese, may face challenges accessing health services during the COVID-19 crisis.

Furthermore, lockdowns and isolation also limit the ability of migrants to gather and speak up about their concerns, and affected their employment status, requiring access to social welfare and support services which may not have been tailored to non-Japanese recipients. Therefore, a thorough, comprehensive assessment is needed to evaluate the diverse problems experienced by migrants during the COVID-19 crisis in Japan. This study aimed to identify barriers associated with access to healthcare due to the COVID-19 crisis with Nepalese migrants as subjects of the study and explore ways to counter these barriers, both in routine and crisis situations.

This research used an exploratory sequential mixed method design to gain a more in-depth understanding of barriers and facilitators to healthcare access. Integration at the methods level was done using the building approach where the item selection for a survey questionnaire was based on previously gathered qualitative data that identifies constructs. (34) Data integration at the interpretation level was done through 'joint display,' which involved displaying the integrated findings in the form of a table. (35) Of the different kinds of joint display, ‘generalizing themes display’ was used. The ‘fit’ of data integration was demonstrated by ‘confirmation’ when the findings confirmed the results, and "discordance," when the findings were contradictory or disagreed with each other. (36, 37) Ethical approval was obtained from the Independent Research Ethics Review Committee of the University of Kochi in Japan and a web-based informed consent was taken from the participants before the discussions and the survey.

Eleven Focus Group Discussions (FGD) were conducted with a total of 89 participants via Zoom. Purposive and snowball sampling techniques were used to recruit participants. Participants included Nepalese aged 18 years and above who had been living in Japan for at least six months and were not on a refugee visa status. It is to note that the FGDs were conducted in August and September 2021, and most participants had either received a single dose of COVID-19 vaccines or not received them due to supply shortages and scheduling difficulties. The FGD questionnaire was conceptually based on the Health Care Access Barrier (HCAB) model of Carrillo et al. (38) Participants were encouraged to express their experiences related to accessing healthcare, what they did if they fell ill, who they approached, how they sought information, any financial issues they had, their opinions of the Japanese healthcare system, opinions on COVID-19, experience of vaccinations, their relationships with schools or employers, coping experience, any factors that they found helpful to overcome any difficulties they had in accessing healthcare, and any recommendations for improving healthcare access to better prepare for the future. All FGDs were conducted by the authors as moderator (SP) facilitator (AKB). Data was initially coding by generation of numerous category codes without limiting the number of codes. (39) The researchers the used focused coding to eliminate, combine, or subdivide the coding categories identified in the first step. Keywords were identified as indicators of important themes of barriers and facilitators to healthcare access during the COVID-19 crisis. Data saturation was said to occur when the researcher had obtained the full range of ideas and there was no new information obtained from another FGD. (40) Data saturation was obtained within eight FGDs.

After the FGD, cross-sectional correlation research design was conducted to evaluate how easy or difficult it was for people to access healthcare during the COVID-19 outbreak, and what factors helped them in doing so. Sample size for the study was determined considering an estimated proportion (p) as 50% owing to health accessibility, at 5% margin of error (d). Based on these assumptions, using the sample size formula n = z²p (1 − p)/d², a minimum sample size of 384 was calculated. (41, 42, 43)

The survey instrument contained a series of questions based on the themes derived from the FGDs conducted in the first phase of the study. To ensure credibility, the researcher held a meeting with experts, a few representative participants, and Nepali stakeholders residing in Japan to discuss the developed themes. The final questionnaire items were translated in Nepali language both by the researcher and a native professional translating company. 30 Nepalese migrants who did not belong to the focus groups were piloted online to determine the clarity, simplicity, and flow of questions. The final version of the questionnaire was then designed using Google Form to administer it online. The survey form was distributed through social media like Facebook pages and groups, Instagram, Messenger, TikTok, and emails. A total of 1234 responses were received, where 297 were eliminated as invalid or incomplete because respondents stated that they had never used any health services or sought any information during the COVID-19 crisis. Overall, 937 responses who utilized health services were used for the analysis in this study.

The outcome variable was healthcare accessibility, assessed using a binary response question, “Were you able to access health care services during COVID-19 pandemic?” and the independent variables related to the barriers and facilitators were measured in the form of their agreement on a 5-point Likert-type scale. The scale was rated as 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree. However, we recoded the themes into binary category as 0 if people stayed neutral, disagreed, or strongly disagreed to the statement and 1 if they agreed or strongly agreed the statement. The data analysis for the study consisted of descriptive statistics represented by frequencies and percentages, and inferential statistics in the forms of correlations and multivariable logistic regression. Multicollinearity among the independent variables was checked through the variance inflation factor (VIF). SPSS was used for data coding and analysis and the barriers and facilitators based on the qualitative and quantitative study findings in the ‘joint display’ process.

Sociodemographic characteristics of our participants in both the FGD and survey study are presented in Table 1. The average age of respondents participating in both of our studies were relatively young with mean age of 27.46 ± 4.7 for FGD and 28.35 ± 4.9 in the survey study. More than half of the respondents were female in both the studies with the majority being Hindu. A very small numbers of participants (< 15%) had not completed 12 years of schooling and about 42.7% of our participants in FGD had completed vocational training during their stay in Japan which was even higher among our survey participants (54.9%). Most of the participants in both the studies had working visa status, with more than 40% being full-time employees in Japan, and less than one-fourth of the survey respondents’ income status was affected by the pandemic. About 58% of our survey participants were married. Many of our respondents had lived in Japan for more than five years and the majority had a Japanese and English language ability ranging from fair to good. About 27% of the participants in the FGD had experienced COVID-19 infection and about half were not vaccinated against the infection, but only 20.7% of survey respondents had COVID-19 infection, with more than 90% being fully vaccinated. (Table 1)

We identified 26 themes of barriers and six themes of facilitating factors based on the Health Care Access Barriers (HCAB) Model. Pearson correlation analysis showed moderate positive correlation between ‘perceived denial of care’ and ‘perception of delay in care’ (r = .65, p < 0.01) and ‘free COVID-19 medical care’ and ‘health insurance’ (r = .74, p < 0.01). (Supplementary file 1) The 'joint display’ is shown in Table 2 which arrays both quantitative and qualitative results. In qualitative analysis, 26 themes of barriers were generated. When quantified to a larger population, the main barrier that respondents agreed with the most was the lack of medical interpreters (68.3%), followed by lack of awareness regarding the health care cost (66.9%) as they were not aware of the health care service utilization cost in Japan. The third was the fear of catching the virus (62.6%). Next was a lack of awareness of health insurance, where respondents agreed that they avoid visiting hospitals thinking that medical health care is expensive in Japan despite paying for health insurance (58.3%).

Nepalese respondents agreed that there were many facilitators to help them access health care services. In qualitative analysis, six themes of facilitators were identified. When quantified to the larger population, the majority agreed that the main facilitator was free COVID-19 medical care from the Japanese Government (73.9%), followed by having health insurance coverage system (70.7%). The next facilitator was mutual aid (62.2%) followed by the helpful health information from Nepali doctors, nurses, and health volunteers (61.2%). The least agreed facilitator was the availability of medical interpreters when needed (27.9%). Some of these results were also confirmed by our multivariable logistic regression analysis which identified the odds ratio of agreement upon the barrier or facilitator comparing those who have poor or better health care accessibility after adjusting for all covariates under analysis. We found that compared to those who have poor accessibility those who have good accessibility were 45% (OR = 0.55, 95% CI= (0.42–0.74), p-value < 0.001) less likely to agree that theme 1 (“Financial barrier”) was a barrier to health care accessibility after adjusting for all confounders. Similarly, those with good accessibility were less likely to agree that perceived delay in care (OR = 0.63, 95% CI= (0.45–0.89), p-value < 0.01), limited operating hours of the hospital (OR = 0.60, 95% CI= (0.45–0.81), p-value < 0.01), perceived complexity in vaccine registration (OR = 0.60, 95% CI= (0.44–0.82), p-value < 0.01), lack of medical interpreters (OR = 0.70, 95% CI= (0.52–0.94), p-value < 0.05), lack of hotline services (OR = 0.67, 95% CI= (0.49–0.92), p-value < 0.05), all cognitive barriers, language barriers (OR = 0.51, 95% CI= (0.38–0.70), p-value < 0.001), communication barriers (OR = 0.55, 95% CI= (0.40–0.75), p-value < 0.001), inefficiency of low dose drug (OR = 0.67, 95% CI= (0.48–0.94), p-value < 0.05), unfamiliarity with Japanese medical system (OR = 0.52, 95% CI= (0.38–0.70), p-value < 0.001), fear of losing job (OR = 0.74, 95% CI= (0.56–0.99), p-value < 0.05), fear of discrimination (OR = 0.57, 95% CI= (0.43–0.76), p-value < 0.001) and legal barriers (OR = 0.61, 95% CI= (0.44–0.86), p-value < 0.01) were the barriers to health care accessibility. Additionally, participants who have good accessibility of health care had higher likelihood of agreeing on every theme of the facilitators compared to their counterparts however, only receiving health information from Nepali doctors/ nurses and health care volunteers was statistically significant after controlling for all confounders under analysis (OR = 1.36, 95% CI= (1.01–1.82), p-value < 0.05). (Table 2)

This mixed-method study explored the barriers to and facilitators of healthcare access among Nepalese migrants during the COVID-19 crisis in Japan. This study identified a lack of awareness about the health care system in Japan and health insurance coverage as one of the significant barriers to healthcare access. In addition to literacy, this barrier may also be due to a lack of experience in using health insurance in their home country, Nepal, which still lacks a fully developed national health insurance system. (44, 45) To help migrants access healthcare, it is important to provide them with information about the health insurance system of the host country before they migrate, as well as guidance on how to choose the appropriate healthcare provider, where consultancies or an embassy of the host country can play a key role. The next barrier identified was the lack of awareness of health care service utilization cost. If people are not aware of the costs of healthcare services before they receive them, they may be more hesitant to pursue treatment due to worries about the potential bills they may have to pay. Studies have shown that price transparency can effectively help to reduce healthcare costs, (46) so more research is needed to explore clinical strategies that can increase awareness on both medical cost and quality among the consumers.

It is also important to note that during the COVID-19 pandemic, the healthcare system was constantly changing. (47) Public health centers were overwhelmed by the number of cases and thousands of patients were not able to get treatment in time due to the delayed emergency care or were denied treatment due to lack of beds. (48) The vaccines were not available in time and when it did many people had to wait for months to get the vaccination which might have been the reason that almost half of our population were not vaccinated during the study period. Similarly, the participants viewed limited hospital hours and the lack of a COVID-19 hotline services significantly impacted their perception of difficulty in healthcare access. During a pandemic, sources providing accurate information can help to reduce panic and confusion among people. Therefore, the Nepal embassy or Nepali associations should work with the Japanese government to create a crisis center that can inform and protect its citizens during an emergency. Moreover, local governments with large Nepali populations in Japan can also play a significant role in helping and services to Nepali citizens during an emergency, in association with Nepali organizations, given their proximity to and familiarity with the local community. There is also an existing language barrier due to the lack of Japanese proficiency among migrant populations, making it difficult for them to access health services. The scarcity of medical interpreters and translators exacerbates the problem. A survey done by the Foreign Medical Measures Committee in 2018 reported that, of the 5,611 hospitals that responded, 94.9% did not have medical interpreters. (49) Additionally, the complex Japanese writing system presents further difficulties. Even those who are proficient in Japanese or English may struggle with medical terminologies and expressing their symptoms accurately. ‌Despite government efforts to address the issue, it remains an ongoing challenge due to the continual movement of people from diverse linguistic backgrounds. In addition to medical interpreters and translation apps, incorporating the existing free Nepalese telehealth services could help to overcome this issue. One of the least agreed upon and not significant, yet still noteworthy, barriers was the complaints about medications in Japan. According to Kinuko, S., a Japanese nurse who conducted a study on pain management, many Brazilian women living in Japan had a similar experience in that the anesthesia and sedatives administered after childbirth did not work as expected. (50) This suggests that healthcare policy makers and practitioners should pay attention to the need for personalized medical therapy rather than simply providing an "equivalent" medicine, as genetic variability, dietary patterns, exercise habits, environmental factors like climate, socio-cultural and psychosocial influences, smoking and alcohol consumption can have a major impact on drug metabolism and absorption. (51) Moreover, education about Japanese prescribing policies is important. While doctors typically prescribe lower doses of pain medication initially and adjust dosage based on response and tolerance, this approach can vary. The cultural concept of “Gaman” (Tolerance) may also lead to under-prescription of pain relief medication unless deemed necessary. (52) Clear communication with healthcare providers is important for appropriate treatment.

Fear of infection, job loss and discrimination were identified as psychological barriers to healthcare access. The impacts of the COVID-19 pandemic have been extreme, damaging public mental health. (53) Further in-depth investigation is needed to understand these delicate problems and the types of psychological interventions available in the Japanese context. Furthermore, legal barriers which include administrative obstacles such as paperwork and registration procedures can be overwhelming. Although welfare support was widely accessible in Japan in 2020 and 2021, the support system relied on paper documents, lacked transparency, and was only provided in the Japanese language. This could have led to numerous difficulties for foreigners who had trouble understanding and navigating the system, ultimately preventing them from obtaining the necessary support. (54) In emergency or crisis periods, alternatives to the usual requirements must be sought.

The most identified facilitator of healthcare access was free COVID-19 medical care. The country's national health insurance system and other forms of insurance have helped migrants gain access to a variety of healthcare services. Some focus group participants mentioned that they received free consultations with Nepali doctors and nurses in the form of Zoom video calls or telephone. Telehealth services provided by the Non-Resident Nepali Association (NRNA) have also helped meet the health needs of the eight million migrant Nepali workers around the world. (55) Similarly, during times of disasters or isolation, the sharing of resources such as food, medicine, and financial aid have been shown to help in minimizing the effects of disasters. (56) Thus, policymakers, stakeholders, and healthcare providers need to be aware of, and better able to work with the mutual aid organizations. There are also many foreign-licensed doctors and nurses living in Japan who can serve as powerful volunteers to save the lives of both natives and non-natives, so governments and stakeholders should actively utilize and deploy these human resources for future disasters.

Though this was the first mixed method study to identify the barriers to and facilitators of health care accessibility among Nepalese immigrants during the COVID-19 pandemic, it has several limitations. One of the researchers was an influencer actively sharing educational contents for Nepalese residing in Japan in the social media hence, the participation rate might have been influenced by this. However, the questionnaire developed was anonymous hence, the researcher was not aware of the respondents’ details. Meanwhile, participants were recruited from social networking sites, it could be possible that those who responded to the survey were already willing to learn new ideas which might have affected the findings of the study. However, we received responses from various socioeconomic groups of people and were able to get responses nearly three times than our expectation. Hence, the results could be generalized to the Nepali immigrants residing in Japan. Also, this study was a cross-sectional study, and causal conclusions cannot be drawn. It was possible that the aid or facilitating factors identified in this study were temporary and may have changed over time as the pandemic changed. For this purpose, a longitudinal study design needs to be employed by future studies to determine the cause and effect in the study area over time.

When a global-scale pandemic such as COVID-19 occurs, each government does its best to protect its citizens. However, migrating populations, especially those with temporary legal permits are more likely to be placed as outliers of the national medical protective measures; hence, they may experience higher burdens of COVID-19 infection. In this context, the host nation’s medical services for migrants become crucial to ensuring their health status during their stay. In this study, even though the qualitative focus groups identified many obstacles, the survey showed that Nepalese migrants found it easy to access healthcare in Japan during the COVID-19 pandemic. Without mixed-methods data integration, identifying important but not-so-significant or least agreed barriers such as inefficacy of low-dose drugs and telehealth services would have been shadowed. The impact of low-dose drugs and the global availability of free Nepali telehealth services during the COVID-19 crisis cannot be ignored, and both findings deserve further in-depth investigations. Similarly, as lack of awareness of health care service utilization cost was the second-most agreed barrier, medical professionals should carefully consider consumers’ barriers in price shopping for healthcare. For future disaster preparedness, the establishment of a crisis information hub by the Nepal embassy or concerned authorities; active deployment of Nepalese health workers and volunteers; making hotlines available, and incorporation of telehealth services are recommended.

EHI

Employee Health Insurance

NHI

National Health Insurance

FGD

Focus Group Discussion

VIF

Variation Inflation Factor

NRNA

Non-Resident Nepali Association

Confidence Interval

Odds Ratio

SNS

Social Networking Sites

ACKNOWLEDGEMENT

The authors appreciate professors from the University of Kochi and St. Luke’s International University, Japan for providing an opportunity and guidance in conducting this study and would like to extend their gratitude towards all the participants who participated in this study. A deep appreciation to the Non-Residential Nepalese Association of Japan for providing their guidance during our focus group discussions and questionnaire distribution. Similarly, the authors would like to extend their gratitude to all well-wishers for sharing their valuable opinions with us. The statements made herein are solely the responsibility of the authors.

Authors’ contributions

Conceptualization SP, HJ, SK; Methodology SP, AKB; Validation SP, AKB; Formal analysis SP, AKB; Investigation SP, AKB; Resources SP, AKB, HJ; Data curation SP, AKB; Writing - original draft preparation SP, AKB; Writing - review and editing SP, AKB, SG, HJ; Visualization SP, AKB, SG, SK; Supervision SG, HJ, SK; Project administration SP, AKB, SG, HJ, SK. All authors have read and approved the final manuscript.

Ethical approval and consent to participate

This study got ethical approval from the Ethical Review Board of University of Kochi, Japan after getting reviewed the research proposal with the International Review Board (IRB). We obtained web-based informed consent from the participants after the disclosure of the objectives, research methodology, data sharing and utilization policy of this research, anticipated risks, burdens and benefits and institutional affiliations of the researcher for this study. The participants were not involved in the design or conduct or reporting or dissemination plans of this research. The methods were performed in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable

Availability of data and materials

The questionnaire and dataset used and/or analyzed during the current study are available from the corresponding author only on reasonable request as they are mostly in the native language of Nepal.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was supported by University of Kochi Graduate School Research Grant.

Authors’ information

Sushila Paudel- [email protected]

Aliza K C Bhandari- [email protected]

Stuart Gilmour- [email protected]

Hyeon Ju Lee- [email protected]

Sakiko Kanbara- [email protected]

O’Brien SF, F. . Crisis translation: Considering language needs in multilingual disaster settings. Disaster Prevention and Management. 2020;29(2):129-43.
Piller I. Covid-19 forces us to take linguistic diversity seriously. Macquarie University. 2020:12-7.
Zheng Y. Mobilizing foreign language students for multilingual crisis translation in Shanghai. Multilingua. 2020;39(5):587-95.
Makiyama K, Kawashima T, Nomura S, Eguchi A, Yoneoka D, Tanoue Y, et al. Trends in Healthcare Access in Japan during the First Wave of the COVID-19 Pandemic, up to June 2020. Int J Environ Res Public Health. 2021;18(6).
Nations U. The Resource : Part V. Persons with disabilities and multiple discrimination - Rights of special groups, 1/10. 2003.
Chapman AR, Carbonetti B. Human Rights Protections for Vulnerable and Disadvantaged Groups: The Contributions of the UN Committee on Economic, Social and Cultural Rights. Human Rights Quarterly. 2011;33(3):682-732.
Koh D. Migrant workers and COVID-19. Occupational and Environmental Medicine. 2020;77(9):634-6.
Ivakhnyuk I. Coronavirus pandemic challenges migrants worldwide and in Russia. Population and Economics. 2020;4(2):49-55.
Berlemann M, Steinhardt MF. Climate Change, Natural Disasters, and Migration—a Survey of the Empirical Evidence. CESifo Economic Studies. 2017;63(4):353-85.
Thiri MA. Social vulnerability and environmental migration: The case of Miyagi Prefecture after the Great East Japan Earthquake. International Journal of Disaster Risk Reduction. 2017;25:212-26.
Gares CE, Montz BE. Disaster Vulnerability of Migrant and Seasonal Farmworkers: A Comparison of Texas and North Carolina. Southeastern Geographer. 2014;54(1):36-54.
Mukumbang FC, Ambe AN, Adebiyi BO. Unspoken inequality: how COVID-19 has exacerbated existing vulnerabilities of asylum-seekers, refugees, and undocumented migrants in South Africa. International Journal for Equity in Health. 2020;19(1).
Mihm S. The ugly history of blaming ethnic groups for disease outbreaks. The Japan Times. 2020.
OECD. Strengthening the frontline: How primary health care helps health systems adapt during the COVID 19 pandemic. 2021.
Esses VM, Hamilton LK. Xenophobia and anti-immigrant attitudes in the time of COVID-19. Group Processes & Intergroup Relations. 2021;24(2):253-9.
Cox A, Iedema R, Li S, Sabbe M, Salaets H, Dauby N. Adding barriers to barriers during the COVID-19 pandemic: a call for interdisciplinary research on communication with migrant patients in the emergency department. European Journal of Emergency Medicine. 2021;28(1):5-6.
Guadagno L. Migrants and the COVID-19 pandemic: An initial analysis. 2020.
Bahar S, Kayi I, Mardin D, Sakarya S, Ekzayez A, Meagher K, et al. COVID-19 barriers and response strategies for refugees and undocumented migrants in Turkey. Journal of Migration and Health. 2020;1-2:100012.
Medact MO, New Economics Foundation. Migrants' Access to Healthcare During the Coronavirus Crisis. 2020.
Asia UNEaSCfW. Impact of COVID-19 on Migrants and Refugees in the Arab Region Technical Paper. 2020.
Adrienne Y, Sabrina G. COVID shows how hard it is for women to access healthcare. Preventionwebnet. 2020.
He L, Zhou W, He M, Nie X, He J. Openness and COVID-19 induced xenophobia: The roles of trade and migration in sustainable development. PLOS ONE. 2021;16(4):e0249579.
Xing Y, Li Y, Wang F-K. How privacy concerns and cultural differences affect public opinion during the COVID-19 pandemic: a case study. Aslib Journal of Information Management. 2021;ahead-of-print(ahead-of-print).
Lebano A, Hamed S, Bradby H, Gil-Salmerón A, Durá-Ferrandis E, Garcés-Ferrer J, et al. Migrants’ and refugees’ health status and healthcare in Europe: a scoping literature review. BMC Public Health. 2020;20(1).
Norredam M. Migrants' access to healthcare. Danish medical bulletin. 2011;58(10).
Sakamoto H, Rahman M, Nomura S, Okamoto E, Koike S, Yasunaga H, et al. Japan health system review. New Delhi: World Health Organization. Regional Office for South-East Asia; 2018 2018.
Kaneko M, Matsushima M. Current trends in Japanese health care: establishing a system for board-certificated GPs. Br J Gen Pract. 2017;67(654):29.
Yasukawa K, Sawada T, Hashimoto H, Jimba M. Health-care disparities for foreign residents in Japan. The Lancet. 2019;393(10174):873-4.
Bhandari AKC, Takahashi O. Knowledge, attitude, practice and perceived barriers of natural disaster preparedness among Nepalese immigrants residing in Japan. BMC Public Health. 2022;22(1):492.
kanbara S, Susa K. The Obstacle to Health Care of Foreign Residents in Japan. Journal of Nursing & Care. 2013.
Bhandari D, Kotera Y, Ozaki A, Abeysinghe S, Kosaka M, Tanimoto T. COVID-19: challenges faced by Nepalese migrants living in Japan. BMC Public Health. 2021;21(1).
K C Bhandari. Aliza TO, . Disaster Preparedness among Nepalese Students Residing in Japan. 2022;9:114.
Shakya P, Tanaka M, Shibanuma A, Jimba M. Nepalese migrants in Japan: What is holding them back in getting access to healthcare? PLOS ONE. 2018;13(9):e0203645.
Fetters MD, Curry LA, Creswell JW. Achieving Integration in Mixed Methods Designs-Principles and Practices. Health Services Research. 2013;48(6pt2):2134-56.
Guetterman TC, Fetters MD, Creswell JW. Integrating Quantitative and Qualitative Results in Health Science Mixed Methods Research Through Joint Displays. The Annals of Family Medicine. 2015;13(6):554-61.
Uprichard E, Dawney L. Data Diffraction: Challenging Data Integration in Mixed Methods Research. Journal of Mixed Methods Research. 2016;13(1):19-32.
Younas A, Pedersen M, Durante A. Characteristics of joint displays illustrating data integration in mixed‐methods nursing studies. Journal of Advanced Nursing. 2019;76(2):676-86.
Carrillo JE, Carrillo VA, Perez HR, Salas-Lopez D, Natale-Pereira A, Byron AT. Defining and targeting health care access barriers. J Health Care Poor Underserved. 2011;22(2):562-75.
Charmaz K. Grounded theory : objectivist and constructivist methods: Sage; 2000.
Francis JJ, Johnston M, Robertson C, Glidewell L, Entwistle V, Eccles MP, et al. What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health. 2010;25(10):1229-45.
Arya R, Antonisamy B, Kumar S. Sample Size Estimation in Prevalence Studies. The Indian Journal of Pediatrics. 2012;79(11):1482-8.
Japan ISAo. Number of foreign residents as of June 2020 (Reiwa 2): Immigration Services Agency of Japan; 2020 [Available from: https://www.isa.go.jp/en/publications/press/nyuukokukanri04_00018.html.
Garcia-Subirats I, Vargas I, Mogollón-Pérez AS, De Paepe P, da Silva MRF, Unger JP, et al. Barriers in access to healthcare in countries with different health systems. A cross-sectional study in municipalities of central Colombia and north-eastern Brazil. Social Science & Medicine. 2014;106:204-13.
Mishra SR, Khanal P, Karki DK, Kallestrup P, Enemark U. National health insurance policy in Nepal: challenges for implementation. Global Health Action. 2015;8(1):28763.
Pokharel R, Silwal PR. Social health insurance in Nepal: A health system departure toward the universal health coverage. The International Journal of Health Planning and Management. 2018;33(3):573-80.
Muir MA, Alessi SA, King JS. Clarifying Costs: Can Increased Price Transparency Reduce Healthcare Spending? SSRN Electronic Journal. 2013.
MHLW. What’s new 2021 Japan2021 [Available from: https://www.mhlw.go.jp/english/new-info/2021.html.
Looi MK. Covid-19: Japan declares second state of emergency as Asia struggles with virus surge. BMJ. 2021:n141.
Report of the Committee on Medical Care for Foreigners. Foreign Medical Measures Committee; 2018.
Kinuko S. Childrearing Brazilian women's perceptions of Perinatal care, the Healthcare System in Japan and related Socio-cultural aspects : The third report. Japanese journal of maternal health. 2009;50(2):267-74.
Burroughs VJ, Maxey RW, Levy RA. Racial and ethnic differences in response to medicines: towards individualized pharmaceutical treatment. Journal of the National Medical Association. 2002;94(10 Suppl):1-26.
S.P. T. Handling Medical Emergencies in Japan: Izanau Beta; 2019 [Available from: https://izanau.com/article/view/medical-emergencies-in-japan.
Posel D, Oyenubi A, Kollamparambil U. Job loss and mental health during the COVID-19 lockdown: Evidence from South Africa. PLoS One. 2021;16(3):e0249352.
Hacker K, Anies M, Folb BL, Zallman L. Barriers to health care for undocumented immigrants: a literature review. Risk Manag Healthc Policy. 2015;8:175-83.
Sapkota S, Adhikari P, Sah S, Bhattarai S, Shrestha SP, Poudel S, et al. Use of telehealth services among Nepali living overseas during Covid-19 pandemic: The opportunities, limitations, lessons learned and recommendations. Journal of Oral Biology and Craniofacial Research. 2021.
Chandra YA, Kawamura Y, Paudel S, Nishigawa M. Value of mutual assistance for disaster risk reduction in Japan, Indonesia, and Nepal: A preliminary study. Health Emergency and Disaster Nursing. 2020;7(1):9-16.

Table 1

Sociodemographic characteristics of the participants
	FGDs, N (%)	Survey, N (%)
Age
18–24 years	25 (28.1)	213 (22.7)
25–34 years	55 (61.8)	624 (66.6)
35 above	9 (10.1)	100 (10.7)
Gender
Male	42 (47.2)	398 (42.5)
Female	47 (52.8)	539 (57.5)
Length of stay in Japan
6 months to 2 years	15 (16.9)	61 (6.5)
2 years above to 6 years	50 (56.2)	520 (55.5)
more than 6 years	24 (26.9)	356 (38)
Religion
Hindu	84 (94.4)	814 (86.9)
Others	5 (5.6)	123 (13.1)
Education in Nepal before migration
12 years of schooling or below	57 (64)	588 (62.7)
Bachelor’s degree and above	32 (36)	349 (37.3)
Education in Japan
Japanese Language school /Training college	49 (55)	604 (64.5)
University undergraduate and above	15 (16.9)	164 (17.5)
No formal education in Japan	25 (28.1)	169 (18)
Family status in Japan
Living together with family/ friends	67 (75.2)	626 (66.8)
Living alone	22 (24.8)	311 (33.2)
Visa status
Student visa	20 (22.5)	293 (31.3)
Working visa/ Skilled Labor visa	37 (41.6)	435 (46.4)
Dependent visa	24 (27)	140 (15)
Business visa	2 (2.2)	22 (2.3)
Permanent resident / Others	6 (6.7)	47 (5)
Employment status
Full-time employee / Self-employed	39 (43.8)	473 (50.4)
Part-time employee	40 (45)	419 (44.8)
Unemployed / not seeking a job	10 (11.2)	45 (4.8)
Income
Affected	43 (48.3)	219 (23.4)
Neutral	17 (19.1)	250 (26.7)
Somehow not affected	29 (32.6)	468 (49.9)
English language ability
Don’t know English at all	2 (2.2)	35 (3.7)
Can understand a basic level of English	54 (60.7)	392 (41.9)
Can do active discussions/express ideas in English	33 (37.1)	510 (54.4)
Japanese language ability
Don’t know Japanese at all	6 (6.7)	32 (3.4)
Speak and understand: Intermediate level	60 (67.4)	521 (55.6)
Speak and understand: Business/ Native level	23 (25.9)	384 (41)
COVID-19 infection
Yes	24 (27)	194 (20.7)
No	65 (73)	743 (79.3)
Vaccination status
Fully Vaccinated (single/two-dose)	44 (49.4)	860 (91.8)
Unvaccinated	45 (50.6)	77 (8.2)
Health insurance
Yes	89 (100)	887 (94.7)
No	0 (0)	50 (5.3)
Previous experience of a hospital visit
Yes	80 (89.9)	862 (92)
No	9 (10.1)	75 (8)
FGDs = Focus Group Discussions, N = Number of participants

Table 2 is available in the Supplementary Files section.

No competing interests reported.

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Barriers and Facilitating Factors to Healthcare Accessibility among Nepalese Migrants during COVID-19 Crisis in Japan: An Exploratory Sequential Mixed Methods Study

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