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Expat Social Determinants Report 2019: How living abroad impacts employee health and well-being

What are the social determinants of health? How does international relocation affect health and well-being? And what can employers do to help?

At Aetna International, we know it is important to understand the needs of our members — the people we serve — including their social determinants of health. Conducting research such as this helps us improve the quality and value of the health and wellness support we provide. But what are social determinants? How does relocating overseas impact the mental and physical well-being of individuals and their families? And what can employers do with this information to help ensure the health, happiness and productivity of their international employees?

Health care around the world is being reimagined. Providers, physicians and payers are collaborating in new care ecosystems where health outcomes and experiences are the focus. By understanding people’s experiences, social determinants and health journeys, we can better deliver care, support and value to those we serve.

This report focuses on the social determinants of health. It uses data from our recent Expat Health and Well-being Survey 2019 of 2,000 expats of working age to examine how social determinants vary and impact those living abroad, compared with the influences on their counterparts at home. The report delivers thought-leading insights from Aetna International doctors and experts to help organisations stay competitive and make the best decisions for the people in their care.


— Introduction
— What are social determinants?
— Key findings
— 1: Economic stability
— 2: Neighbourhood and physical environment
— 3: Education
— 4: Food/nutrition
— 5: Community and social context
— 6: Health care system
— Conclusion



Introduction: Understanding expats — Maintaining a healthy, productive international workforce

Every corner of the world is being made more accessible by the relentless rise of technology.  However, whilst many organisations now operate on a global platform, technology cannot always offer the same commercial benefits as local knowledge and personal relationships.  As a result, we continue to see a rise in global mobility, as businesses put their own employees on the ground, in geographies around the world.

At Aetna International we are privileged to join many of these people on their global journeys, supporting their health — and that of their families — as they settle into life in different cultures.   We firmly believe that healthy, happy employees, with healthy, happy families, are critical to the success of any overseas assignment.

So, what does it take to maintain a healthy workforce?  We believe that health care is personal — every individual has a unique health history, personal circumstances and health goals.  Whilst health histories, vital signs and lab results can offer a snapshot of an individual’s health, it is vital that personal circumstances are not overlooked — often referred to as ‘social determinants of health’.  This might include where an individual lives and works, what socio-economic factors impact them and which lifestyle choices they have made.

In fact, only 10 percent of a person’s health is influenced by the care he or she receives; genetics influence around 7 percent, while the remaining 83 percent is influenced by socio-economic influences and behaviours. (We explore this topic in our white paper Bespoke health promotion: How personalisation is transforming health.) To really improve people’s health, and to help them become more productive members of an international community or workforce, we must develop a greater understanding of the social determinants of health.

And, social determinants can vary drastically between domestic workers and expats. Leaving home and relocating internationally creates a unique set of social, professional, cultural and mental health pressures, and it is these expat social determinants that we explore in this report.

At Aetna International, we are very pleased to work hand-in-hand with organisations to ensure that globally mobile employees and their families receive the best possible health and wellness support.  As we understand more and more about the factors affecting healthcare, we can customise the support that every individual receives, and in turn, we can help employers maintain a happy, healthy and productive workforce, wherever they are in the world.

Richard di Benedetto
President, Aetna International



What are the social determinants of health?

From the moment we’re born, we’re influenced by our unique circumstances, and the influences continue as we grow, work and eventually die. These circumstances — called ‘the social determinants of health’ — include a range of economic, environmental and community factors. Some of these we can control (e.g., whether we use tobacco), and some we can’t (e.g., whether the local health care system is adequate). Social determinants are increasingly being used to inform and guide health, well-being and health care decisions. For employers, they affect not just the health of employees and their families, but also the viability of organisations as a whole.

But what are the social determinants, and why are they important to employers with expat workers? Regardless of setting, the social determinants fall into six broad categories: economic stability, neighbourhood and physical environment, education, food, community and social context and the health care system. But the specific factors in each category vary greatly between domestic and international settings.

Consider employment, a factor in economic stability. Broadly speaking, a greater continuum of employment conditions exists in a domestic environment, ranging from job precariousness to secure employment. International assignees and globally mobile workers generally fall into the upper end of this continuum: the gold standard of a secure, full-time, year-round, well-compensated and socially protected employment contract.1

Yet there are a host of other determinants at work. International workers who enjoy secure, well-compensated employment may also suffer from social isolation abroad due to language barriers and unfamiliar cultural norms. So social integration could become a more significant factor for these workers.

As an industry, little has been done to document these influences, which is why this report is so important. To ensure they’re nurturing resilient, productive employees and workforces, employers need to understand the distinction between the social determinants, as detailed in figures 1 and 2 below. Only then can they find the solutions to assignment failure and benefit from having a more loyal, happy, healthy, resilient and productive workforce.

Figure 1. The social determinants of health in a domestic setting

The social determinants of health in a domestic setting chart for Aetna International Expat Social Determinants Report 2019 article The social determinants of health in a domestic setting chart for Aetna International Expat Social Determinants Report 2019 article

Figure 2. The social determinants of health in an expatriate setting 

The social determinants of health in an expatriate setting for Aetna International Expat Social Determinants Report 2019 article The social determinants of health in an expatriate setting for Aetna International Expat Social Determinants Report 2019 article

Key findings

The remainder of this report explores the wide range of findings in our recent survey. Here we highlight four key findings of significant immediate benefit to employers.

Work and money

1.    Twenty-eight percent of our respondents said that wage levels had a positive impact on their well-being after their move. Other aspects of employment, however, were more detrimental. For example, 21 percent of respondents said that the new corporate culture had reduced their well-being. The corporate culture of an organisation or regional office can play a significant role in workforce well-being and productivity; for example, flexible working and good work/life balance can impact well-being positively.

Takeaway: Employers have the opportunity to adapt their culture to respond to the needs of the modern workforce to ensure the healthiest, most productive employees. The availability of some flexibility in the working day, encouraging a work/life balance and fostering a culture of diversity and inclusion are likely to resonate and more positively influence well-being than a focus on wage levels, as expat assignments tend fall into the ‘gold standard’ of employment conditions.

Health and fitness

2.    Eighty-two percent of respondents either feel that they should keep fit and healthy to improve their well-being, or actively make an effort to keep fit and healthy most of the time.

Takeaway: Employers have an interested, willing audience when it comes to introducing wellness initiatives and promoting healthier habits. They can capitalise on this enthusiasm to successfully embed health and wellness into the corporate culture. Expats, by and large, have a vested interest in ensuring their overseas assignment or relocation is a success, and it’s becoming more widely accepted that there’s a strong link between mental and physical wellness and performance at work. While it’s largely incumbent on individuals to adopt healthy behaviours, encouragement from employers can help people to feel empowered and supported to make better choices.

Settling in

3.    Forty-six percent of respondents said it took them up to six months to do things like try the local cuisine; 41 percent took up to six months to feel part of a local community. Our data also shows that expats who have been abroad for between two and five years are less likely to have achieved these first experiences at all than those whose tenure is under two years. (The fact that employees with a shorter expat tenure are more likely to have achieved expat firsts could point to the fact that the benefits of ‘living like a local’ on well-being has become more widely recognised in recent years.)

Takeaway: The sooner employers can help workers feel part of a community and achieve ‘firsts’ the better. From experiencing a local dish to making their first expat or local friend, the quicker these experiences happen, the greater the chance of an employee feeling a sense of belonging in their host country, finding a sense of normality and experiencing greater well-being in the long run. As an industry, we’ve started having the conversation about the chances of assignment success increasing the sooner people accept and adapt to local cultures and norms, but more can be done to put this wisdom into practise within organisations. Expats are more sensitised and prone to anxiety and stress by virtue of being away from their traditional support networks of friends and family back home. The employer has the potential to step in to help fill this void.

Health care tech

4.    Seventy-eight percent of respondents indicated that they are quite likely to extremely likely to use virtual (remote access) health care technology and services to access health care to maintain overall well-being. Those in the 30-49 age bracket are particularly receptive to the concept of using virtual care to keep themselves and their family well overseas, as were those with children under 18. The data also suggests that the younger age groups are more likely to be very positive to virtual health, the older age groups more likely to be broadly positive.

5.    This marks a rise of 28 percent in the number of people likely to use a virtual care service since our Pioneering Change survey in 2016, showing that attitudes to virtual health are changing — acceptance, even enthusiasm, is growing.

Takeaway: Enthusiasm for virtual health tech is significant and growing. The technology is particularly useful for expats who live far from quality care facilities and/or have demanding jobs, as it allows them to access primary care and manage chronic conditions remotely. This is a convenient, time-saving benefit for international assignees and their families. It can also help employers contain costs by helping employees keep well or get them back on their feet if they are ill. Across a population, the benefits of preventative medicine and access to quality care can help to reduce the health-related risks workers face.

Read on to discover other insights into how understanding expat social determinants of health that can help inspire change at the organisational level and create more resilient, healthy, happy, productive workforces around the world.

Colleagues meeting over coffee at a cafe table Colleagues meeting over coffee at a cafe table

Economic stability

Employment • Income • Corporate culture • Job pressure

Aspects of economic stability are an important and powerful driver of health and well-being. It is not hard to see how money troubles such as debt or unemployment might impact mental health — or even physical health if care, treatment and/or medications are interrupted. Even stress relating to job security can have a negative effect. Taken together, these problems can have a knock-on effect on productivity as individuals become distracted or preoccupied at work (‘presenteeism’) or miss work frequently or for long periods of time.

These stressors can be amplified by international relocation and living outside one’s country of origin, away from traditional support networks of friends and family. Expats are often stepping into the unknown, with cost of living, changing household bills and a potentially different health care system all weighing heavily. The high rate of international assignment failure is testament to this.

The data

  • We asked our respondents about the impact of various aspects of working in a new country. Here is what they said:
  • 59 percent said the new language was a challenge, though only 9 percent of these said it had an impact on their well-being
  • 56 percent said new ways of working were a challenge, with 23 percent of these saying it had a significant impact on their overall well-being
  • 50 percent said their new job was a challenge, with 19 percent saying it had a significant impact on their overall well-being
  • 28 percent said their new salary improved their well-being
  • 21 percent said corporate culture negatively impacted their well-being
  • Other factors, including working practises, discrimination, HR support, and employee rights, all impacted well-being more negatively than positively

Expert insight


Dr Stella George says, ‘Whatever impacts the local economy of the country in which an expat lives will ultimately impact that individual in some way‘.

Where the cost of living is much lower, many people suddenly have access to household help that they didn’t have before, such as drivers and nannies. As Dr Lori Stetz explains, ‘It can make life run more smoothly’.

‘The cost of living can often surprise people,’ says Dr Mitesh Patel. ‘For example, if you’re from the U.S., and you’re off to Angola, you might initially think, “I can take a fantastic salary and have a great standard of living there”. But Angola is phenomenally expensive for expats. A gallon of milk might cost you $USD10. The cost of an apartment for an expat might cost a lot more than it does for a local’. He adds that employers should at a bare minimum offer a basic fact sheet to their international workers.

Dr George describes meeting a staff member from a not-for-profit who explained that people often think of expats on assignment as being more well off than locals. ‘She pointed out that there are some assignments where conditions are very tough for expats,’ says Dr George. ‘Even getting their next meal or determining where they’ll be sleeping might be through an arrangement with a local family. Accommodation might be a sofa in a host’s house’.


Dr Stella George explains that, on a micro level, an individual can feel intense pressure from earning a promotion and/or performing for a boss and family to maintain their job and lifestyle. This pressure compounds other challenges.

‘In spite of these challenges, the individual has to keep the job going, no matter what might be going on in their personal life’, she says. ‘This can be even worse for those with health conditions’.

Certain career pressures can mean that health and family often come second.

The unknown

Relocation can involve many unknowns and, consequently, much unpredictability. ‘Most people know what to expect next year – for example, rent, childcare, household expenses,’ explains Dr Lori Stetz. ‘But, when you move abroad, everything becomes unscripted’. Expats may not know how tax differences and other factors may impact their income, and this can skew cost of living and lifestyle. ‘And,’ she continues, ‘if the move doesn’t work out and you have to go home, will your job still be there?’

The unknown is a stressor, and the consequences of unknowns can also be a stressor.

The role of employer

Employers can benefit from providing education for their employees, whether outsourced or in-house. ‘It’s important to set employees off on the right foot’, says Dr Lori Stetz. After the move, there is also an ongoing employer role with support and guidance. This helps international employees build and maintain healthy and happy lifestyles, which, adds Dr Lori Stetz, ‘can help make their assignment a success’.

Advice for employers

While money has the power to boost people’s well-being, money worries — such as debt — have the power to drive stress. Understanding the impact of finances on employees’ well-being can help employers manage that impact with appropriate support. Employers can adapt their on-boarding and foreign assignment processes to respond to the needs of the modern workforce to ensure the healthiest, most productive employees.

1.    It is important for employers to check the cost of living in the new country and provide advice or guidance to employees on assignment. Even a higher salary may result in a lower quality of life in the new country if the cost of living there is high, and this can put undue pressure on individuals and families, potentially resulting in assignment failure.

2.    Comprehensive induction and continued support for employees as they settle into their new job is essential to mitigate the risk of challenges impacting well-being while fostering a healthy, productive working environment that breeds employee loyalty and retention. A good on-boarding process to explain the corporate culture and integrate individuals is therefore important.

3.    Preparing international assignees for cultural differences can be more important than preparing them for changes in corporate culture. They need to know what to expect, where to turn for advice and help in a non-medical or medical capacity and what they should understand about the culture into which they are hoping to integrate. All these aspects form part of a robust pre-trip planning strategy.

4.    Related to the above is the fact that it is just as important for the health benefits partner or employer to have a good understanding of the cultural beliefs and traits of the employees themselves. What’s important to them? How do they conduct themselves and how do they expect to be treated? What cultural etiquette must those who make up their support network appreciate and respect? Having a full appreciation of the cultural identity of an employee can inform the quality and efficacy of the support an employer and health services providers can offer.

How we can help:

  • Comprehensive destination information

From local culture and business etiquette, to finding a home, making sure you can access the health care support you may need, and much more, our Destination Guides help members on their way.

  • Cultural reports and assessments

We can provide eligible employees with personalised city security briefs, country intelligence reports and cultural guidance on a destination country, including business etiquette and how to greet associates, and local customs.

  • Work/life balance and ‘life administration’

Members have access to confidential counselling, lifestyle coaches, and help finding support for everyday work-life balance and life admin solutions — from financial or legal concerns to help finding local childcare providers.

To find out more about our services and support, contact one of our expert sales consultants. Customers can liaise with their dedicated account manager for more information.

Family enjoying a walk through a tree-lined neighborhood Family enjoying a walk through a tree-lined neighborhood

Neighbourhood and physical environment

Housing • Safety • Parks • Playgrounds • Walkability • Geography • Climate • Transportation

Environment is a key factor in determining health and can have a big impact on well-being. The safety of a neighbourhood is of primary concern and not only has the power to cause stress but to cause direct harm, whether through pollution or crime. Another aspect is access to outdoor spaces and proximity to amenities — especially schools for those with children. Climate is also often cited as a driver of mental well-being and mood.

The challenge for those relocating internationally is to understand the nature of specific areas (towns, cities and rural areas in the new country) and how that might affect personal safety, amenities, weather and access to health care. Failing to assess these factors correctly may leave expats and their families living in areas with reduced well-being and increased stress, danger or other risks.

The data

  • 68 percent said finding accommodation was a challenge
    • Of these, 39 percent said it impacted their well-being (both ‘significant’ and ‘limited’).
  • 10 percent said climate improved their well-being, while 19 percent said it had a negative affect
  • 82 percent of expats are not concerned about civil war, unrest or political upheaval, while 18 percent are worried about these threats
    • Of these, 4 percent are very worried
  • Of those who are glad they’re living abroad, only 14 percent are concerned about civil war, unrest or political either a lot or a little
  • Of those who wish they were living at home, 41 percent are concerned about civil war, unrest or political upheaval either a lot or a little.

Our 2018 Expat Experiences Survey also gathered advice from expats, a common these being that they wished they’d known more about the local area.

Expert insight

Safety, security and culture

Various countries can offer very different environments for expats. Dr Mitesh Patel describes the example of moving to Saudi Arabia, where many expats live in compounds that provide safety and security. ‘In Saudi Arabia the rules inside the compound may be less restrictive than outside’, he says.

Dr Patel adds that Europe can be a completely different scenario because the expat community structure is different. As such, it is important for expats to take their own culture into consideration when moving abroad. ‘This often boils down to security’, he says.

Safety and security implications can have a big impact on an expat’s life. For example, Dr Lori Stetz says, ‘If you’re used to going for a walk outside after dinner where you’re from, suddenly you might not be able to do that anymore’.

Advice for employers

1.    Employers can support employees to ensure they make the best decisions about where to live as well as help to organise accommodation by providing advice or even on-the-ground support from relevant organisations. As such, employers can mitigate the risk of relocation having a significant impact on well-being — which it did for 14 percent of those who found accommodation a challenge.

2.    Employers should encourage those being sent on assignment to visit the country before they relocate to gauge the climate and how they might feel living there. They can also provide advice on how to cope with the new climate, whether that means taking warmer clothing or finding accommodation with air-conditioning. Getting a glimpse of how (and how much) workers may need to adapt their lifestyles to a new climate, culture and working environment can lessen the culture shock when the assignment begins. A visit provides an opportunity for the individual to think realistically about whether the move is really going to work.

3.    An inability to settle children is a significant threat to assignment success, so the whole family should be a focus for employers — not just the employee. This can include family health care plans, schools advice and accommodation and amenities advice. Creating a robust relocation guide and offering support for employees could save employers time and money in the long-run.

There are number of things employees can do to contain costs and maintain a duty of care for those on assignment and local hires alike, including understanding how and where they prefer to seek treatment and building up a picture of the health of the workforce and which conditions might lead to the need for specialist care abroad. With this information in hand, employers will be able to build the right mix of benefits and manage costs.

How we can help:

  • Cultural reports and assessments

We can provide eligible employees with personalised city security briefs, country intelligence reports and cultural guidance on a destination country, including business etiquette and how to greet associates, and local customs.

  • Work/life balance and ‘life administration’

Members have access to confidential counselling, lifestyle coaches, and help finding support for everyday work-life balance and life admin solutions — from financial or legal concerns to help finding local childcare providers.

  • A smooth transition

Pre-trip planning assesses the member’s lifestyle and health care requirements and those of eligible family members. This ensures that immediate needs are met, such as a continuation of medication and treatment, and potential future needs are anticipated. The service also provides:

  • An understanding of the health care system in the new country
  • Help shipping medication
  • Medical support for chronic conditions
  • Help accessing well-being programmes in the new country

To find out more about our services and support, contact one of our expert sales consultants. Customers can liaise with their dedicated account manager for more information.

Multi-ethnic group of children posing for a photo and smiling Multi-ethnic group of children posing for a photo and smiling


Language • Quality of education

Education is a social determinant of health because it is a gauge of how much someone knows about what it means to have a healthy lifestyle and how to go about building one. While most people know that junk food is bad for you and that they should exercise, many don’t know how to create a balanced diet or how much exercise they need — or smart ways of getting that exercise without gyms or organised sports.

In an expat context, language can play a key role in the quality and level of the health care and well-being advice that an individual is able to access — from not being able to book doctor’s appointments to not understanding diagnoses, medical advice or medication directions. As Dr Lori Stetz states, ‘By and large, expats are more educated than average, but the challenges in the new country are higher than average’.

As our doctors explain below, education can often clash with cultural teaching, restrictions, taboos and manners.

Another factor is access to education for expat children, which can be a challenge in many locations. While international schools exist in many global cities, they can be expensive. In rural areas education in the home language may be limited, as our data suggests.

The data

  • 59 percent said the new language was a challenge
    • but it did not impact the well-being of many (2% ‘significant impact’, and 7% ‘limited impact’)
  • 39 percent said education for their children in the new country had a positive impact on well-being, while 4 percent said the move had negatively impacted education for their children

Expert insight

Culture and education

‘The place of one’s upbringing shapes so much of their life,’ says Dr Stella George. ‘Whether and how you’re educated has an impact on employment and standards of living.

‘This can bring challenges to certain medical advice. When it comes to dietary advice for anaemic patients, certain food items might not permissible, and this leads to complications which could be avoided.  There are also cultural beliefs around inoculations’.

She continues, ‘For our inbound members into United States, when we look at the Technology sector, we find higher rate of pre-term labour needing NICU admission compared to other business sectors. The female employees or spouses are highly educated, but due to factors such as social isolation often do not seek care in the first trimester. This is the crucial time to be engaged with the local doctor and the health care system. They will rely on advice from family back home and get engaged later in their care. In the U.S. this particular vulnerability can lead to higher maternal morbidity, preterm labour and neonatal intensive care’.

Children and education

In some countries, children as young as five are being taught yoga and mindfulness. ‘Once it’s ingrained, this will set foundations for how they adapt to life growing up’, says Dr Mitesh Patel. ‘It’s much easier to change behaviours at a young age.’

Advice for employers

1.    Employers can aid settling in by offering language lessons. There are apps that exist to aid conversational language use and to translate spoken words into a voice or written message. While these may not teach the language, they will help individuals communicate with locals and even build important friendships.

2.    International relocation can also offer opportunities for employees to train, improve their skills and/or achieve qualifications which can increase their sense of job satisfaction and loyalty. This can give a good return on investment for employers.

3.    For advice on settling children, finding the right school, understanding the fee structure and quality of education, and understanding how the application process works, see the section on ‘neighbourhood and physical environment’.

How we can help:

  • Security threat analysis

Members with eligible plans have access to intelligence reports on safety and security threats worldwide. Members can access global and regional country intelligence and travel safety briefs via an app, 24/7 travel assistance phone line, SMS alerts and email bulletins and email.

  • Everyday incident support

To help members cope with mishaps or incidents, such as a lost or stolen passport, support services are available to help resolve problems quickly and efficiently — putting the member’s plans back on track.

  • International rescue

Thanks to a network of more than 400 security specialists worldwide, we have experts that can help eligible members with: kidnap and hostage negotiation; terrorist attacks; war zone evacuation; political and civil unrest; and natural disasters.

To find out more about our services and support, contact one of our expert sales consultants. Customers can liaise with their dedicated account manager for more information. 

Woman eating appetizers at a diner Woman eating appetizers at a diner


Quality of food • Access to healthy options • Nutrition and food education

Food is obviously a key driver of health outcomes, from the quality and choice of foods to the amount. Nutrition and diet can affect many aspects of our general health and well-being, from energy levels to specific conditions such as diabetes. Nutrition can be linked to income and money issues, with financial constraints leading to reduced access to healthy foods. It can be linked to education, since some people don’t know how to build a healthy diet. It can also be associated with stress, with many people deprioritising healthy eating or even stress-eating or self-starving.

In an expat context food can be one of the hardest areas to tackle. New countries may have completely alien foods (especially in rural areas). Expats must learn what foods are nutritious and which should only be had in moderation, which of them they like to eat, where to get them, how they fit into their budget and how to prepare them.

Many government ministries have their own guidance on healthy eating for citizens. For example, Japan’s ‘spinning top’ model lists types of food, defines recommended amounts of the various types and includes guidance on snacks, exercise and water intake. The guide reflects Japan’s high life expectancy which is, in part, put down to their diet of heart-healthy fish (which are rich in omega-3 fatty acids), tofu, seaweed and octopus — all of which carry a low risk for some cancers and arteriosclerosis. 

Those with allergies or other conditions face special challenges when encountering new foods. For example, many Thai dishes contain comparatively large amounts of sugar compared to western savoury courses.

With the other pressures and logistics of moving — from visas and flights to accommodation and childcare — working out what and how you are going to feed your family and create healthy meals that they like to eat can be a challenging undertaking.

On the other hand, as our data shows, many expats’ diets are positively impacted by the move — often giving increased access to healthier, better quality food – so the news isn’t all bad.

Another key aspect of building a healthy lifestyle is exercise. Many people find making time for exercise a challenge, and those living in unfamiliar countries, often with high-pressure jobs, can find it harder still. Is there access to outdoor spaces? Are there affordable gyms or other facilities nearby? Does the climate impact one’s ability to go for a run? As the data shows, wearables such as Fitbits can play a larger role in helping expats maintain a healthy lifestyle.

Most people have good intentions towards diet, fitness and mental health. How well they stick to those intentions can impact choices about sleep, smoking and other habits that affect the well-being of individuals and families.

The data

  • 82 percent of expats either feel they should make a conscious effort to stay fit and healthy, or make an effort at least some of the time
  • 55 percent of expats said they try to stay healthy, while 18 percent of expats make no effort to stay fit and healthy and are happy with that.
  • 40 percent of expats have a wearable such as a Fitbit
    • Of these, 70 percent would be happy to use the data it gathers to help insurers and medical professionals
  • 86 percent said their wearables are equally or more useful for fitness tracking having moved abroad
  • 24 percent of expats said that food quality was positively impacted by their move, while only 5 percent said that it was negatively impacted
  • 15 percent of expats said that healthy food options were positively impacted, while 10 percent said they were negatively impacted
  • 46 percent of expats said it took between 2-6 months to try a local dish

Advice for employers

1.    Many businesses offer gym membership as part of corporate benefits, which can yield great results for both employer and employee. For those on assignment, it is important to research local facilities ahead of the move — whether gyms or specific sports facilities such as pools — as this may influence accommodation choices. Where choices are limited, contingency planning is powerful in setting up healthy lifestyles as part of the new routine.

2.    Employers can work with health care partners to help their employees build healthy lifestyles including dietary and nutritional guidance for new locations. A great idea is to send individuals or families on local cookery courses — which is also a great way to meet people.

3.    Employers have an interested, willing audience when it comes to improving personal health and wellness. Businesses can capitalise on this enthusiasm to successfully embed health and wellness into the corporate culture by introducing wellness initiatives and promoting healthier habits.

How we can help:

  • Cultural assessments

We can provide eligible employees with country intelligence reports and cultural guidance on a destination country, including business etiquette and how to greet associates.

  • Work/life balance and ‘life administration’

Members have access to confidential counselling, lifestyle coaches, and help finding support finding solutions to everyday challenges — from financial or legal concerns to help finding local language lessons.

  • Comprehensive destination information

From local culture and business etiquette, to finding a home, making sure you can access the health care support you may need, and much more, our Destination Guides help members on their way.

To find out more about our services and support, contact one of our expert sales consultants. Customers can liaise with their dedicated account manager for more information. 

Friends enjoying meal preparation together in a kitchen Friends enjoying meal preparation together in a kitchen

Community and Social Context

Social integration • Support systems • Community engagement • Discrimination • Stress

Another big influence on health is the impact of people. As social creatures, humans can thrive when they are part of a community and are supported by others. From logistics such as childcare to emotional support in times of stress or personal crisis, having a support network of friends, family and even governmental or other organisations can help workers avoid events taking a toll on their health and well-being.

This is a particular challenge for expats, whether solo or with partners and families.

If solo expats fail to meet locals or other expats and join a community, they can become isolated, and that can trigger mental health issues such as depression. Those with families often feel the challenges of raising children without family members available to help with tasks such as childcare. Even couples without children can feel an increased pressure to provide more within their relationship if both fail to build a life outside it.

If support networks and community engagement are not built early on, assignments can end in failure as stress, depression and other issues take their toll.

Also, within this social category is the impact of discrimination — which has obvious detrimental effects on mental health and ability to settle into a new home. This is particularly true when biases exist in the host country that don’t exist back home.

The data

  • 64 percent said finding friends was a challenge
    • 43 percent said finding friends had an impact on well-being, with 12 percent of these saying it was significant
  • 44 percent of expats took 2-6 months to make their first expat friend
  • 42 percent of expats took 2-6 months to make their first foreign friend
    • 10 percent took longer than a year
  • Women are more likely to feel a negative impact from the challenge of making new friends (48 percent vs 40 percent of men) and (to a lesser extent) finding a new community (26 percent vs 23 percent of men)
  • 63 percent said finding a community is a challenge
    • 24 percent of expats said it took 2-6 months to feel part of the community
    • 41 percent of expats said it took 7-12 months to feel part of the community
    • 9 percent said it took longer than a year
  • 25 percent of women said that gender was a barrier to settling in, while 9 percent of both sexes said ethnicity was.
Barriers to settling in a host country graphic for Aetna International Expat Social Determinants Report 2019 article Barriers to settling in a host country graphic for Aetna International Expat Social Determinants Report 2019 article

Expert insight

Connected tech

Dr Lori Stetz is keen to point out that technology has helped people stay connected with those back home while ‘they build bridges with their new local community’. And, she says, ‘we should take a moment to celebrate this’.

Long-term vs short-term

The length of assignment is relevant. Those on short assignments might be happy not to make local connections, and as Dr Stella George explains, they may not want to make the effort or attempt to connect. On the other hand, expats who attempt to integrate and be more like a local often get out and about more and end up loving it.

Advice for employers

1.    Social integration and having a support network are essential to maintaining good mental health and avoiding stress and depression. But finding a community can be a slow process and people are at their most isolated when they need community the most. Employers can support and promote integration with corporate social events and check in on progress with monthly catch-ups to identify any problems as they develop and provide support and guidance where necessary. Another powerful initiative is the ‘buddy system’ — pairing new arrivals with more settled expats. Having a lively, welcoming and inclusive corporate culture with a social calendar can prove a worthwhile investment because the sooner expats can experience and normalise local life, the greater the chance they have of feeling a sense of belonging in their host country and experiencing greater well-being in the long run.

2.    Work-related factors have the power to affect well-being, but there a number of tactics employers can employ to mitigate this risk.

3.    To tackle stress, many employers provide support such as regular mental health check-ins. Dr Lori Stetz suggests employers check in after two to three months and again after nine months. In addition, some employers implement support networks in and/or out of the workplace to reduce stress, as well as proactively tackle issues before they threaten assignment success.

4.    Employers can also aid social integration by encouraging or supporting community events or initiatives within organisations, as well as helping people stay in touch with friends and family at home.

How we can help

  • Condition management and lifestyle education

Rated 4 out of 5 by human resource managers, we run a series of monthly group coaching wellness webinars available to employers and members with an Americas plan. The programme is designed to provide members with useful clinical and lifestyle information to help them manage their conditions and achieve their wellness goals. Group coaching wellness webinars are available at no additional cost to customers on Americas-based plans. 

  • In-office health and wellness programmes

People often need support when it comes to achieving their health goals and making good lifestyle choices. We’re here to partner with our customers where we can to help them embed health and wellness into corporate culture for the benefit of their employees. Read about this initiative, which helped a customer’s employees achieve their weight loss, cholesterol and blood sugar management goals.

  • Mental health and well-being support

Members have access to confidential counselling, lifestyle coaches, and help finding support for everyday work-life balance and life admin solutions — from financial or legal concerns to help finding local childcare providers.

  • ‘Fit for Duty’ health and wellness information for employers and workers

We have reviewed research, talked with experts and brought together the latest thinking to help our customers set up their in-house health and wellness initiatives, and employees embrace fitness as part of their everyday life. Find out more about the corporate health and wellness content designed to help employers drive health care costs down and workforce health, happiness and productivity up.

To find out more about our services and support, contact one of our expert sales consultants. Customers can liaise with their dedicated account manager for more information.

Asian doctor explaining diagnosis to senior Asian patient Asian doctor explaining diagnosis to senior Asian patient

Health care system

Health coverage • Quality of care • Access to care • Provider availability • Provider language and cultural competency

Only 10 percent of the impact on health and life expectancy is determined by the care individuals receive from health care providers. (This may be different for those with chronic or ongoing conditions, for whom health care plays an important and frequent role in helping them stay well.) Even so, many expats have particular challenges with health care when relocating.

What is the health care system in their new home? Is there good access to services? And is it of a comparable quality to their home country? If not, how will they access quality care?

All of these questions must be researched and answered, but, as Dr Mitesh Patel indicates, health care is often an afterthought for expats — especially those who are healthy and don’t need ongoing care or treatment. Even those with specific medications often fail to check availability — even legality — of their drugs in their new home, which can lead to complications ranging from no access or poor quality off-brand replacements to legal problems.

While some expats find the health care in their new home an improvement on that of their home country, many find themselves with reduced access and quality. Increasingly, technology such as virtual health is helping to connect people to care — especially primary care, GPs or family doctors. Software such as Aetna International’s vHealth can help those with busy schedules or large distances to clinicians get the attention they need through their phone or computer. It is unsurprising that expats are so positive about this connected technology.

The data

  • 56 percent of expats have a private health insurance plan
    • Of them, 69 percent have insurance through work or as part of a family member’s plan, while 21 percent pay for their own individual plan (10 percent have both)
  • 48 percent of women have health insurance, while 60 percent of men do
  • 21 percent of expats have travelled for treatment outside their host country
  • The majority of expats said they would be likely or highly likely to use virtual health care services
    • Younger age groups (30-49) are more likely to use virtual health than older ages groups (50+)
    • Those with children were more likely to use virtual health than those without.

Expert insight

Cultural familiarity

There is often an issue with cultural familiarity when it comes to perceptions of health care quality in a country. Dr Stella George describes a hypothetical: ‘Imagine a U.S. expat going to an Asian country. At first, they might be uncertain about how to access quality care locally, but once they have, the health outcome would be excellent — with millions of cases treated successfully every year. But U.S. expats often want familiarity and seek out American doctors and American structures. Similarly, [as someone with an Asian cultural background], where there’s a choice of primary care physician, I might choose someone with an Indian name. The American doctor might miss the cultural relevance and history.’

Employer advice


As a social determinant, it is essential to choose a health care plan that suits the needs to the individual in their location. First, employers need to assess the needs of the employee: do they have any chronic conditions, or do social determinants and medical history point to other potential needs? What is the quality of care at the destination and will the employee be able to access quality care? While those working in cities usually have access, expats in remote locations or developing countries may not have that access — especially in emergencies. Does the plan suit the person and the location?


International Private Medical Insurance (IPMI) provides an important safety net, with many providers — such as Aetna International — ensuring access to quality care for those with otherwise limited access to quality doctors, facilities or medications.


Many health care companies can also help with cultural competency by providing information on language, local food and cultural background. It can also be valuable to assess the individual’s attitudes to other cultures and abilities to get on and integrate with other people.


Our data shows that most expats are keen to stay fit and healthy, with 25 percent wanting to do more. Forty percent have wearables such as Fitbits, and 70 percent would happily work with health care providers to improve their health. Employers can leverage this willing audience with group coaching and other initiatives.


Expats’ attitudes to virtual health are also very positive. With improved accessibility, connectedness and potential for cost savings, virtual health can play a huge role in supporting expats — especially those in remote locations or with chronic conditions, anxiety or depression.

How we can help:

  • Navigating the local health system

From understanding which medications employees can take into their destination country and if they can get prescription refills locally, or for help finding a suitable physician, we provide members with a pre-trip planning service. This includes providing information about the health care system in the destination country.

  • The right care, in the right place at the right time

Aetna International's Care and Response Excellence (CARE) team is ultimately responsible for ensuring our members receive high quality health care solutions wherever they are in the world. If an Aetna International member needs help, their treating physician will send referrals and requests for treatment through to the CARE team. The team is also on hand to provide support to members at risk of developing a chronic condition, help with lifestyle coaching, pre-trip planning guidance and second opinions on proposed treatment plans. In addition, in the event of an accident or emergency, the team helps to ensure members receive the right treatment, in the right location to support the best health outcomes.

  • Virtual access to health care

We have developed vHealth, an app that enables users to consult a doctor virtually by phone or computer at any time of the day or night, and from anywhere in the world. The convenient service makes it easy to access personal, affordable, high quality health care. Click here to view a short video about Aetna International’s vHealth service.

To find out more about our services and support, contact one of our expert sales consultants. Customers can liaise with their dedicated account manager for more information.


A broad range of factors impact our health and well-being — not just diet or fitness, not just mental health, not just access to quality health care. As expats move to new countries, they face particular challenges around many of the social determinants, as discussed above, and many of these can impact their well-being, potentially endangering assignment success. Expats and the globally mobile need tailored — often region-specific — strategies and support to ensure they stay happy, healthy and productive for the duration of their stay.

While the right benefits providers and employers can offer effective health and wellness benefits to employees, unless there’s a commitment to embedding those solutions into the corporate agenda and culture and providing employees with the right support, employers won’t benefit as much as they could. True partnership with an expert health and wellness partner matched by a conscious effort to drive change and healthy behaviours throughout an organisation will help result in the best outcome for employees and the employer. By creating processes and/or partnering with organisations who can help you ensure success for your international employees, you are fulfilling your duty of care as an employer as well as maximising the productivity of your teams.

Learn more about social determinants of health in our in our Fit For Duty podcast episode below.

Read the results of the Expat Health and Well-being Survey 2019 here

At Aetna, we believe in the power of partnerships. Speak to one of our experts about how we can help you support your international employees.

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