Expat Experiences Survey 2020

• Key findings
• The challenges of moving abroad
• Experiences of living abroad
• Mental health and COVID-19
• Work, lifestyle and COVID-19
• Conclusion

Executive summary

At Aetna International, we know that expat health insurance is about more than just appointments, treatment, medicines and bills. While these aspects are essential, they are not the whole picture. In fact, Aetna International is part of a revolution in health care that puts members at the centre of care, helping to keep them healthy, rather than just supporting them when they’re sick.

Just as insurance is about more than paying bills, staying healthy is about more than just physical health. That’s why our holistic view of personal health includes six dimensions of well-being, also known as social determinants of health, such as economic stability, environment, education and community, as well as access to health care and nutrition. While traditional Western medicine often looks at symptoms in isolation, we look at all of the factors that can affect a person’s health and well-being — and offer support to address each, from mental health counselling to DNA health tests.

Expats in particular, can face increased challenges with these and additional factors — such as cultural integration — which can all impact their physical and mental health.

This latest report follows the 2018 Aetna International Expat Experiences Survey, which explored the challenges of moving abroad and how much they affected health and well-being. We found that most expats thought locals perceived them as ‘important’, ‘vital and ‘rude’; that 31% of expats said they were a better person for moving away; and that saying goodbye to family and friends was the hardest part of relocation for children.

Halfway through 2020, we are in the middle of a global pandemic as COVID-19 sweeps the world. As such, these multifaceted considerations have never been more important for those living away from home.

This is the current backdrop to our ongoing commitment to understanding the ever-changing expat experience, during which we conducted a survey of 1,000 expats across six countries (UK, U.S., Singapore, China, Thailand and UAE) to examine:

• The true challenges of moving abroad
• How expats feel about their new home
• How they think they are viewed by the locals
• Expat opinions of the locals
• The impact of COVID-19 on the lives of expats.

As well as revealing insights, this report includes advice for both businesses and individuals, from ensuring access to quality care to settling into a new culture.

Key findings

• Missing home, family and friends is the biggest challenge for expats (33.1%)
• Expats feel happy (43.7%), safe (42.2%) and welcome (37.1%) while living abroad
• Expats believe they are seen by locals as friendly (53.1%)
• Expats see locals as friendly (49.4%) and welcoming (42.5%)
• More than half of expats would rather be living in their home country during the COVID-19 pandemic (56.3%)
• 32% of expats who already suffered with mental illness say that COVID-19 has seriously affected their overall well-being
• Expats have made improvements to their health and well-being during the COVID-19 pandemic
  • 60% admitted to eating more healthily
  • 27% said they are drinking less alcohol
  • 43% said they are exercising more.

The challenges of moving abroad

Moving to another country can offer new and exciting opportunities. It can also bring its share of stresses and strains, from sorting visas to finding somewhere to live. Many expats are also leaving loved ones behind as they adopt a new way of life, all of which is a big undertaking. With this in mind, we asked our respondents which aspect of moving abroad they found most difficult.

Respondents said that the biggest challenge expats face is ‘missing home, family and friends’. The answer accounted for a third of all votes (33.1%). This result was mirrored in our 2018 survey so there has been little movement in what expats see as the biggest challenge in moving abroad.

‘Climate’ and the ‘process of moving’ were seen as the least challenging aspects of moving abroad (14.6% and 12.1% of respondents, respectively). This may be because these factors are easier to prepare for and people come to terms with them early on in their decision and planning to relocate; they will know where they are going and be expecting the stresses of packing up and moving overseas. In contrast, missing home might be inevitable, but is perhaps more difficult to prepare for. Also, once you have arrived, the stresses of the moving process begin to subside, whereas missing home can start.

‘Employment’, ‘cost of living’ and ‘cultural differences’ were also highlighted as challenging aspects of moving abroad (29.7%, 28.4% and 23% respectively).

Regional differences

There are many factors that affect the ease of relocation and where you’re moving to is one of the biggest. Some expat destinations have a more cosmopolitan population, for example UAE and Singapore. However, while these places might be set up for expat life, the culture may vary greatly.

For expats living in Thailand and the U.S., ‘working’ and ‘employment’ is the most common problem: 36% and 26.4% respectively, compared to the average of 29.7%. However, while it is also almost twice as challenging than missing loved ones (19%) for Thai-based expats, for those living in the U.S., the difference between the challenges of ‘working’ and ‘employment’ on the one hand and ‘missing loved ones’ on the other is much smaller.

When compared to the other countries surveyed, ‘missing loved ones’ was selected by those living in China more often than in any other country (48% compared to the average of 33.1%). Despite this, expats based in China actually said that the most difficult aspect of moving abroad was ‘social and cultural differences’, accounting for 61% of the total responses from this group.

‘Health care’ also received a higher percentage of the total responses, compared to any other country — 32% versus 20.4% for U.S. expats.

‘Cost of living’ was named the most difficult aspect of moving abroad in both Singapore (45.3%) and UAE (44.7%). While Singapore appears 11th out of 113 countries in the Numbeo Cost of Living Index by Country 2020, the UK and the U.S. are both higher in the list than the UAE. However, UAE has a much smaller population than the UK and U.S. where cost of living varies dramatically.

Mental health

The percentage of people with mental health conditions who selected ‘missing friends and family’ as the top challenge, is smaller than for those without mental health problems — 25% versus 38.2%. In contrast, the most difficult aspect of moving abroad for people with mental health issues is more likely to be ‘financial administration, health care and housing’.

These results don’t mean that people with mental health issues miss their loved ones any less, just that having mental health issues can mean other aspects of moving abroad are more challenging. This is why it is essential to consider all aspects of your international move - to identify your personal needs and define where you need specific support.

Hindsight

An experience in our past can be remembered very differently, depending on whether it happened recently or long ago. The simple act of recalling memories has been shown to actually change the memory. For example, who you are currently talking to can influence how you remember something. Our results reflect this.

Only 34.3% of expats who have lived abroad for 4-5 years state that ‘cultural and social differences’ were the most difficult aspect of moving abroad. In contrast, only 17% of those living abroad for a year or less chose this as the biggest challenge.

Our survey also reveals that ‘missing friends and family’ peaks for expats who have been abroad for 5-10 years (46% compared to the average of 33.1%). Perhaps after this point, the allure of the ‘new’ is no longer as strong and expats feel more settled - their ‘new’ lives now the norm.

For expats who have lived abroad for 10 years or more, ‘paperwork and visas’, ‘employment’, ‘housing’ and ‘cost of living’ all rank highly on the list of challenges. For example, 38.4% of people living abroad for 10-20 years say ‘cost of living’ is the biggest challenge (compared to the average of 28.4%). 20.6% of those living abroad for 20-30 years say ‘paperwork and visas’ is the most difficult aspect, versus the average of 16.4%. Is this because the initial challenges have subsided, while some remain or emerge?

However, for those living abroad for 50 or more years, 37% said that they had no difficulties with living abroad. In fact, the longer someone lives abroad, the more likely they are to report no issues. This suggests that for some, hindsight eliminates the stressors felt early in their move — a comforting notion for those whose relocation is a more recent memory.

Homesickness and COVID-19

Our survey revealed that the most difficult aspect of moving abroad is ‘missing home, family and friends’ (33.1%) — in line with the 2018 results. But to what extent has COVID-19 affected this homesickness? To answer this question, we asked expats whether they would rather be in their home country during the pandemic.

56.3% of the respondents agreed that, if they had the option, they would prefer to be in their own country during the pandemic. This is despite the fact that physical distancing measures may prevent expats from seeing their loved ones in their home country — if they follow guidelines. Whether respondents considered this latter fact or not, it suggests expats take comfort from being in their native country, whether driven by access to friends and family or simply the drive to be in more familiar surroundings during a crisis.

Compared to the U.S., UK, China and Thailand, fewer respondents from the UAE and Singapore said that they would like to be in their home country during the pandemic. Thailand had the highest number of people who agree, at 71% (14.7% percentage points higher than the national average). This may reflect the differing expat lifestyles in different locations. UAE and Singapore tend to be employment hubs for international workers, while Thailand attracts a younger, entrepreneurial type of expat. Worldbackpackers.com, for example, names Chiang Mai as a top three city for digital nomads. It may be the case that younger entrepreneurs do not set down roots — start or take families — and therefore have less in-country support network. These individuals may be more inclined to head home in times of crises.

Experiences of living abroad

The physical move to a new country is just one part of a wider experience, one full of new cultural and social discoveries. As an expat, life will be shaped by the community you live in, your work and your family life. While all experiences are unique, there are some universal trends and general consensus particular to expats and expat life and we want to explore and  understand these. What have the positive and negative aspects of this experience been? Do expats feel like the ‘odd one out’ or warmly embraced by their host nation?

A positive experience

‘Happy’, ‘safe’ and ‘welcome’. These are the words most commonly chosen by our respondents when asked how they feel about living in their new country. In fact, these words were chosen by 37.1% to 43.7% of all respondents. The words ‘accepted’ and ‘loved’ also scored highly (35% and 27.8%). In contrast, words like ‘hostile’, ‘scared’ and ‘alienated’ are among the lowest scoring from the options (6%, 8% and 8.3% respectively).

This suggests that despite the challenges outlined in the previous section, relocating abroad is a positive experience in their new home country. Of course, there are regional differences to consider: the environment, culture and socio-political attitudes of a country has as much to do with how settled an expat feels as their work and home life.

The 2018 Aetna International Expat Experiences Survey had slightly different options, so can’t be directly compared. However, ‘hostile’ was the least common answer chosen while ‘safe’ and ‘welcome’ were the most common responses. This is in line with the 2020 results, further supporting the assertion that expatriates have a generally positive attitude regarding their relocation.

Regional differences

Breaking down the survey data regionally shows that respondents from the UAE scored ‘positive’ words more highly than respondents in other regions. For example, the word ‘safe’ was selected by 66.7% of expats in the UAE compared to the average of 42.2%. ‘Loved’ and ‘inspired’ were chosen by 35.3% and 38.7% of respondents, which are both more than 10 percentage points higher than the global average

In contrast, some regional data suggests a more negative experience. Only 30.8% of the UK respondents said they felt ‘happy’, lower than the global average of 43.7%. In contrast, 14% said they felt ‘trapped’ and 12.8% chose the word ‘isolated’, both higher than the global averages of 8.7% and 9.3% respectively.

Expats living in China chose the word ‘alienated’ more than any other region — 14% compared to 2.7% in the UAE, 6.7% in Singapore and 8.4% in the US. They also chose the word ‘accepted’ less often than their counterparts in other countries (28% versus 45.3% in the UAE and 35% global average). This data suggests that while expats in China may feel like they are a part of society, they are not as content as those in other regions.

However, in stark contrast to this, expats in China chose ‘included’ 3.5 times more than those in the UAE. This suggests that there are polarising views within the expat community in China — some who feel included, while others feel alienated.

Mental health

Expats who have suffered with a mental health issue tended to choose more negative words than those without. Of all responses given by those with poor mental health, around one third (32%) chose negative words about their experience, compared to a quarter (26%) of those with none.

We already know that moving abroad can have an impact on mental health — expats are 2.5 times more likely to face mental health challenges than those living in their home country. These results highlight that mental health can shape a person’s experience of being an expat. While this study does not prove that poor mental health causes a more negative experience, it is clear that mental health problems can play a role in feeling scared or sensing hostility in a person’s new country.

Expats versus locals

Another aspect of how expat experiences are shaped, is how they are viewed by local people. If an expat feels like a useful or revered member of society, he/she will probably settle in a lot faster than if they feel unwanted. We asked our respondents how they think the locals view them to determine general attitudes towards expatriates.

53.1% of respondents said that they believe the national population would use the word ‘friendly’ to describe them. This is followed by the words ‘helpful’ (39.4%), ‘polite’ (38.9%), ‘kind’ (35.2%) and ‘welcoming’ (33.3%) — an overall positive attitude, which mirrors respondents’ feelings about living abroad generally.

In 2018, the words ‘important’ and ‘vital’ came top of the list for the same question, followed by ‘rude’ and ‘insensitive’. This suggests that expats felt necessary, but perhaps had not integrated well. Our 2020 survey was conducted during the COVID-19 pandemic. Could this be a driver of the latest report’s more positive findings? Has the crisis brought expats and locals together under a shared experience and/or facing a mutual ‘enemy’?

Mental health

Respondents that suffer from mental health problems selected more negative words than expats without these issues. Only 63% of all the responses selected by those with poor mental health were positive compared to 81% of those who identified as mentally well.

It is clear that mental health has a massive impact on the experiences and perceptions of expats. Not only do they feel more negatively about living abroad, but they also believe they are seen more negatively by locals. While we do not know how locals really feel about the expats we surveyed, this data still highlights how essential it is to have access to quality mental health support to ensure a positive international life.

The feeling is mutual

How expats think they are perceived, is one side of the story. We also asked expats how they view the locals, and found that ‘friendly’ was also top of the list (49.4%) — a sentiment shared. Other words that scored highly include ‘welcoming’ (42.5%) and ‘kind’ (39.1%).

Comparing the responses to each question — ‘what do locals think of expats?’ and ‘what do you think of the locals?’ — shows that these mutual feelings run through all the results.

The biggest discrepancy is for the word ‘welcoming’, which received 9.2% fewer votes when asked how locals might perceive expats. That is, expats say locals are welcoming more than they think locals would say the same of them. However, it is likely that this is because the word fits more with the experience of a new person joining a community from a local’s point of view.

Regional differences

The UK and the U.S. are less likely to think that they would be seen as ‘friendly’ by local people — just 41.2% and 44% respectively, compared to the survey average of 51.1%. In contrast, as many as 78% of expats in the UAE think they’d be described by locals as ‘friendly’ — 16 percentage points more than the next highest scoring country (Singapore, 62%).

A higher proportion of respondents in the UK and the U.S. (compared to the other regions surveyed), think that locals would describe them as ‘destructive’, ‘a burden’ and ‘rude’. In fact, overall the U.S. and UK expats were generally more negative about how they think they’re perceived by the local community.

The data suggests a cultural, East/West divide, with expats feeling that local communities are less welcoming in the West. InterNation’s Ease of Settling Index 2019 puts Singapore and UAE 11th and 20th out of 64 countries. In contrast, the U.S. and UK don’t even feature in the top 30. China ranks very low at 58 and Thailand only just reached the top 30 at position 29. As such, opinions appear to be mixed — and there is also plenty of evidence of happy, settled expats in the U.S. and the UK.

In fact, our survey shows that the U.S. expats described their local counterparts as ‘important’ more than the global average (28.4% versus 23.5%). In the UAE, only 6.7% of people used the term ‘vital’, less than half the respondents in the U.S. (14%). 

Mental health and COVID-19

COVID-19 has affected the lives of billions of people around the world, and in many ways. From mass unemployment to travel restrictions, expat and local lives have been disrupted — financially, logistically and emotionally. A ‘second wave’ of the pandemic impact is expected to manifest in the form of mental health difficulties related to lockdown, anxiety and the uncertainty 2020 has brought with it.

Our recent report about technology suggests that the pandemic has created an opportunity for international employers to improve their mental health support for its workers. Employers could adopt digital technologies from mobile apps to virtual health and online counselling to improve staff health and wellness.

Read the digital health dilemma: Is technology keeping workers healthy or making them ill?

In this survey, we wanted to explore how the pandemic has affected expats’ health, lifestyle and working practices as well as their mental health.

The impact of COVID-19 on expat mental health

63.6% of expats agree that the COVID-19 pandemic has affected their mental health. This is despite the fact that only 38.8% of our respondents declared having a mental health condition. This highlights the broad-reaching and deep impact the pandemic has had.

Our World in Data reports that around one in seven people across the globe have a mental health disorder, but also state that “mental health is typically underreported, and under-diagnosed.” Indeed, our data shows that just because someone says they don’t have mental health problems, this doesn’t necessarily mean that their mental health is unaffected by the world around them.

However, our survey also reveals that those who do admit to mental health issues are more affected by COVID-19 than their fellow expats. Only 9% of those with mental health problems remain unaffected by COVID-19, while 41% of those without these issues say the same. 

Regional differences

The highest percentage of respondents saying that COVID-19 has seriously impacted their mental health are the U.S. and Thailand (28.8% and 29% respectively) — the global average is just 16.9%. Expats in Singapore and the UAE appear to be the least affected, with only 21.3% and 25.4% respectively, reporting that their mental health has been ‘impacted’ or ‘seriously impacted’.

Thailand is the most affected nation (50% of expats there report an impact on their mental health). This is interesting considering they have the lowest COVID-19 deaths per million rate (as per 9th June 2020) of the countries we surveyed at just 0.8. In contrast, the UK has a rate of 602 deaths per million — the highest from the countries in this study — yet only 37.6% said their mental health has been affected.

The feelings of expats in Thailand may be related to the fact that the country’s economy is heavily reliant on tourism. With travel being hard hit during the global crisis and many expats working in the industry, concern for job security may be driving anxiety and stress.

Challenges of isolation

The main challenge of living abroad is the main challenge of lockdown, social distancing and self-isolation. ‘Missing friends and family members’ tops the list of challenges related to the COVID-19 lockdowns (37%), closely followed by ‘boredom’ (35%) and ‘the feeling of being trapped’ (31%).

For respondents with mental health issues, ‘loneliness’ plays a big role — 30.7% noted this as a challenge, compared to 22.9% of those without a mental health problem. ‘Homesickness’ also stands out. This answer was chosen by 25% of those with a mental health issue compared to 18.6% of those without. ‘Lack of focus’ and ‘keeping up to date’ with the latest news and regulations also scored higher in the group that say they suffer from poor mental health.

While missing friends and family is the answer most often chosen by people with a mental health issue, it was selected 8.8 percentage points less than those without mental health problems. This seems to be because there is a wider spread of challenges for those with poor mental health — the three least chosen answers for this group (not including ‘other’) total 32% of all responses. In contrast, the three least chosen options for the group without mental health issues total 25% of all answers. The state of your mental health can, therefore, change your experience of a crisis.

Regional differences

Thailand was the only country not to rate ‘missing friends and family’ or ‘feeling trapped’ in the top three challenges related to COVID-19. ‘Work/life balance’ and ‘Staying up to date with news’ ranked highly, but don’t appear in the top responses for any other countries. As suggested previously, this could be due to the difference in Thailand’s expat population — one heavily involved in tourism. No matter the reason, it is important to note that expat experiences are shaped in part by cultural and environmental factors.

Work, lifestyle and COVID-19

Working from home

The impact of COVID-19 on business is well reported across the global media, and the expat community has been no less affected. Almost half the expats we surveyed (49.6%) have started to work from home since the coronavirus pandemic while a further 15.5% are no longer able to work. Surprisingly, more than a quarter (27.1%) said that they have continued to go to work as normal.

Regional differences

It’s hard to consider the impact of COVID-19 on working life for our expats on a global scale due to the differing situations and responses in each country. For example, the UAE imposed strict restrictions to public movements on 26 March, with fines in places for violations. In contrast, the U.S. has been criticised for mixed messages and a delayed lockdown response.

Our data shows that expats in the U.S. are the most likely (35.2%) to continue to go to work as normal while expats in the UAE and Singapore are the least likely (15.3% for both). However, the global media attention on the U.S. does not mean that working life for people in other countries is fine. In fact, the highest percentage of expats who are no longer able to work due to the COVID-19 pandemic live in the UAE (25.3% compared to a global average of 15.5%.

Expats in China have the lowest percentage (1%) of people no longer able to work. This may be due to the early peak of COVID-19 in the country, meaning that the timing of the survey was when the country was getting back to normal — people able to find new work or return to previous jobs while other countries are still seeing heavy lockdown restrictions.

A healthier lifestyle

While the pandemic is negatively impacting physical health directly and mental health indirectly, it seems that it is also having a positive effect on many. The data suggests that expats are taking control of their health.

• Nearly 60% of participants have admitted to eating more healthily since the COVID-19 pandemic. Only 21% are eating less healthy
• 43% of participants are exercising more
• 27% of people are drinking less alcohol, perhaps due to the closure of cafes, bars and restaurants. Only 18% of participants are drinking more.

Regional differences

80% of respondents in Thailand have started to eat more healthily during the pandemic — a vast difference from the next healthiest nation (China, 67%). The UK has the fewest number of expats saying they are eating more healthily, only 48.8%.

We also asked about people’s alcohol habits during lockdown. For every region we surveyed except the U.S., more people said that they were drinking less alcohol than those who said they were drinking more. The country with the most people reducing their alcohol intake is China — 43% chose this option compared to the global average of just 27.8%.

In the U.S., 26% said they were consuming more alcohol than usual during lockdown while the global average is just 18.5%. However, 37.6% of our expat cohort in the U.S. said that they didn’t drink, representing the response with the highest percentage of answers. This option also had the most responses in the UAE, Singapore and Thailand.

Less than a quarter of the respondents from each region said they were exercising the same amount. This suggests that people’s physical activity has been affected by the pandemic in some way.

Over 30% of participants in each country are exercising more as a result of the pandemic.  Topping the more active expats are those in Thailand (57%), while those who aren’t exercising more are expats in Singapore (40%). This could be due to the geography of Singapore — as a densely populated urban area, COVID-19 restrictions would make it difficult for people to find a place to exercise that provides adequate physical distance. Lockdown restrictions and their timeframes are likely to be a driver of regional differences, more so intent or inclination to exercise.

Conclusion

As well confirming many of our previous findings — for example, that expats have a positive experience of living abroad — this survey has delved deeper into important areas of the expat experience and revealed interesting results. As well as summarising our findings, we want to provide advice and guidance on the various aspects of international living to help expats, the globally mobile and soon-to-be-expats live their best life abroad.

Homesickness

• Finding: Missing home/family/friends is the biggest challenge as an expat
• Takeaway: Loneliness and feeling isolated from friends and family can impact mental health, so it is important to ensure you have a support network — whether local or back home  
• Read: How to stay connected with people while living abroad.

Cultural integration

• Finding: Expats find locals friendly and welcoming, they also think locals view them as friendly. Despite missing home, expats feel happy, safe and welcome in their new homes
• Takeaway: Cultural integration such as speaking the local language is a powerful tool in making sure expats settle into their new homes.
• Read: Live like a local: Tips on integrating into new countries

The COVID-19 pandemic

• Finding:
  • About half of expats would prefer to be in their own country when the pandemic hit, suggesting that the other three quarters are happy in their new home.
  • A third of expats who already suffer with their mental health say that COVID-19 has seriously affected their well-being
  • Many expats have made improvements to their health and well-being during the pandemic, from exercise to healthier eating

• Takeaway: While the pandemic has impacted expat mental health whether they suffer from existing issues or not. The urge of many to return home shows just how much we need support and familiarity during a crisis. Despite its negative impact, many expats have taken the opportunity to implement healthier habits.
• Read: We have created an extensive resource to help expats during the pandemic, including advice on mental health, home working, homeschooling and accessing care while self-isolating. Remote working and self-isolation resource.

Throughout this report, we have highlighted the different impacts that mental health issues and destination have on:

• The challenges of moving abroad
• Experiences of living abroad, including attitudes to locals and perceptions of locals’ attitudes towards expats
• Work, lifestyle and other challenges during the COVID-19 pandemic.

These differences support the need for holistic, personalised health care for expatriates. At Aetna International, we believe in helping people on their path to better health. We have more than 160 years’ industry experience, and each of our 19 offices around the world is focused on re-shaping health care across the globe by developing solutions to improve the quality, affordability, and accessibility of health care.

As a leading global health benefits provider, the key to fulfilling our mission and helping expats and the globally mobile live healthier, happier lives is to place our customers and members at the heart of everything we do.

We recognise the unique challenges faced by every expat — based on factors such as cultural integration, support network and mental well-being. We also understand the importance of helping people keep well, rather than just focusing on medical needs as and when they arise. This understanding is reflected in our benefits, which extend beyond insurance, our holistic support for expats, before, during and after an international assignment, our extensive health provider network and our investment in future innovation.

For more information on the data sets and experience that inform our insights, visit us or contact us. Whether you’re an individual in search of private medical insurance, an employer with an international workforce, a health care broker or intermediary, we’re here to help.

Appendix

About this research

Expat Experiences Survey 2020 is an independent consumer research study into the experiences of expats living in five countries commissioned by Aetna International and carried out by 3Gem. The research was conducted online via quantitative questionnaires to an international research panel.

Who was surveyed?

1,000 adult expatriates living in six countries:

• UK: 250 respondents
• U.S.: 250 respondents
• Singapore: 150 respondents
• UAE: 150 respondents
• China: 100 respondents
• Thailand: 100 respondents

Aetna® is a trademark of Aetna Inc. and is protected throughout the world by trademark registrations and treaties.