Pre-Analysis of Service Quality Design for Intercultural Care Service Facilities by International Medical Aid

This paper presents a rough design of service system for international care service facilities proposed to be constructed in developing areas or countries by the financial and technical aid from developed areas or countries. A main problem is how to fill the cultural gap between care providers and care recipients, both in human service aspects and information-technological aspects. Here, “culture” includes language, food, custom, art, value system, religion, and the views of life and death. Information technology is expected to narrow the medico-technical gap between developed and developing areas or countries. Further, information exchange or frequent communication with the homeland or home countries of care service recipients is expected to mitigate their loneliness in distance from their homeland. Further, the administrative, legal and other formal barriers like the health insurance and the visa system are discussed.


Background
The demographic or population structure is not simple but is very skewed in many countries. In many developed countries, many babies were born in the second half of the 1940s as the postwar effect. This was called the baby boom and now resulted in the so-called aging or aged society with the big population of this generation (called the baby boomers). They are now around 70 years old [1]. Most of them are already retired, and some are lonely [2]. Further, some are physically or mentally ill. Such countries or societies used to be called the aging countries or aging societies but now often called the (already) aged countries or aged societies. As the social system and the value (family, community, ethics, religion, etc.) vary from one country or area to another [3], the solutions to this problem vary from one country to another. Meanwhile, many developing countries have the different demographic structure, where the middle-aged workforces are central in the societies but will become old in the future. The societies with such demographic structure may be called the not-yet aged societies or the futureaged societies. Nikolich-Žugich & Goldman [4] warn that all the countries must prepare for this problem.

Need
The countries of the already aged society are mostly rich. But the economic power does not necessarily solve this problem. One of the serious problems of the aged society is who takes care of so many elders and how. As their workforce is limited in number as compared with the aged population, such countries need the aid of workforce from other countries. The not-yet aged countries are not necessarily poor but still need to receive some technological information or economic resources from developed countries. They are relatively rich in workforce in comparison with the already aged countries. As the "soon-aged" countries, they particularly need to learn the experiences of the aged society to prepare for their own future.

Solution
For the purpose to satisfy the above-stated needs and to solve the above-stated problems, Eto & Mahujchariyawong [5] proposed a new type of medical aid program of developed countries with the aged society to developing countries with the not-yet aged society, to construct medical and welfare facilities in developing countries for both the local people and the aged people of developed countries, and to employ and train local people of not-yet aged society. This training is expected to be extremely useful for notyet aged countries to prepare for their own aged societies in the coming future. Among various categories of welfare services, care services system for elders are expected to be useful to the soonaged societies. This paper discusses how to implement this idea.
Hereafter, the word "welfare service" is used to include medical service, care service, and possibly others. This paper uses "care service" mainly to denote the care service for elders including the end-of-life care.

Literature Survey
The quality of care service depends on a variety of factors. In order to implement this idea of international care services, Bowers et al. [6] and Bogh & Falstie Jensen [7] maintained that the quality of service is critically important. In managing the service quality, there are several tasks. Kaldjian [8] stressed that the human service aspects including ethical services are important to welfare services. Rohn [9] remarked that the intercultural viewpoint is important to international welfare service providers.
As the care recipients have their own cultural backgrounds, it is important to satisfy their cultural requirements including their needs of religious or artistic services and activities [10][11][12]. Stewart [13] said that food is a serious problem in relation to national or religious culture. George & Kinghorn [14] discussed the relation between religion and health. Garrido & Idler [15] discussed the end of life values beyond religion because the nursing homes are now inseparable from hospice for terminal care as Zheng & Mukamel [16] noted.
In management aspects, Keller & Bergman [17] noted that the communication between care providers and recipients improves the care quality. Similarly, Groene & Sunol [18] found that the involvement of care service recipients and the recipients-centered care strategies are useful in service quality management. Brown et al. [19] proposed the use of internal audit of clinical systems and its methodology. Specifically, Harrison & Walton [20] applied the complaint analysis method to welfare service improvement. As in any management, Wagner & Mannion [21] and Kristensen & Hammer [22] and Iqbal et al. [23] remarked that the organizational culture or climate and organizational structure including work environment are deeply related with quality improvement. As Twigg & Martin [24] presented the idea to challenge of cultural gerontology, now the idea of cultural welfare is demanded.
In order to implement these ideas and proposals, a variety of 'soft technology or techniques' have been developed and applied. A typical one is the conceptual instrument SERVQUAL [25] and other methods for service qualities including the medical and welfare service qualities. Meanwhile, the applications of these modern methods with strong leadership of management to welfare service management largely change the welfare culture [26] and tend to cause the stress of care workers like nurses. Castle & Ferguson Rome [27] worried about their absenteeism, which degrades the service quality. Siegel & Young [28] demanded the adequate management for the nursing resources. In contrast, Banaszak Holl & Castle [29] demonstrated that the modern management method for organizational culture is useful to preventing the absenteeism of care workers.
Contrary to paying attentions to the human aspects, Garcia & Scally [30] observed the future trend of digital technology in medical field. Lutz [31] and Banerjee & Nath [32] noted that the medical electro-communication devices contribute to narrow or fill the technical gap between the developed and the developing countries. Menachemi & Saunders [33] and Patrick & Griswold [34] paid attention to the contribution of information technology to the service quality improvement.
Regarding formal, political, administrative and legal barriers in international welfare, Eto & Mahujchariyawong [5] discussed the long-stay or medical visa systems. Mattoo & Rathindran [35] pointed out that the poverty of international health insurance system obstructs the international medical or welfare activities. Later, Liu & Chen [36] described the present state of national policy of health insurance or medical insurance system for foreigners.
The comprehensive study by Debata et al. [37] identified 58 items perceived by service recipients and experts, and scored the items of care service quality by psychometric methods. This paper learns their observations, analyses, and experiences.

Focuses
As the aging process of Japan is the fastest in the world [38], the aging problem of Japan provides a universal lesson to other countries. Japanese industries once developed the national ethos of quality management [39,40], the Kano model [41] and the qualityfunction deployment (QFD) method, which have been successfully used in quality management for service and production. These past experiences lead to the expectation of Japanese success in care service.

Need and benefit analyses
The discussion above roughly sketched the need of the construction of care service facilities in developing countries by the investment or the aid of developed countries and also pointed out their benefits to both sides. Then it is needed to discuss how implement it. The international medical tourism is demanded and already in operation. It is beneficial to both of developed and developing countries. The use of high-tech medical systems is beneficial to both sides, because it narrows the medical gaps between developed and developing countries in some aspects and stimulates the high-tech industries in developing countries. As the major parts of medical or welfare services are provided by human workforce, another critical need is to fill the cultural or religious gaps between care service providers and care service recipients.

Aim
This paper aims at proposing a rough design of international care service management in conceptual ways. Allen [42] presented the federal guidelines for nursing home in general. This paper places the focus on the intercultural aspects of managing the services in international care systems.
The focuses of service quality management have been placed on industrial and commercial aspects of services to customers. But this paper is concerned with care services in international context, where it is critically important to solve language barriers; cultural gaps; contradictions between the complaints of care service recipients and those of care providers; managerial dilemmas between the satisfactions of care service recipients and care service providers; religious gaps and conflicts regarding the views of life and death; unacceptable or tragic results despite religiously or folk therapeutically good intentions; obstacles due to international treaties; and others.
These problems make the international care services extremely difficult. The care service is no easy task and causes the stress of care service providers such as nurses. Their psychological stresses often obstruct the improvement of their care services. This causes them to leave the care service. Another problem is that few doctors want to work in countryside because of the lack of new information there. But now they can get new medical information by communication devices. But the care service recipients still want to leave the care service facilities. These problems are often based on the barriers, contradictions, dilemmas, gaps, ironies and obstacles underlying intercultural or international problems.

Structure of this paper
Section 3 describes the characteristics, properties or attributes of international care service facilities and their management. Section 4 discusses the problems related to the management of cultural gaps and conflicts between care service providers and recipients. Section 5 discusses how to enjoy the aging with high quality of life in international care service facilities. Section 6 states the conclusion.

Construction of international care service facilities
Eto & Mahujchariyawong [5] proposed a new type of international medical aid from developed countries to developing countries to construct welfare facilities for both local people and the people (mainly elders) of developed countries by employing and training the local people as care staff. This paper also consider the facilities located far from the homes of many care service recipients, where the service recipients and the service staff have different culture.
As developed countries are suffering from the shortage of care service workforce, this program mitigates their problem. This is beneficial to developing countries as this is a sort of the international medical aid to developing countries. As developing countries certainly face the problem of aged society in the future, developing countries learn the experiences of the aged society through this program.

From community-dwelling to care facility-dwelling
As Rantakokko & Iwarson [2] pointed out, the dwelling in community causes the loneliness of single elders from the community. In this aspect, dwelling in care facilities is expected to relieve elders from the isolation and loneliness. When care service facilities are connected with medical facilities, this is expected to ease the anxieties of care service recipients and the families.
Despite these merits of care service facilities, many care service recipients still feel lonely in long distance from the hometowns or home countries. The loneliness negatively affects the service recipients. This geographic handicap can be mitigated to some extent. The use of communication devices like e-mal or fax mitigates it.

Distant or foreign locations of care service facilities
Many dwellers in international care service facilities are far from hometowns or home countries. The visas are required for foreigners if they stay there long. Some countries have the systems of medical visa (often one year valid) or long-stay visa (often 10 years). As care service recipients often need to stay long in the facilities, one-year visas or even 10 years visas are inconvenient to care service recipients. As the families live in distance, they cannot help the care recipients in the application for the extension. The revision of the present visa system is needed.
The families of care service recipients want to inquire after the parents dwelling in the care service facilities. If they are foreigners, they need the visas in many cases. At present, the tedious procedures are required to get the visas in some cases. The revision of visa systems is needed. Information technology enables care service recipients in care service facilities to frequently communicate with the families, the old friends or the home doctors in hometowns or home countries. Through these technical devices, the doctors in the care service facilities can communicate or consult with the home doctors, who know the histories of the past diseases of care service recipients.

Difficult environments of care service providers
The working environments of care service providers are not easy in welfare service systems in general and in international care service systems in particular. In general, welfare service providers are severely required to be responsible to the health of care service recipients. Particularly in international care service systems, intercultural conflicts cause their psychological stresses. This makes the personnel management difficult. In solving these problems, learning the successful experiences of Japanese personnel management for quality may be useful.

Language barrier
The language barriers are serious. Although English is more widely spoken than other languages, there is no universally spoken language at present in the world. This is particularly so in international care service facilities, where many care service recipients are old and hard of hearing. Some of them even suffer from dementia. Teaching English to them is often harmful and ironically causes the hostility against English speaking people.
There are serious lessons of failure in cultural and language unification. About 150 years ago, American and Japanese anthropologists and linguists considered the Ainu people as the original inhabitants of the eastern part of Japan including the area called Tokyo today. This theory led to the language education theory that the Ainu people can easily learn Japanese. Based on this theory, Japanese teachers taught the Japanese language to Ainu people and forced them to speak only Japanese. This resulted in the hostility of Ainu people against Japan. Later, Japan colonized Korea. At that time, many Japanese and western linguists considered the Korean language as the sister language of Japanese with the common root. Believing this theory, Japanese teachers taught the Japanese language to Korean people and prohibited the Korean language in classrooms. This damaged the pride of Korean people. The Japanese management of Korea failed despite the economic development of Korea under Japanese investment. Many Korean economists were pragmatic and accepted the Japanese domination, but many Korean intellectuals proudly rejected the linguistic domination of Japan over Korean. These two experiences of failure provide very serious lessons. Another lesson is that many Japanese students still do not accept foreign language (actually English) education despite the very strong pressure of English education in Japanese schools and the influences of American songs. English education in Japan is never successful. Many linguists say that Japanese language is an isolated and unique language. Many specialists in language education say that Japan is an internationally isolated country. It should not be forgot that every people is proud of the own culture including the own language.
A few of care service providers can be bilingual, but there are so many different languages in the world. The language training is useful to both care service providers and recipients, but its effectiveness is limited. Only the ethics of tolerance solves this difficult problem. Therefore, the ethical training of both sides is needed to mitigate this difficult problem.

Conflicting views of life and death in relation to religion
The ways of medical therapy is not necessarily universal but often related to national culture [42]. However, it is important in international care service activities to avoid religion-related conflicts. The tolerance of other religions is required. The history has seen so many religion-related conflicts. As religions are deeply related to geographic (climate or natural features, etc.), social (agriculture, administration systems, etc.) and others, they influence everyday life styles (cooking, drinking, family systems, etc.). The tolerance of religious difference alone does not necessarily prevent the conflicts between care service recipients. For example, Japanese are often said to be tolerant of religious difference as shown in the coexistence of different religions (Buddhism and Shinto), but they stick to the Japanese way of life. The tolerance of religious difference does not necessarily solve the conflict regarding the difference in the way of daily life.
A difficult problem in care service systems is the cultural conflict regarding the view of death. The Catholic does not allow the suicide, meanwhile many Japanese people admire the suicide for justice as the heroic and honorable act. Indeed, the esthetics of death has long been a central theme in Japanese literature. Contrary to the praise of suicide for the justice, however, many Japanese people despise the suicide for economic reasons or illness. In this aspect, many Japanese people regard the suicide of lonely elders as dishonorable. This subtle distinction in Japanese culture is often beyond the understanding among non-Japanese. In worldwide, it is controversial whether the so-called brain death is the "true" death or not, whether the transplant of organs from the dead to living persons is immoral or not, whether doctors should tell the truth to dying patients or not. In Japanese customs, doctors usually do not tell the truth to cancer patients; Japanese doctors avoid the heart transplant; Japanese rules strictly require the consent of organ donors, which indirectly prohibits the donation of organs of young children.
The style of funeral services varies from one culture to another. In some culture, the family of the dead is morally obliged to collect many guests to the funeral service and to offer them luxurious meals. In Japanese funerals, the family delivers the guests some salt and alcohol for the disinfection purpose. Certainly, salt has the disinfection effect, but many people wonder why people drink alcohol after the funeral service. Alcohol certainly kills bacteria, but drinking weakens the immunity against bacteria and viruses. In other culture, alcohol is never allowed in funeral service.
Some people consider the cremation as sanitarily desirable. If people traditionally believe that the spirit of the dead wants to go up to the sky with smoke, the cremation satisfies the will of the dead. Some people insist to bring the ashes to the homeland to bury in the family grave with the ancestors even if to distant homeland. Some people believe that the spirit of the dead wants to return to soil. In this idea, the interment is strongly desired while the cremation is cruel and dishonors the dead. Some people believe that their ancestors came from or beyond the sea and want to return the bodies into the sea. Then the water burial in the sea is desired. Sailors or navies used to practice the seawater burial. The water burial in river has the similar meaning, but many people hate it as unsanitary. In many cultures, it is regarded as being against morals and good customs not to follow the prevalent customs of funeral service.
It is almost impossible for international care service facilities to follow so much various manners of funeral services. Here again, the moral of tolerance is requested. The moral education for tolerance is needed for both care service providers and recipients. As the desired way of funeral service depends on the family, care service facilities need to tolerantly accept the wills of care service recipients and the requests of the families if possible. The style of mourning is another problem. In some culture, the family and the friends of the dead are strictly required to remember the dead for many days or even years after the death without drinking or amusement. The style of tombs or graves is also related to religion and is a serious problem. Here again, the mutual tolerance is strongly requested.
The moral of tolerance can be bred or trained within or outside the care service facilities. Care service providers, recipients and their families are expected to get accustomed to different cultures. Through these experiences, they are expected to go beyond the barriers, remove obstacles, and solve conflicts. The education or learning of other cultures, religions or customs is no easy task. In some aspects, however, the "lecture", the "seminar" or the videos of other cultures or religions attract the intellectual attentions of care service recipients and providers. In this regard, the mutual understanding and tolerance can be achievable to some extent.

Food and drinking culture
The problem of food is very serious. Medical doctors advise elders to avoid meat. The Buddhism used to strictly prohibit killing animals, and still now many Buddhists tend not to kill the livings. Islam and Jewish people avoid pork. Many people do not eat snake. Eel, a kind of fish, looks like snake but is one of the most favorite foods in Japan, where people hate snake. Many Japanese people like raw fish but did not eat raw meat until recently. Meanwhile raw meat is one of the best foods among Korean people including Korean immigrants in Japan. Islam people (Muslim) have the religious custom of fasting and are supposed not to eat on some particular days. This is a very important rule to them. Alcohol is prohibited in some religion like Muslim and is discouraged in Buddhism. Coffee used to be (and is sometimes even today) considered as a sort of "drug" like opium. Smoking is recently controlled in many countries but not in Japan, where the government needs the income from tobacco taxes.

Scheduling of events
Event scheduling is related to culture or religion. Sunday and Friday have the special meaning in some religions. Many non-Christian people do not know when the Easter Day is. Christmas Day is no religious day in non-Christian countries. In Japan, the Christmas Eve is the drinking day. In many non-Christian countries, the New Year Day is the most important holiday. Japanese people cerebrate the New Year on the 1 January in the present calendar. Meanwhile Chinese people cerebrate the New Year Day in the classic lunar calendar, according to which the New Year Day is sometimes in February or even March in the present calendar.
It depends on culture or religion whether to openly cerebrate the birthday or only within family at home. In many Christian countries, the parents bring the newborn baby to the church after the birth. The baby is given the name by the priest or according to the name day system such as in Poland and Ukraine. Therefore, the birthday and the name are important. Meanwhile, the birthday and the given name were the secret information if a heathen king came and conquered the area. Indeed, some people do not know the birthdays. Therefore, the birthday party is not necessarily acceptable in international care service facilities. In the feudal ages of Japan, the parents brought the newborn baby to the master, who gave the name to the baby. That is, the name told who was the master. Therefore, the name was the dangerous information and sometimes kept hidden if the enemy conquers and controls the area.

Room assignment
The room assignment is often required to be careful for religious reasons. Some people do not like some particular number(s). Some Christian people avoid Room No. 13 in hotels, apartment and hospital. Similarly, some Japanese people avoid Room No. 4 or No. 9. Some Japanese people avoid the rooms in northeast corner because the devil is believed to come from this direction. This must be considered in assigning the rooms to care service recipients. The landscape outside window of room is not necessarily the matter of personal taste. Many people like the landscape of waterfalls or mountains including volcanoes. However, waterfalls or volcanoes are the symbols of devil to some people. In assigning rooms to care service recipients, these "strange" claims must be considered.

Pets, robots and plants
Care service recipients feel lonely in distance from homeland and families and often want to keep pets in room to forget the loneliness. But some care service recipients dislike pets in general or particular kinds of pets. Therefore, keeping pets often causes troubles among care service recipients. Further, many facilities decline to keep pets within houses for the sanitary reason. One solution is to keep animals (goats, rabbits, chickens, etc.) outdoors. Similarly, it is useful to keep carps, turtles (the symbol of long life), etc. in pond, birds in cage, etc. But another solution is to "keep" pet-like robots. The technological advance of robotics has recently succeeded in the development of pet-like robots for relatively cheap cost. Such robots stimulate the scientific curiosity of care service recipients.
Flowers and trees can cause some troubles. Some particular plants or trees are associated with some countries and the royal families as the floral emblems: Lotus flowers with India, Thailand, Vietnam and Egypt; cherry blossoms and chrysanthemum with Japan; cedar trees with Canada; tulip with Kazakhstan, Hungary and Holland; etc. Considering this, it is needed to avoid the "biased" design of garden.

Successful aging
Homeland culture and religions heal the lonely minds of elders and lead them to the happy lives and the peaceful endings. In international environments, however, religions could cause the troubles. Fine arts and music also give people the peaceful minds. But some arts are deeply associated with religions. The sculptures attract people but they sometimes play the role of idle of particular religion, which other religions reject as the idle worship.
The nature such as landscapes and plants are basically neutral, although some landscape might be associated with devils and some plants are associated with particular cultures or countries as stated above. But the nature and the plants (and possibly animals including pet robots) are often the most successful passage to the high quality of life and peaceful ending.

Intercultural tolerance training
In international care service system, the tolerance of other cultures like religions and living customs is necessary. Fundamentally, this is a matter of moral of each person. But the managers of international care service facilities are required to train care service providers and recipients for the cultural tolerance. Giving lecture with the visual aids is necessary but not sufficient. There are some cultural tolerance programs to train diplomats, sailors, soldiers, trade persons, hotel staff, air cabin attendants. These experiences may be useful for international care service providers and recipients [43].

Bilateral care service system
It is difficult to perfectly resolve intercultural troubles. It may be recommendable that the intercultural care service system starts with the system with two or three countries. For example, it may be expected that the cultural gap between China and Southeast Asian countries can be solvable to some extent. Japan also has long had the cultural friendship with Southeast Asian countries. It may be expected to be fairly successful if Japan aids these countries to construct bilateral care service facilities for local and Japanese care service demands. After succeeding in these bilateral ones, then the program can be gradually extended to other countries in the step by step way for the multilateral ones [44].

Conclusion
This paper proposed a new type of international medical aid to construct care service facilities in developing countries for local and foreign care service recipients by training and employing the local workforce. This paper investigated the care quality management in human and technological respects. This paper discussed the difficulty to breed the moral of tolerance among the care service recipients and providers, and stressed the need of the ethics of intercultural tolerance. To overcome this difficulty, this paper proposed to start with the international care service facilities in the bilateral style between culturally friendly countries such as between East and Southeast Asian countries.