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Expat Family Wellness Survey 2020

Expat Family Wellness Survey 2020: The Impact of COVID-19

The COVID-19 pandemic has brought about many challenges for individuals and families. For those living abroad, away from friends and family, these challenges can have an even bigger impact. We know from our previous whitepaper, Expatriate mental health: Breaking the silence and ending the stigma, that expats are more susceptible to mental health issues than those living nationally.

We surveyed 1,000 expats in the UK, US, Singapore and UAE, to learn more about the unique challenges facing expat families during the pandemic. From anxiety around medical appointments to accessing health care in their host country, this report reveals our findings and offers suggestions for how expats can protect their physical and mental health, and that of their loved ones.

Key findings

  • Expats are neglecting their medical health amidst COVID-19 crisis
  • One third of expats have fears around accessing health services due to COVID-19 pandemic
  • 82% of expats developed healthier habits during COVID-19 crisis
  • Most expat children felt worried, lonely and anxious during lockdown
  • Almost half of expats rethink living abroad to access better health care
  • 78.3% of expats said they had sleep problems during the pandemic
  • A quarter of expats took out new health insurance plans to cover family members amidst coronavirus

Mixed feelings: medical appointments and COVID-19

Social distancing is a common restriction enforced by governments across the globe in response to the pandemic. We have been told to protect ourselves and others by self-isolating when sick and keeping public trips to a minimum. But how have these rules affected attendance at medical appointments?

Reduced attendance

Most participants in our survey agreed that they prefer not to attend a medical appointment but will if it is necessary. However, 20% said they will not go to a routine check up or doctor's appointment during the pandemic, and 13.4% said they wouldn’t attend a hospital appointment.

Reduced attendance is likely to have a knock-on effect on non-communicable diseases, such as diabetes, heart disease, cancer, etc. In a report published in September 2020, the World Health Organization (WHO) found that just under 75% of countries (out of 164) reported disruptions to services for non-communicable diseases due to the pandemic. The main reason (65%) for this was a “decrease in inpatient volume due to cancellation of elective care”; 25% of countries reported a “decrease in outpatient volume due to patients not presenting.”

Our survey also revealed that 1 in 10 expats will not go to hospital for a medical emergency during the pandemic — a finding that is in keeping with data being published elsewhere. Dr Hemal Desai, Senior Medical Director, Aetna International, highlighted in an article on the indirect impact of COVID-19 that in the US, emergency visits reduced by 23% for heart attacks and 20% for stroke in the 10 weeks following the emergency declaration compared with the preceding 10-week period. And in the UK, deaths from heart and circulatory diseases (in under 65s) were 13% higher than usual between May and July 2020. The British Heart Foundation attributes this, in part, to people putting off seeking treatment.

Expats are worried and anxious

Of our respondents that already attended an appointment during the pandemic, either for themselves or a family member, 53.5% admitted to feeling ‘worried’ and 36.2% said they were ‘anxious’. The next answer chosen most often was ‘confident’ — while positive, far fewer people selected this answer (26.6%) and a similar number said they were ‘scared’ (25.9%).

Aetna Expat Family Survey Graphic: How did you feel about going to the doctor/hospital during the pandemic top 5 answers Aetna Expat Family Survey Graphic: How did you feel about going to the doctor/hospital during the pandemic top 5 answers


Split by country, we can see that expats in UAE and Singapore are more cautious about visiting medical facilities during the pandemic than in the UK and U.S. In the UAE and Singapore, the top three answers were all negative: worried, anxious, scared. In contrast, 31% of respondents in the U.S. reported that they felt ‘confident’ about attending appointments, more than in any other country.

Overcoming the challenge

To reduce the impact of COVID-19 on routine appointments and early intervention programmes, many health care providers have adopted telemedicine (appointments via phone, mobile or online). This reduces the need for physical proximity to clinical professionals without disrupting patient care. WHO notes that 58% of the countries covered in their report are now using telemedicine to replace in-person consultations, although utilisation drops to 40% in low-income countries.

These services are especially important for expats, who may not be familiar with the care systems in their country of residence. Expats have been early adopters of using technology to improve health care services. In our 2016 research Pioneering Change: Understanding Health & Healthcare for Globally Mobile & High Net Worth Local Populations, we found that:

  • 52% of expats think future health services will be dominated by virtual support
  • 51% are strong supporters of wearables to support healthy living.

As a champion of telemedicine, Aetna International developed its own virtual health care service, vHealth — for which it won Best Innovative Medical Product at the Times Network Awards 2018.

Lastly, a key message is that an emergency must be treated as an emergency, regardless of the pandemic. While the anxiety around hospital attendance is understandable, the sad fact is that deaths are happening as a result. Expats in need of medical attention should not wait until it is too late to seek help.

Homesick? Expats rethink living abroad

Expats are used to being separated from loved ones — but the events of 2020 have created unique pressures and for some, have been a stark reminder of the home they have left behind. We previously learned, as part of our Expat Experiences Survey 2020, that 56.3% of expats would prefer to be in their own country during the pandemic.

This most recent survey, which was conducted about four months further into the pandemic, reveals that 59.9% of expats are rethinking the decision to live abroad due to the COVID-19 pandemic. When asked for the reasons for this, 43.9% said: to have access to better health care.

It is understandable that health care is a priority to expats at this time. With the threat of the pandemic keeping many of us inside our homes lest we catch the virus, the fear of ill health is very near and very real — it’s only natural for people to want easily accessible health services.

It is also important to note that our data shows that access to improved health care can be a persuasive reason for many expats to move abroad. Of those who agreed that health care is better in their current country of residence, 77.2% said that better health care was a deciding factor in their choice to live abroad. If these expats are doubting the care they might receive, exacerbated by the emotional pressures of COVID-19, this may be amplifying their homesickness. For example, 50% of our respondents in the U.S. said that they don’t have enough access to health services (compared to the global average of 39.8%).

iPMI and improved access to health care

With access to health care a key issue for many expats, it is unsurprising to learn that 60% of our respondents added family members to an existing insurance plan or took out new cover so their immediate relatives could be added. A further 23.2% said they have or would consider buying additional cover due to the COVID-19 pandemic.

45% of expats with health insurance in the U.S. added their family to their current health care plan due to the COVID-19 pandemic. While in the UK, 33% said that they took out new plans. These figures are higher than in the UAE and Singapore, although this is probably due to higher rates of cover in these regions, insurance being mandatory for most expats in UAE — and 45.2% of respondents from Singapore already had cover for the whole family.

While expat concerns around health care access have grown, insurance has offered many families peace of mind. As well as providing members with the insurance safety net, international private medical insurance providers, such as Aetna International, can help to improve physical and mental health by offering well-being resources such as mental health apps, fitness membership discounts and virtual health services.

Speaking in our video on virtual health and its benefits for expats, Richard di Benedetto, President, Aetna International, said: “It helps when you are an expat and you’re not familiar with the environment.

“If you are in Singapore, or in Africa, and you think that you have fever or a cough you can immediately consult with less than a half hour waiting time, a doctor through a video call. And he will see all your medical conditions and he can give you advice, or he can give you a diagnosis.”

Concerned kids: how children feel about COVID-19

For expats with families, the COVID-19 pandemic has brought additional pressures. Not only have parents had to juggle work with homeschool and childcare, they have had to explain the unprecedented situation to their children — why they can’t go to school or see their friends. As such, we wanted to understand the impact of the pandemic on the children of expats.

Our results were unsurpinging. Expat parents reported that their children feel:

  • worried (31.2%)
  • lonely (28.5%)
  • anxious (20.5%).

Older children, aged 13-17 and 18 or older, were the most worried (36.4%), anxious (24.5-27.3%) and uncertain (23-25.8%) compared to children of other ages. This may be because they have more understanding of the situation and the global impact of the pandemic. In contrast, children aged 4-6 were more likely to feel lonely (30.2%), probably due to the closure of schools and being too young to use online communication services on their own to stay in touch with friends.

Staying mindful

Feelings of worry are normal, especially during a global crisis and for children who may not fully understand why their routines have changed. Mindfulness is a useful technique for helping children to manage their emotions. There are many ways for children to practice mindfulness: for older children, listening to music and breathing exercises may help them to relax. Younger children can be encouraged to use their senses or talk about things they are thankful for. 

It is also important to know when a child’s worry becomes a concern and when a parent should seek help. In an article from Aetna.com, the two key signs of clinical anxiety, that is, when your child may need professional help, are: avoidance and extreme distress. You can learn more about this in the full article on anxiety in children.

COVID-19: a catalyst for healthier lifestyles

Physical health and diet plays a pivotal role in an individual’s ability to maintain their sense of wellness. But in our 2016 research, Pioneering Change, we learned that 51% of expats intend to be healthier but don’t get round to doing anything about it.

When we spoke to expat families in 2018 as part of our What is Wellness? Survey, we identified that expats’ focus on diet and fitness was dependent on time. One respondent said: “With family and work, something has to give. There aren’t enough hours.”

However, with lockdowns, travel restrictions and remote working policies part of the COVID-19 ‘new normal’, people have had more time to dedicate to their well-being. When we surveyed expats earlier in the year, we found that many had developed healthier lifestyles during the pandemic: almost 60% were eating more healthily and 43% were exercising more.

In this survey, our most recent research into expat wellness, 82.6% of expats reported that they have developed healthier habits during the COVID-19 crisis. Of these respondents, 69.5% said that the pandemic made them aware of their own health and 27.5% said they had been meaning to improve their health for a while.

More men than women have developed healthier habits (84.1% compared to 80.8%), with 72.7% saying this was directly related to the pandemic. It is well-known that men have a shorter life expectancy than women, which the WHO reports is partly due to “health behaviour paradigms related to masculinity and the fact that men are less likely to visit a doctor when they are ill”. Men’s current motivation to pursue healthier lifestyles is a positive trend, which could help to close this gender gap.

Aetna Expat Family Survey Graphic: Main reason for pursuing a healthier lifestyle Aetna Expat Family Survey Graphic: Main reason for pursuing a healthier lifestyle


The silver lining

For expat men and women, the growing awareness of their own health and well-being can be seen as the pandemic’s silver lining. COVID-19 has made people face their own health vulnerabilities and take action to improve this.

However, we must remember that other lifestyle changes, such as working from home and increased isolation, are likely a factor in people’s ability to make changes. When the risks from the pandemic are such that people start returning to their pre-COVID-19 routines, there is a danger of expats slipping back into bad habits. Only by embedding healthy eating and fitness into your lifestyle can these changes be sustained long-term and have a positive impact on health outcomes, especially for men.

Restless nights: sleep problems during the pandemic

There is a clear link between stress and sleep problems. In our Business of Health 2020 survey, which took place before the pandemic, 56% of employees said that they don’t get enough sleep, with work stress being a major factor. In our recent survey, we wanted to learn if the stress and uncertainty of the COVID-19 pandemic have impacted expats’ sleep.

Our results show that 4 out of 5 of our respondents have experienced sleepless nights or trouble sleeping related specifically to worries around COVID-19. 20.4% said that these issues have lasted throughout the whole of the pandemic and in the U.S., which saw a fast rise in COVID-19 cases early in the pandemic, it is even higher, at 35%.

Aetna Expat Family Survey Graphic: Have you had sleepless nights due to COVID-19 worries? Aetna Expat Family Survey Graphic: Have you had sleepless nights due to COVID-19 worries?


Respondents also noted that certain sleep problems occurred more often during the pandemic. 24.8% of all the expats we surveyed have had more nightmares than usual. Vivid dreams and night sweats have also been more common (18% and 18.8% respectively).

Considering this in a family context, parents of children 18 or older experienced the fewest sleep problems: 35.6% had no trouble getting to sleep and 50.8% had no sleep habits that they would class as ‘out of the ordinary’.

In contrast, parents of children aged up to 12 were the most affected by sleep problems — around 81% reported sleepless nights due to pandemic-related concerns. This may be related to uncertainties around schooling and balancing childcare with work — while older children can often entertain themselves, looking after younger children can be more of a challenge.

The importance of good sleep

These findings show that the COVID-19 pandemic has had a significant and lasting impact on expats’ quality of sleep. This is very concerning, as sleep deprivation is linked to poor health outcomes. For example, lack of sleep can:

  • weaken your immune system
  • increase mental health symptoms
  • make it harder to manage behaviours and emotions
  • impair your judgments.

There are plenty of ways to improve your sleep, such as avoiding caffeine after noon and turning off screens an hour before bed. However, as the sleep problems reported here are specifically related to concerns about the COVID-19 pandemic, it is also important to focus on your general well-being during the crisis by:

Take action

It’s clear from this report that the COVID-19 pandemic has had a major impact on the health and well-being of expats and their families. Here is our summary of key takeaways from our findings above:

  • Expats must seek medical attention when they need it but should consider virtual health services to address their around accessing care and attending medical appointments in person.
  • Expats using the pandemic as an opportunity to make lifestyle changes must try to balance emotional, mental and physical well-being and lifestyle changes to help make long-lasting changes and improve their health outcomes.
  • Mindfulness can be practiced to ease worries and help to protect mental health and improve sleep.
  • Expats should choose an iPMI provider that:

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