Cultural Sensitivity and Global Pharmacy Engagement in Asia: China, Japan, South Korea, and Taiwan

China/Macau/Hong Kong.

The People’s Republic of China, commonly referred to simply as China, is the largest Asian country and the largest country by population in the world (nearly 1.4 billion people, representing one-fifth of the world’s population).¹³ China is made of 33 administrative units which report to the central government.¹⁴ This includes 22 provinces, five autonomous regions, four municipalities (Chongqing, Beijing, Shanghai, and Tianjin), and two special administrative regions (Hong Kong and Macau).¹⁴ Each province, region, and officially designated municipality has a government which has power locally but reports to the central government. Mandarin is the official language of China; however, the dialects spoken throughout the country differ, with only the written language being common across all regions. In Southern China, Hong Kong, and Macau, Cantonese is commonly spoken. The currency in China is the Ren Min Bi (RMB), usually referred to as the Yuan. Travel to China requires a visa, which must be applied for prior to arrival in most cases. Some exceptions are US visitors to Hong Kong or Macau who are staying for no more than 90 days and have a valid passport.¹⁵

Hong Kong has significant Western influence. Originally under Chinese rule, it seceded to Great Britain in 1842 after the first Opium War.¹⁶ Except for a short occupation by Japan in 1941, Hong Kong remained an independent British territory until July 1997, when it was turned back over to China.^14,16 Hong Kong maintains its own currency (the Hong Kong dollar), elects its own leaders, and flies its own flag under the handover agreement, which promotes “one country, two systems” and designates Hong Kong as a “special administrative region” of China.¹⁷

Similarly, Macau (also spelled Macao), located at the entrance of the Pearl River estuary in Southern China, is located on a peninsula and two islands, comprising an area of just over 10 square miles. Macau holds the distinction of being the most densely populated place on Earth, with over 20,000 people per square kilometer of land area in 2016.¹⁸ By comparison, Hong Kong is the fourth most densely populated place on Earth at a distant 7,000 people per square kilometer.¹⁸ Macau’s population comprises mostly ethnic Chinese born either on the mainland of China or in Macau, although there is a substantial population from Portugal, the Philippines, Nepal, and other countries.¹⁹ Like Hong Kong, Macau is designated as a “special administrative region.” Having been under the rule of Portugal until 1999, Macau also maintains its own currency (the Pataca), flies an independent flag, and elects its own leaders through a 50-year “one country, two systems” arrangement agreed upon prior to the handover of the area from Portugal to China.¹⁹

Japan.

The population of Japan is about 126 million and has been declining continuously for the past eight years.²⁰ This decline is the result of a low national birth rate, which is currently less than one million per year.²⁰ While the number of children 14 years of age or below is decreasing and now accounts for only 13% of the country’s population, the number of elderly (those 65 years of age or above) is increasing, with this group accounting for 27% of the population.²⁰ Because of the declining birth rates and increasing elderly population, the size of Japan’s workforce is shrinking, raising concerns for Japanese society.

In Japan, many religions coexist. According to the Agency for Cultural Affairs, the number of organizational registrations is largest for Buddhism, followed by Shintoism and then Christianity.²¹ Additionally, there are many other religions which combine some of the teachings from Buddhism, Shinto, and Christianity. However, approximately 60% of Japanese people identified themselves as not being religious and 10% as being atheist.²² Religious practices do not conspicuously affect Japanese daily life; however, various religious holidays are celebrated in Japan. Interestingly, certain holidays are celebrated despite individuals’ own beliefs; for example, some non-Christians celebrate Christmas in Japan. However, religious holidays are typically not considered national holidays as some are in the United States. Because of the coexistence of various religions in Japan, many Buddhist temples, Shinto shrines, and Christian churches welcome visitors regardless of their religious affiliations.

The people of Japan speak Japanese at home, school, and work. Even though people learn English as their second language in school, their proficiency levels vary considerably. Public transportation signs in cities are written in English as well as Japanese; thus, non-Japanese-speaking visitors usually do not have trouble navigating through the city. Japan has an extensive public transportation network, including subway and rail systems. Within cities, the Japanese usually use public transportation for their commute to work and school. Motor vehicles are driven on the left side of the road with the driver’s seat located on the right side of the car; thus, driving in Japan can be challenging for visitors from the United States. The currency used in Japan is solely the Japanese yen, which is expressed with the symbol ¥. Some local Japanese shops and restaurants may not accept credit cards, so carrying some Japanese currency is advisable. Tipping is not expected for services in restaurants or taxi drivers as this is not customary.

Republic of Korea.

The Republic of Korea, also known as South Korea, is located on the southern half of the Korean Peninsula. The country is approximately 70% mountainous, and the majority of its 51 million people live in the lowland areas.²³ The official language is Korean, but English is widely taught in school as a second language. Koreans use the Hangul alphabet. For newspapers and certain other documents, however, the Chinese alphabet, Hanmun, is still used.

In Korea, freedom of religion is guaranteed by the constitution, and there are various religions practiced across the country including Protestant (19.7%), Buddhist (15.5%), and Catholic (7.9%). However, approximately 60% of the population does not practice a religion.²³ Korean culture is influenced by Shamanism, Buddhism, Daoism, Confucianism, and Christianity.²⁴ In particular, Confucianism has both positive and negative effects on people’s lives, For example, respecting the elderly is valued, but it has created a social hierarchy. Showing respect for elders is significant and expected not only within the family structure but also in business interactions. Another concept widely embraced by Koreans is Jeong, which is the practice of showing kindness, affection, and/or commitment when caring for family, friends and neighbors.²⁵ Two major holidays celebrated in Korea are the Lunar New Year and the Harvest Moon Festival, the dates for which are determined by the lunar calendar.²⁴ The currency is the Korean Won (₩). Tipping at restaurants and in taxis is generally not expected.

Taiwan.

Taiwan, the Republic of China (ROC), is an island located in Eastern Asia bordering the East China Sea, the Philippine Sea, the South China Sea, and the Taiwan Strait. The ROC government relocated to Taiwan in 1949 during the Chinese Civil War.²⁶ Since then, the ROC has continued to exercise jurisdiction over Taiwan. Since 1996, the people have elected a president and a vice president every four years.²⁶ Taipei serves as its capital with additional major cities being Kaohsiung, Taichung, and Tainan.

The population of approximately 23 million consists of over 95% Han Chinese and 2% indigenous Malayo-Polynesian peoples.²⁷ Mandarin Chinese is the official language, but Taiwanese and Hakka dialects are also spoken. People 25 to 54 years of age make up nearly 47% of the Taiwanese population.²⁷ Predominant religions are Buddhism (35.3%) and Taoism (33.2%). Other religions such as Christianity, Catholicism, Islam, and indigenous religions are also practiced by some Taiwanese.²⁷ Major holidays include the Chinese (Lunar) New Year, Memorial Day in February, and the Dragon Boat Festival on the fifth day of the fifth lunar month.²⁷ The currency is different from that of China and is New Taiwan Dollars (TWD).

China/Macau/Hong Kong.

China’s health care system is undergoing rapid change. The government is responsible for the health care system, and every Chinese citizen is entitled to basic health care. The provinces, autonomous regions, and recognized municipalities have the responsibility to provide health care. While people often imagine China in terms of its densely populated cities like Beijing and Shanghai, much of China is rural. Many small villages and towns have their own rural hospital run by local health authorities. Larger cities have a combination of government-run hospitals and government-approved privately owned hospitals. The health care system is centered around these hospitals, and outpatient physicians are most frequently located within the campus of a hospital. Some private practice physician offices are also available within a community and outside of the hospital; however, this is less common in smaller cities. Beyond hospitals, there are traditional Chinese medicine (TCM) practitioners both within the hospital and in private practice within the community. Community-based pharmacies sell a variety of Western medicines and are located in nearly every community. However, community pharmacies may not be owned by pharmacists, and those running the pharmacies are often pharmacy technicians rather than pharmacists.²⁸ Traditional Chinese medicine pharmacies are typically operated separately from those selling Western medicines.

Patient interactions in China are influenced by the incredibly large volume of patients seen within a hospital on a daily basis. For example, it is relatively common in a public hospital in Beijing to have over 5,000 patient visits per day, including both inpatient and outpatient encounters. Chinese outpatient pharmacies in hospitals may fill upward of 5,000 to 10,000 Western medicine prescriptions per day, in addition to hundreds of TCM prescriptions. Because of the patient volume, hospital expenses must be paid by the patient’s family prior to discharge, and often fees must be paid even prior to receiving care. Approximately one-third of health care costs are paid for by the government, with the remainder being privately paid.²⁹ The Commonwealth Fund reports that China spends about 5.6% of its gross domestic product on health care.²⁹

The Chinese Ministry of Education reported in 2014 that there were 2,246 colleges and universities in China, of which 444 were private and the remainder were public institutions.³⁰ Referring specifically to pharmacy education, the Bachelor of Science (BS) degree in pharmacy is the entry-level degree and focuses on pharmaceutical sciences. A BS degree in clinical pharmacy and a clinical pharmacy concentration within a BS program of pharmacy or medicine are also offered (Table 1).^31,32 For graduate students in pharmacy, examples of subdisciplines are pharmaceutical chemistry, pharmaceutics, pharmacognosy, pharmaceutical analysis, microbiology and biochemical pharmacy, and pharmacology. The graduate-level training for the Master of Science (MS) and the Doctor of Philosophy (PhD) levels are typically for drug discovery and drug development research; however, MS and PhD in clinical pharmacy degree programs have more recently become available.^31,32 Individuals who wish to pursue clinical pharmacy can do so by completing a postgraduate hospital-based clinical pharmacy training program. Although a system for licensure was implemented in 1994, passing the licensure examination is not necessarily a requirement to practice pharmacy.^31,32

Pharmacy practice in China continues to evolve. In 2009, the launch of a new health care system putting primary care as the foundation and focus gave community pharmacists larger responsibilities.²⁸ Although the responsibilities of community pharmacist increased, there was approximately one pharmacist per 7,300 people in 2010, which is a ratio much higher than that in the United States (approximately 1:1770), Canada (approximately 1:1450), and other developed nations.^28,33,34 Rates of self-medication in China continue to rise, placing community pharmacists in a good position to provide pharmaceutical care; however, they are limited by the lack of reimbursement for services and, in some cases, insufficient knowledge and skills in specific areas.²⁸

Clinical pharmacy has only gained significant attention since the turn of the 21st century, and demand for clinical pharmacy services is growing in the hospital setting.³⁵ Despite the need, most hospital pharmacies in China have a shortage of pharmacists. Current staffing requirements, according to the Rule of Pharmaceutical Affairs, states that a county hospital must have a minimum of three clinical pharmacists in the pharmaceutical service team.³⁵ In a survey of clinical pharmacy services, only 52% of sampled hospitals met the clinical pharmacy staffing requirements in China.³⁵

Japan.

The Japanese government provides universal health insurance with the following goals: to cover all citizens, to allow citizens to use the health care systems/institutions of their choice, to ensure high-quality health care at a low cost, and to allocate public subsidy to maintain the universal health insurance coverage based on the social insurance system.³⁶ A system equivalent to US Medicare is applicable for the elderly when they become 75 years old in Japan.³⁶ The need of health care for and care to ensure the welfare of the elderly is expected to further increase, especially in 2025 when the ages of baby boomers become 75 years or over.³⁷ By 2025, the Japanese government projects that one in three citizens will be over 65 years of age and one in five will be over 75 years.³⁷ The government currently promotes a policy to create a “community-based integrated care system” in which health care, long-term care, preventive long-term care, housing, and livelihood support are provided in an integrated manner at the community-level.³⁷ Another policy is targeted at establishing a society where the elderly will be able to live with ease even if they are diagnosed with dementia. Yet another policy emphasizes improvement in the work environment at long-term care sites.³⁷ In 2012, the provider to patient ratios in Japan were 226 physicians, 78 dentists, and 161 pharmacists per 100,000 people.³⁸

Some Japanese patients, especially the elderly, think highly of health care professionals. These patients may hesitate to voluntarily state their symptoms or treatment preferences unless they are specifically asked. These patients tend to receive information more passively from health care professionals, rather than actively seeking advice from them. Because of Japan’s universal health insurance coverage, patients’ self-treatment with over-the-counter medications is not as widespread as it is in the United States.³⁷ However, because of political measures to mitigate increasing health care costs and the increasing role of pharmacists as patient advocates in communities, the number of patients who consider self-treatment seems to be growing.³⁷

Japanese students take university entrance examinations at the end of their senior year in high school and directly enter a professional school, such as dental, medical, pharmacy, and veterinary schools, upon graduation.³⁹ The length of study at these professional schools is six years. However, the degree after the six-year curriculum is currently not considered as a doctorate degree as in the United States (Table 1).³⁹ The length of pharmacy school in Japan was four years until a policy was implemented for pharmacy schools to offer two separate curricula in 2006: one focusing on research (four years in length) and the other focusing on the clinical aspects of pharmacy (six years in length).^39,40 During the six-year curriculum, fifth-year students go to experiential sites to complete an 11-week rotation at a hospital and another 11-week rotation at a community pharmacy. To become a pharmacist, students need to successfully graduate from the six-year curriculum and pass a national licensure examination administered by the Ministry of Health, Labor, and Welfare.⁴⁰ After obtaining their license, Japanese pharmacists practice in various settings: community pharmacy (55%), hospitals/clinics (19%), manufacturer/marketer (11%), drug distributor (5%), academia (2%), health and hygiene services (2%), and others (6%).⁴⁰

In certain hospitals, pharmacists have recently started offering clinical pharmacy services in particular areas such as oncology. However, because there are no pharmacy technicians, pharmacists’ work is primarily focused on filling prescriptions. As mentioned in the section for China, use of herbal or traditional medicine, called kampo, is common in Japan, and is often covered by the same insurance used for prescription medicine. Pharmacists are also responsible for dispensing these traditional medicines as a unique aspect of pharmacy practice in Japan.

Republic of Korea.

The Republic of Korea achieved universal health coverage in 1989 and has since made significant improvements in the health status of its population. The Ministry of Health is responsible for overseeing the National Health Insurance as well as the hospital accreditation program and the licensure for health care workers.⁴¹ Pharmacists were able to give medicine to patients without prescriptions since the first Korean pharmacists appeared in 1920; however, the policy of separating the roles of prescribing and dispensing medicine passed in 2000 and affected this custom. Traditional Korean medicine professionals see patients from a holistic viewpoint rather than according to disease states. The theory of Eum (darkness) and Yang (lightness) is sometimes used for diagnosing patients.

Regarding pharmacy education, all colleges of pharmacy changed from a four-year system to a 2+4-year system in 2010 (Table 1). After two years of coursework in a related field, such as chemistry or biology, students take the Pharmacy Education Eligibility Test (PEET), which is an entrance examination for colleges of pharmacy. This 2+4-year system was created to ensure that students entering the pharmacy profession have the appropriate level of life experience and aptitude.⁴² In 2015, roughly 1,350 student pharmacists graduated and were eligible to sit for the National Pharmacy Board Examination.⁴³ Unfortunately, implementation of the new system created many concerns, such as high numbers of students dropping out of the affected colleges and others having to take the PEET several times before passing. Therefore, the current 2+4 system is expected to shift to a full six-year system without the PEET in the near future.

Pharmacy practice in the Republic of Korea has expanded in scope with the change in pharmacy education. Pharmacists have opportunities to work within community pharmacy, health care institutions, industry, government, and academia.⁴³ Within hospitals, pharmacist’s roles are not always as delineated as they are in the United States, and one pharmacist could hold simultaneous roles in dispensing, research, and clinical rounds. Within large community pharmacies that are associated with hospitals, it is not uncommon to serve nearly 1000 patients per day. Therefore, although opportunities for pharmacists continue to grow, the emphasis on drug dispensing is still high. Among 2015 new graduates, the top three most preferred areas for career establishment were in community pharmacy (28.6%), industry (21%), and hospital pharmacy (18.3%).⁴³ Additionally, opportunities exist for pharmacists to contribute their expertise to other fields, including law and journalism, or to serve as consultants or activists in nongovernmental organizations.⁴² The Korean Pharmaceutical Association and the Pharmaceutical Society of Korea are organizations supporting pharmacists in Korea. These organizations work towards improving social welfare, advancing research in pharmaceutical sciences and pharmacy practice, improving pharmacy education, advocating for pharmacists, and enhancing public health care.⁴⁴

Taiwan.

Taiwan introduced a national health insurance system in 1995.⁴⁵ Since its launch, it has been known for providing good accessibility, affordability, and comprehensive coverage. Its structure allows for extensive data collection, providing the ability to conduct research into its population’s health.⁴⁵ As a unique disease burden, dengue fever increased over recent years exhibiting its largest outbreak in 2014.⁴⁶ Taiwanese students enter pharmacy schools after graduating from high school by meeting required standards based on their performance on the university entrance examination or by recommendations and a screening program. Pharmacy education in Taiwan is a four-year or five-year bachelor’s degree in pharmacy; however, select schools are now providing six-year Doctor of Pharmacy programs (Table 1). There are several requirements for pharmacy graduates prior to sitting for the National Board Examination, including internships for 640 hours in a hospital pharmacy setting and 200 hours each in community pharmacy and industry settings. The National Board Examination is administered by the Ministry of Examination and is composed of roughly 50% pharmaceutical sciences and 50% clinical pharmacy questions.

Since the separation of dispensing from prescribing in 1997, pharmacy practice in Taiwan has shifted to patient-centered care and earned the second place as people’s most-trusted occupation in the nation.⁴⁷ In 2007, after amendment of the pharmacy law, pharmacists began providing pharmaceutical care.⁴⁸ Community pharmacists have implemented home visits to discover and solve medication-related problems in order to decrease outpatient hospital visits and medical expenses. Hospital pharmacists take care of medication evaluation for inpatients and have also developed various pharmacist clinics in medication therapy management, anticoagulation, and more.^49,50 These pharmaceutical care practices were rapidly promoted as a result of the establishment of PharmaCloud, a medication monitoring program implemented among all hospitals and clinics in 2013 by the National Health Insurance program.⁵¹ In 2015, good pharmacy practice guidelines were developed by the Taiwan Society of Health-System Pharmacists.⁵² To meet the guidelines, pharmacists must effectively fulfill four roles: prepare, obtain, store, secure, distribute, administer, dispense, and dispose of medical products; provide effective pharmaceutical care; maintain professional development and contribute to the professional development of others; and contribute to the effectiveness of Taiwan’s health care system.⁵² Although pharmacists do not administer vaccines as they do in the United States, the Taiwan Center for Disease Control promotes pharmacists as educators in efforts to facilitate vaccination programs.⁵² There are also no pharmacy technicians; therefore, pharmacists complete all the tasks for filling prescriptions.

The Pharmaceutical Society of Taiwan supports the profession through the advancement of research, practice, and global collaboration among pharmacy professionals.⁵² According to National Health Research Institutes, positions in hospitals, industry, and academia are in high demand because of the increasing need for clinical pharmacy services, hospital-based teaching, and research for developing new treatments and biotechnology.^53,54

China/Macau/Hong Kong.

There are several common misconceptions and incorrect stereotypes of China and Chinese culture. The first misconception is that all Chinese people are the same. Chinese culture differs substantially by region, and the languages or dialects also differ. Visitors should not assume learning Mandarin will be sufficient for communicating throughout the country. Similar to the the United States, cultural practices, foods and cooking styles, music preferences, and other aspects of society in China vary greatly from region to region. Travelers should be open to the rich diversity China affords.

A second misconception is that Chinese people do not have siblings. While China implemented a one-child policy beginning in 1978, some segments of the population were allowed to have more than one child.¹⁴ Families could also have more than one child if they paid a financial penalty. This policy was revised in 2015, and now all Chinese families are allowed to have two children.²⁶

A third major misconception is that Chinese people are indecisive and unhappy based on their expression and appearance. Quite often, when a Chinese person is asked a question, they preface their comment with phrases such as “I think.” This is not indecisiveness but their way of being less direct when responding to a question as that is considered the polite way to respond. Additionally, Chinese people tend to be animated when talking. This should not be perceived as being rude but rather as being passionate about what they are communicating. Regarding the unhappiness, visitors should be careful not to judge a Chinese person’s mood simply by their facial expressions, as these are quite different from those of Americans. A final common stereotype is that the Chinese health care system needs to be improved by the “wisdom” of Western medicine. While the Chinese may have adopted certain practices of Western medicine later, a close inspection of the health system in China would show that some aspects of their system are actually more advanced than those in the United States. For example, the system for processing prescriptions in the outpatient setting relies on advanced technologies that have not yet been fully implemented in the United States.

Japan.

Some Americans might think that Japanese and Americans do not get along because of the events during World War II. However, this is a misconception. Japan and the United States have developed a nurturing relationship since the war, not only politically but also culturally and economically. Various sister cities exist between Japan and the United States that have helped build friendship and encouraged cultural exchange. Travelers from the United States can expect a warm welcome when visiting Japan.

According to a study conducted among Japanese college students, the three most common descriptions identified for the Japanese under the category of “characteristics” were hard-working, shy, and unconcerned with distant matters.⁵⁵ Under the category of “values,” the three most common descriptions of the Japanese were that they knew when to express tatemae (what people believe is appropriate in public or to others) and when to express honne (what people actually feel or think), honor favor and courtesy, and respect their superiors and elders.⁵⁵ The descriptions under the category of “collectivism” were that the Japanese imply rather than being explicit, respect harmony, and try not to embarrass themselves in front of a group.⁵⁵ These descriptions are likely considered as accurate characteristics of the Japanese and a good representation of their values in general. However, certain discrepancies were observed in this study between the overall level of these characteristics among the Japanese people and the individual level, ie, these stereotypes may not be true for all Japanese.⁵⁵ Also, in this study, “imply” was a descriptive word for the Japanese as they often rely on nonverbal communication and do not express directly unless they think what needs to be spoken is very true or important to be explicitly said. Standard expressions or communication styles of Americans may be perceived as being more exaggerated than intended.

Republic of Korea.

Some typical stereotypes attributed to Koreans include: that they do not say what they mean and that they are obedient to authority.⁵⁶ These stereotypes may be considered a reflection of their cultural values. In Korean tradition, having patience and modesty and not verbalizing much have been desirable traits, but these could be misperceived by those who do not understand the culture. Confucianism also influences Koreans to see people as part of a hierarchy, such as in their family and social structures, and to respect authority.

Regarding communication styles, most Koreans usually avoid direct eye contact during conversations. Although the lack of eye contact may indicate dishonesty or disrespect in the American culture, this is how Koreans show respect to others. More recently, however, Koreans are learning Western styles of communication. Having eye contact with the person they are talking to is becoming more common.

Misconceptions regarding patient care include the idea that, with a cultural background reflecting collectivism, decision-making related to health care involves gathering input from authority figures within the family rather than determining the patient’s desires. A common assumption is that shared decision-making between patients and health care providers may be less influential than decisions involving the patient and family. This notion may not be accurate as the health care in South Korea continues to evolve and include more team-based approaches between providers and patients.^57,58

Taiwan.

Common stereotypes include that Taiwanese are overly respectful of authority and only emotionally open with family while emotionally concealed with others.⁵⁹ The respect for authority is actually a value reflecting their culture; Taiwanese people respect elders and superiors. Their reserved behavior is likely a reflection of their cultural appreciation for having a modest demeanors rather than a sign of not being open. Showing warmth and hospitality is reserved for well-known associates, but this is not always the case.⁵⁹ As younger generations more openly express acceptance of and affection for new acquaintances and colleagues, this cultural norm is changing.

Because of the historical background discussed earlier, Taiwan has a close relationship with China. Some Taiwanese people view themselves as being culturally distinct and desire to be separate from China.⁵⁹ On the other hand, others are emotionally connected to their historical roots with China.⁵⁹ Stereotypes based on these two views of Taiwan’s relationship with China may be influenced by age. The younger generation is more often associated with a desire for independence and greater acceptance of Western influences, while the older population may lean more towards unity and the idea of being one China.⁵⁹ However, this difference seems less important in recent decades as Taiwan and China have ongoing communication and collaborations not only in business but also in health care and research.

China/Macau/Hong Kong.

Chinese culture has developed from the roots of Confucianism. Confucian principles in China focus on patriotism, relationships, hierarchy, and family.⁶⁰ The concepts of saving or preserving mianzi and guanxi are very important.⁶⁰ Mianzi refers to one’s honor, dignity, trustworthiness, reputation, and social standing.⁶⁰ To maintain mianzi, the Chinese may often avoid expressing open conflict, providing critical feedback openly, and saying no directly. This is important for US visitors to be aware of because in US culture, people are much more direct and open. When initiating conversations, visitors should ensure that they are not acting in a way that would cause their host to lose mianzi, such as engaging in public criticism.⁶¹ On the contrary, visitors can provide mianzi by acknowledging or complimenting their host’s success or effort in public, reciprocating received kindness, showing respect and trust, and remembering people’s names and titles so they are able to address them properly.⁶¹

Visitors should remember that, in maintaining mianzi, the Chinese may not always say what they truly mean. For instance, their “yes” may not always mean an actual yes. Pay attention to nonverbal cues such as long pauses, side glances, or silence, which may indicate something different than what is verbally expressed. If visitors are interested in more accurate responses, rather than being direct, they should ask to discuss or explore the matter further. Keeping these communication styles in mind, US health care professionals and students engaging in patient care should be prepared for patients to similarly adhere to the concept of saving mianzi. When conducting patient interviews and asking questions about medication adherence, lifestyle activities, and other relevant information, patients may politely nod and say yes or provide the answer they think the caregiver is looking for. To gather more accurate information while upholding their mianzi, it may be necessary to ask questions in different ways to explore that topic further.

The concept of guanxi is complex but important in the development of business and personal relationships with the Chinese. Guanxi refers to mutually beneficial relationships.⁶⁰ As a visitor, local Chinese people may introduce you, through guanxi, to another friend or business partner. This introduction through guanxi implies their personal seal of approval and a guarantee that the partner to whom you were just introduced will deal with you honestly and fairly. Guanxi allows for the development of trusted networks for engagement.

Health care professionals traveling to China for conferences and meetings should anticipate the need for business cards. When exchanging business cards, it should be given with two hands with the text on the card facing the receiver.⁶⁰ Additionally, business cards should remain on the table, arranged in a vertical line that reflects the hierarchy of the people named on them.⁶⁰ A crucial component of building trusting relationships with the Chinese is being punctual, so visitors should always plan to arrive five minutes early. When eating with locals, guests should keep the following in mind: do not tap chopsticks on the table or leave them stuck vertically in the bowl. If attending dinner at someone’s home, guests should try some of each dish as a sign of respect. Lastly, some Western gestures may be considered rude. In particular, visitors should avoid snapping their fingers, whistling, and showing the soles of their shoes when sitting, especially when crossing their legs.

Japan.

Pharmacies and health care institutions in Japan may have limited experience in providing clinical experience to guests from other countries. One reason may be the language barrier as English is not commonly spoken in Japan. Visitors from the United States may find certain phrasing used by Japanese hosts awkward, and this is likely because there is no matching English word or phrase or because the order of their words is different from that a native English speaker would use. Visitors should not confuse their Japanese hosts’ English proficiency with their professional competency. Instead, US guests should expect that Japanese health care professionals who are highly competent in their field might not always be completely proficient in English. Visitors should show patience and express their understanding if they notice their Japanese hosts seem unsure whether they are accurately communicating their message.

When US guests visit pharmacies or health care institutions in Japan, they should visit different sites to fully understand the scope of practice. This is because, even within the same chain of retail pharmacies, their functions may differ depending on their locations and the patient populations they are intended to serve. Clinical services offered by pharmacists as well as types of medications each pharmacy carry can differ significantly from one place to another. Additionally, herbal medicines (kampo) coexist with Western medicines; this may provide an excellent opportunity for US visitors to learn more about the safe use of herbal medicines.⁶²

Japanese hosts usually try to create detailed schedules and plans in advance. For this reason, it is important for US visitors to communicate what their expectations are and what they would like to see or experience ahead of time. In order to meet visitors’ expectations and needs, proposed schedules from Japanese hosts can be very busy and full. Punctuality is highly respected, and it is crucial for visitors to check schedules in advance to ensure they are manageable. The Japanese usually expect visitors to show up on time or a little earlier than the scheduled time. Pharmacists and pharmacy students from the United States should bring appropriate business attire in addition to “business casual” clothing when they visit pharmacies in Japan. Some Japanese pharmacies may have a more formal dress code than those in the United States. For men, wearing a tie may be advisable, especially when visiting a new place or meeting a person for the first time. The Japanese also have a tradition of exchanging business cards in various business settings, so preparing business cards is recommended. The Japanese greeting when meeting someone is to bow rather than to shake hands. If invited to enter a house, visitors should remove their shoes in the designated area.

Because religious practice does not heavily affect daily life in Japan, they may lack consideration sometimes for visitors who would like to practice their religion. Visitors should communicate these needs in advance, such as special dietary needs or time needed for praying.

Republic of Korea.

Understanding views on education, authority, and business is important when initiating collaboration. Education is viewed as the most important way to elevate one’s status in Korea. According to the Organisation for Economic Co-operation and Development (OECD), 70% of Koreans between the ages of 25 and 34 years have earned the doctoral level of education.⁶³ In terms of authority, considerations need to be made, based on both age and professional status. Loyalty in the workplace is often associated with being loyal to a boss, not necessarily to a company.⁵⁶ It is customary to incorporate a sense of “family” in business, but similar to many nations around the world, Korean culture has been influenced by globalization. As a result, Korean culture, economy, and society have undergone westernization to some degree.^64,65 According to the most recent OECD data, Koreans worked the third most hours among participating countries, almost 48 hours per week.^56,63

When communicating, eye contact is essential but should typically be kept to a minimum. Also, a visitor’s efforts to listen more and talk less are usually received well. Physical contact is not typically welcomed, and distance and space are appreciated when conversing. Pointing at a person is disrespectful. Koreans are usually soft-spoken when communicating, and rushed or aggressive discussions can cause them to feel uncomfortable. A formal and polite communication style is recommended, especially when speaking with the elderly and superiors.⁵⁶

Students visiting Korea for experiential rotations should be aware of proper etiquette. Punctuality is expected, and students should strive to arrive early. Space in hospital and community pharmacies is often very limited with few chairs available for personnel. Because of this, visiting students should be aware that while shadowing, long periods of standing may be necessary. Additionally, appropriate student etiquette includes always sitting properly when speaking to professors. For example, students should avoid putting legs on chairs or slouching. Students should also refrain from putting their hands in their pockets. Not following these common social rules could be considered rude. If provided with the opportunity to be a part of the classroom, visiting students should be aware that questions are generally not asked during lectures but individually, after class time. If the presenter or professor makes a mistake, it would be considered rude for a student to correct them. Students with long hair are usually required to tie their hair up during working hours. Also, wearing nail polish and/or unnaturally colored hair is generally unacceptable. Finally, students should thoroughly research a question before asking their preceptor. Most pharmacists have heavy workloads and may get frustrated with student questions that could have been answered independently.

Taiwan.

Taiwanese value hard work, patience, humility, friendliness, and respect for others. They typically dislike loud, showy, and unrefined behavior, so US visitors should be aware of their mannerisms. Ren ching wei refers to the notion of being sincere and modest and denotes civilized discourse.⁵⁹ Age is respected outwardly in Taiwanese daily life. Influenced by Buddhist culture, the Taiwanese view time in a circular pattern as opposed to the linear structure observed in Western culture. Circular time suggests that there is no beginning or end, and aligns with the Buddhist concept of fluidity. Such belief may also influence patient’s health-related decisions, so visitors should be aware, especially if they provide care to Taiwanese patients.⁵⁹

The Taiwanese may seem conservative in communication or collaboration. Both socially and in business interactions, touching in public, such as a hug, is rare, and generally reserved for family and close friends. When moving an object, visitors should not use their feet because feet are considered dirty. As commonly seen in many Asian cultures, communicating in a manner to keep harmony and balance is essential in social and business relationships.⁵⁹ In communication, the Taiwanese avoid arrogance, are patient, and maintain their dignity. Because of this, Taiwanese pharmacists, for example, may be reluctant to discuss or showcase their skills to visitors. However, with sufficient communication and encouragement, they can be motivated to share their knowledge and expertise.

China/Macau/Hong Kong.

The Chinese often put their guests’ needs before their own. If Americans are hosting visitors from China, the guests may have similar expectations. Chinese visitors may expect their hosts to be readily available and able to provide for their needs.⁶⁶ American phrases such as “make yourself at home” and “help yourself” are typically interpreted by Chinese guests as meaning they should act however they like and take action without the assistance of their hosts. This type of hospitality is often misunderstood and not received well by Chinese visitors. Instead, they would prefer that US hosts give them more specific instructions, provide them with food and drink, or even suggest where they should sit.⁶⁶ This may seem pushy or overbearing by American standards, but for the Chinese, this is closer to their standards and norm. Similarly, it is important for hosts to have a detailed plan for how guests will spend their time while visiting.⁶⁶ Whether it is having dinner one evening and/or being given a tour of a university the next day, the Chinese will appreciate it that you have carefully considered how you will spend your time together.

In the health care professional setting, many of these concepts apply. Formal meetings held with Chinese visitors should be strategically planned, down to the seating arrangements at dinner, what kind of tea will be served, and what it will be served in.⁶⁷ Guests should be invited to sit in specific locations, often with the most important persons seated in the middle, across from his or her equal in the other party. Tours can be a great way to show visitors the hosts’ work environments and at the same time to identify other things they may want to do while they are visiting.

Just as there may be Western gestures considered rude by the Chinese, there may be Chinese customs that US hosts will find less than pleasing. For this reason, hosts should familiarize themselves with these customs prior to the visit and understand that their guests’ actions are not intended to be rude. For the Chinese, talking while eating is the norm and slurping is a show of appreciation for food.⁶⁰ Gift giving by the visitor or host builds guangxi, but do not be surprised if the Chinese refuse the gift two or three times before accepting it as this is Chinese etiquette. The giver is expected to gently persist until the gift is accepted.⁶⁰ This gift-giving behavior applies to some other Asian countries such as Japan.

Japan.

When Japanese students visit institutions in the United States, they may not recognize that their cultural norms differ from those of the United States. This is especially true if they are visiting a foreign country or encountering another culture for the first time. These students may tend to behave timidly and remain quiet because they do not know that expressing their thoughts and ideas is appreciated in US culture. In addition, their quietness may reflect their lack of confidence in their English proficiency. Preceptors in the United States may interpret visiting students’ shyness as a lack of interest, so the hosts should let Japanese students know that they can speak up and share their interests and opinions. If students seem hesitant to speak, telling them that their English does not need to be perfect to initiate conversation may make them more comfortable. The hosts should routinely check with students to determine if everything is going well because students do not always disclose issues they may be having with housing, roommates, food, or their health unless they are asked. Providing peer support may be beneficial as Japanese students tend to be more open about their feelings with their peers. Addressing elders with respect by using words corresponding to Mr., Ms., Mrs., Miss, or Dr. is the norm in Japan. If hosts prefer to be on a first-name basis with students, they should clearly communicate this to the students. Japanese students are almost never allowed to communicate on a first-name basis with their professors and preceptors, so they may be surprised and need some time to adjust to this custom.

Most students or pharmacists who grew up in Japan are used to a safe environment; for instance, owning or carrying a gun is illegal nationwide. It may not occur to them that some places or neighborhoods in the United States can be dangerous. Hosts should communicate which areas to avoid when their guests arrive. Finally, Japanese visitors may not be accustomed to a population so rich in ethnic diversity. It is important for hosts to prepare visitors for interactions with people of broad-ranging backgrounds in terms of race/ethnicity, sexual orientation, and religion.

Republic of Korea.

Before entertaining Korean visitors, the hosts should have a good understanding of Korean customs for greeting. Koreans may greet their US hosts with either a handshake or a bow, as bowing is a traditional greeting within the Republic of Korea. If the host wishes to return the bow, he or she should take notice of how low the Korean visitor bowed and return a slightly lower bow.⁶⁸ Bowing is a sign of respect for the person you are greeting; thus, Korean students may bow low when meeting their preceptors. In these instances, if returning the bow, it is not necessary for the preceptor or faculty member to bow lower than the student. As in many other Asian cultures, hierarchy is respected, and attention should be paid to the most important or eldest visitors first. When entering rooms with multiple pharmacists/health care professionals, Korean visitors will likely, if given the opportunity, greet the most important people in the room first. Koreans may consider it rude to address a visitor by his or her first name, and it is often never custom for students to address their teachers on a first name basis. When hosting pharmacists or health care professionals, the hosts should address their Korean guests by their professional titles until permission is given otherwise to avoid accidentally offending them.⁶⁹ As seen in China and Taiwan, Korean culture is rooted in Confucianism.⁶⁹ Hosts should familiarize themselves with the Koreans’ indirect communication style and use of personal space so that visitors are not offended. As hosts, Koreans often have a strong desire to make their visitors feel welcome, and make themselves available to provide anything their guests may need. Thus, hosts of Korean visitors should try their best to arrange time to show their guests around town and take them out to enjoy popular activities in the area. If hosting visitors for a pharmacy experience, the host should pay as much attention to the social aspects of hosting as they do to the clinical pharmacy experiences.

Those hosting Korean pharmacy students should share what expectations exist for US students and that the same would apply to visiting Korean students. For example, Korean students often dress more casually on rotations, and when coming to the United States, they may not be aware of the dress code requirements. Hosts should inform them about what attire is necessary (including if they need a white coat) so they can prepare accordingly. Additionally, similar to US students, student pharmacists from Korea may wish to prepare in advance for topics they may encounter on their rotation. Organizers or coordinators should provide students with a broad level of information about their rotation, to allow students sufficient preparation time.

Taiwan.

In Taiwanese culture, the people can be overly hospitable to guests, often going out of their way to ensure visitors are comfortable and enjoying themselves. Although the same courtesy may not be expected, it is respectful to ensure that Taiwanese guests are well cared for. This may include ensuring that the guests have transportation from the airport or even accompanying them on a weekend site-seeing trip. When inviting guests to events, offering them warm tea and food is also well appreciated. Taiwanese culture has an expectation of removing one’s shoes before entering a home, and hosts should be aware that if shoes are removed by their guests, it is courteous to offer slippers for them to wear inside the home.⁷⁰

Much like the United States, freedom of religion is fully guaranteed in Taiwan. Many Taiwanese are either Buddhist or Taoist, but Christianity and Islam are also practiced.⁷⁰ With a variety of religions in the country, welcoming Taiwanese visitors requires that the hosts show respect for their beliefs and traditions. In terms of greeting Taiwanese visitors, handshakes are a common form of greeting foreigners.⁷⁰ Notably, the Taiwanese look towards the ground when greeting someone, and this should be taken as a sign of respect.⁷⁰ If meeting with a group, the eldest person or the one with the highest title should be greeted first. When exchanging business cards, ensure that both hands are used in giving and receiving cards as discussed above. Gift giving is often exhibited when welcoming foreign guests, and hosts should be aware of Taiwanese beliefs surrounding gift-giving etiquette (Table 2), avoiding gifts that symbolize negative messages. Gifts that are elaborately wrapped in red, pink, or yellow will be greatly appreciated and should be presented with both hands.⁷⁰ In the health care setting, these same principles apply. It is not unusual for a visiting student pharmacist to have brought a suitcase filled with small gifts to give to every pharmacist with whom they have worked.

Overall, Taiwanese communication emphasizes the sharing of broad contextual knowledge to deliver a core message, and brevity may not be valued as in the United States. The US host should begin communication carefully and not be too direct as such messages may be perceived by visitors as rude.⁷⁰ It will be important for hosts to educate visitors who are staying for several weeks about the informal tone of personal and professional communication in the United States to ensure their guests are not offended and have the opportunity to adapt. Taiwanese students may be quiet at times, and preceptors should recognize this and encourage students to speak up and ask questions.