Revisiting the Andersen Model: Transnational Ties With the Home Country and Healthcare Utilization Among Chinese International Students in South Korea

Abstract

The present study aimed to understand how Chinese international students perceived and experience healthcare utilization in Korea and to broaden Andersen’s framework in the age of globalization, allowing easier maintenance of transnational relationships with one’s native country. We analyzed the in-depth personal interviews with 31 Chinese international students. The grounded theory was employed to analyze the interview data. Among factors suggested by Andersen, predisposing (perceptions about the Korean healthcare system) and enabling (financial barriers, language barriers, and lack of social support) factors contributed to healthcare utilization among Chinese international students in Korea. Self-medication via broad medical transnational ties with the home country (bringing medications from home) impeded their healthcare utilization. We highlighted the roles of their campus health center to promote optimal healthcare utilization for Chinese international students. It is important to educate international students about the risks or negative effects of self-medication.

Plain Language Summary

This study aimed to understand how Chinese international students viewed and used healthcare in Korea. The researchers interviewed 31 students in-depth and used a grounded theory approach to analyze the data. They found that the students’ perceptions of the Korean healthcare system, financial barriers, language barriers, and lack of social support affected their use of healthcare. Bringing medications from their home country hindered their use of healthcare. The study highlighted the importance of campus health centers in promoting optimal healthcare utilization for Chinese international students and recommended educating them about the risks of self-medication. The study extended Andersen’s framework in the era of globalization to facilitate maintaining transnational relationships with one’s home country.

Keywords

Chinese international students healthcare utilization Andersen’s healthcare utilization model self-medication medical transnationalism South Korea

Introduction

Over five million international students have travelled to other countries to study (Migration Data Portal, 2020). Moving and adjusting to a new place can have a negative influence on international students’ mental and physical health (Masai et al., 2021). Although numerous studies have investigated the mental health and adaptation of international students in Western countries (Zhou et al., 2022), only a limited amount of research has focused on their physical health and use of healthcare services. International students, despite generally being young and healthy, can be considered a “non-traditional” vulnerable group, much like prisoners or homeless individuals, due to the obstacles they encounter in obtaining healthcare services in their host nations (Jang, 2023a). For example, they utilize limited healthcare by deferring care until they return to the home country during school breaks (Jang, 2023a). Reasons for delaying care include unfamiliarity with the health insurance system, financial difficulties, and language and cultural barriers (Masai et al., 2021; Skromanis et al., 2018).

South Korea (hereafter Korea) has traditionally been a “home” country of international students in the United States (U.S.), but it is now accepting an increasing number of international students, who account for around 3.7% of the entire. In 2003, there were only about 12,000 international students, but it was expected that by 2020, there would be more than 153,000 international students in Korea, with Chinese students accounting for most (Ministry of Education, 2020). As of March 1st, 2021, all international students are automatically enrolled in the national health insurance program, but less than 40% of them have utilized the insurance in Korea (K. Kim et al., 2021). The fact that international students underutilize healthcare services suggests that they may have insufficient understanding of how to utilize health insurance programs (D. Lee et al., 2021). Despite their potential to provide information on health insurance and healthcare utilization, international students tend to utilize the campus health center mainly for medication, rather than for health counseling or information (An et al., 2016).

As previously pointed out (An et al., 2016), international students’ health and healthcare utilization have been understudied in Korea; instead of their healthcare utilization, academic and life adaptations (Kwon & Chung, 2020) or acculturative stress and discrimination (Y. Kim & Lee, 2021) among Chinese international students in Korea have been the focus of previous research. As far as we know, only one study has quantitatively examined this population’s healthcare utilization (Cho & Kim, 2013). Since the pioneering quantitative study on university health center utilization included all international students, it did not explore the perceptions and healthcare usage of a specific subgroup, such as Chinese international students, despite the fact that international students are characterized by a diverse range of cultural backgrounds (McKinley, 2019).

By analyzing in-depth personal interviews with Chinese international students in Korea, the present study had the following three aims. First, it explored Chinese international students’ perceptions of the Korean healthcare services and system, as well as their experiences of healthcare utilization in Korea. Second, it investigated whether Andersen’s healthcare utilization model, which proposed predisposing, enabling, and need factors to influence an individual’s healthcare utilization, can be used to explain healthcare utilization among Chinese international students in Korea. Finally, the current study examined other factors that influenced Chinese foreign students’ beliefs and behaviors regarding healthcare utilization.

Theoretical Framework

Andersen’s Healthcare Utilization Model

The present study applied Andersen’s healthcare utilization model (Andersen, 1995), which defines three key elements that influence individuals’ utilization of healthcare: predisposing, enabling, and need factors. To begin, predisposing factors are personal characteristics of individuals that influence their healthcare utilization. Predisposing factors include demographic characteristics (e.g., age, gender, race/ethnicity), as well as beliefs about health and healthcare utilization. For instance, if an individual has a positive attitude toward healthcare, believing it to be effective, they are more likely to seek it out. In regards to international students, a prior study (D. Lee et al., 2021) makes the suggestion that race/ethnicity may serve as a predisposing factor for international students. Specifically, students originating from countries such as China and Vietnam, where healthcare may be less developed and the use of complementary and alternative medicine is high, may be less likely to actively seek out healthcare services in Korea. Second, Andersen proposed enabling factors that could either facilitate or impede an individual’s use of healthcare. Financial resources, such as health insurance, and non-financial resources, such as support from family, friends, and the community, are examples of enabling factors. Last, need factors refer to an individual’s actual health needs, which can be perceived (e.g., self-reported health) or diagnosed (e.g., chronic disease).

Researchers have applied Andersen’s healthcare utilization model among immigrants (Babitsch et al., 2012). Early research on immigrant healthcare utilization found that English proficiency is a strong enabling factor that interacts with gender; limited English proficiency had a greater negative impact on healthcare utilization among male immigrants than female immigrants (Akresh, 2009; Read & Smith, 2018; Surood & Lai, 2010). Other studies commonly found disparities in healthcare utilization by gender, ethnicity, and years in the U.S. For instance, immigrant women are more likely to utilize healthcare than men (Read & Smith, 2018; Shafeek Amin & Driver, 2022), and Middle Eastern immigrants are more likely to utilize healthcare than Asian immigrants (Shafeek Amin & Driver, 2022). Recent immigrants who have lived in the U.S. fewer than 10 years are less likely to utilize healthcare than those who have lived in the U.S. more than 10 years (Leclere et al., 1994).

Only a few studies have applied Andersen’s healthcare model to explain international students’ healthcare utilization, in contrast to the number of studies that have used this framework to study immigrants’ healthcare utilization. In addition to the predisposing, enabling, and need factors suggested by Andersen, they have found factors more relevant to international students’ healthcare utilization, such as transnational ties with the home country (Jang, 2023a) and environmental factors (e.g., medical expenses in the country of study) (He et al., 2020). Exploring the distinct factors that influence healthcare utilization among international students, beyond the conventional factors outlined by Andersen, could prove helpful in facilitating their timely and appropriate use of healthcare services.

Medical Transnationalism

International students, who are often considered as sojourners rather than settlers after completion of their study in the destination countries (Araujo, 2011), might maintain a higher degree of transnational ties with the home country. This immigrant transnationalism is defined as “the process by which immigrants forge and sustain multistranded social relations that link together their societies of origin and settlement (Schiller et al., 1995, p. 48).” Recent immigrants and international students in the globalization period were able to maintain transnational relationships with their home country owing to the information and communication technologies (Portes & Fernández-Kelly, 2015). Researchers (Portes, 2003; Portes et al., 1999) have proposed that immigrant transnationalism can occur in a variety of contexts, including political (e.g., voting in home country elections), economic (e.g., sending remittances to home country), and social (e.g., contacting home country). Previous studies have suggested broad and narrow types of immigrant transnationalism, depending on the necessity of physical movement to the home country and the frequency of engaging in transnational activities (Jang, 2018). In the political sphere, for example, broad transnationalism may include supporting politicians in one’s home country, whereas narrow transnationalism may involve immigrants visiting their home country to vote in local elections (Jang, 2023b).

While previous research on immigrant transnationalism has primarily focused on the economic (e.g., sending remittances to the home country) and social (e.g., contacting the home country), some researchers have recently suggested that some immigrants engage in the broad or narrow type of medical transnationalism, which can also be divided into broad and narrow types based on the necessity of visiting the home country (Jang, 2018, 2021b). On the one hand, broad medical transnationalism refers to transnational ties with the home country in the medical sphere that do not necessitate an individual’s return to the home country. When it comes to international students, examples of broad medical transnationalism include international students receiving or sending medications from/to their home countries, as well as searching for health information on home country websites. On the other hand, narrow type of medical transnationalism refers to an individual’s physical return to the home country for medical care. In the case of international students, a trip home during the break could be classified as this narrow type. Several studies on Korean immigrants have found that they engage both in broad and narrow types of medical transnationalism (Jang, 2021b; Surood & Lai, 2010). Nonetheless, only a few studies have attempted to understand the impact of transnational ties on international students’ healthcare utilization in destination countries, finding a higher tendency for international students to return to their home country to receive healthcare (Jang, 2023a).

Methods

Participants

To better understand the perceptions and experiences of Chinese international students in Korea, we conducted in-depth semi-structured interviews with 31 students. Between October and November 2020, interviewees were recruited using bilingual (Chinese and Korean) leaflets distributed via internet websites and in person until the interview data were saturated. The study was authorized by the institution which the corresponding is affiliated.

The inclusion criteria for the current study were Chinese international students who are over 18 years old, and who were enrolled in universities in Korea. We excluded Chinese international students who had been in Korea for less than a year, assuming that they would not have enough time to access healthcare. We obtained verbal informed consent for study participation. Each interview lasted about 60 min and was conducted in Chinese by three bilingual Chinese international students. A $30 cash incentive was sent after participants completed the demographic questionnaire and interviews. Interviews were audio-recorded, transcribed, and translated into Korean and English. The researchers reviewed the interview transcripts to confirm accuracy.

Data Analysis

Since there is very limited literature on Chinese international students’ healthcare utilization in Korea, we used the grounded theory that allows a researcher to flexibly explore themes (Glaser et al., 1968). As the grounded theory suggests, two researchers created codes independently at the open coding stage. Next, they compared, sorted, and combined some similar codes that emerged at the open coding via iterative processes, until the two researchers achieved consensus. After an inter-rater reliability check, at the axial coding stage, the codes were organized into categories, then examined for patterns and similar responses. Finally, at the theoretical integration, two researchers revisited the coding scheme for agreement. All qualitative analyses were conducted using ATLAS.ti 9.

Results

Characteristics of Study Participants

Table 1 summarizes the demographic characteristics of interviewees. Most interviewees were between 21 and 30 years old. About two-thirds were female. Except for one interviewee, all were unmarried. More than half were enrolled in an undergraduate program, whereas about 42% were in a graduate program. Most interviewees reported that their Korean proficiency was good or excellent. A majority of interviewees had lived in Korea for more than 3 years. Most of them were insured and spent $12,000 to 24,000 for annual living expenses in Korea.

Table 1.

Demographic Characteristics of Interviewees (n = 31).

	n	%
Age group
21–30 years old	28	90.32
31–40 years old	3	9.68
Sex
Male	12	38.71
Female	19	61.29
Marital status
Unmarried	30	96.77
Married	1	3.23
Academic program
Undergraduate	17	54.84
Graduate	13	41.94
Language program	1	3.23
Academic major
Social science	14	45.16
Language and literature	8	25.81
Business/economics	5	16.13
Fine art/cultural studies	4	12.90
Korean proficiency
Poor	2	6.45
Good	23	74.19
Excellent	6	19.35
Length of stay
1–2 years	9	29.03
3–4 years	13	41.94
5 years or longer	9	29.03
Perceived health status
Poor	1	3.23
Fair	19	61.28
Excellent	11	35.48
Health insured in Korea
No	3	9.68
Yes	28	90.32
Annual living expenses
Less than $12,000	6	19.35
$12,000-24,000	25	80.65

Note. $1 was calculated as 1,000 won.

Healthcare Utilization in Korea

Most interviewees reported that they have utilized healthcare in Korea for various reasons. While most interviewees sought acute healthcare (dental, flu/cold, appendicitis, stomachache, and allergy), a few interviewees received elective care (e.g., Botox and skin care). While there were no medical facilities they visited regularly, they generally chose hospitals or private clinics near their university (whether university-affiliated or not) or the university’s campus health center.

Interviewees expressed their satisfaction with the campus health center because it was easily accessible and provided free medical services. For example, an uninsured male student who had stayed in Korea for more than 5 years stated, “I had a fever in the middle of class, so I urgently visited the school health center and received a fever reducer for free.”

Predisposing Factors

While possible predisposing factors such as age and gender did not appear to play a significant role in Chinese international students’ healthcare utilization, perceptions of the Korean healthcare system did. Some people believe that the Korean health insurance system is very complex, and that there is considerable waiting time compared to the healthcare system in China:

Medical care in China and South Korea differs significantly. Getting test results takes much longer time in Korea than in China, and most Korean clinicians require a reservation. Patients with acute diseases must suffer a lot until they meet a doctor.

Enabling Factors

Interviewees identified three main factors that impeded their healthcare utilization in Korea—financial barriers, lack of social support, and language barriers. First of all, most of the interviewees found it difficult to use Korean health insurance; medical costs were too expensive, even after the insurance was applied. Combined with the lack of social support in Korea, one male student who has lived in Korea for 3 to 4 years described how he felt when he had surgery for appendicitis:

I was anxious, and my family was not around, but I had to undergo surgery alone. The cost is very expensive. Even with the same appendicitis, treatment costs are very different between China and Korea. I couldn’t get reimbursed because my insurance didn’t cover it, so I changed insurance as soon as I was discharged from the hospital.

Although most interviewees reported strong or excellent Korean proficiency, all of them indicated language barriers (e.g., communication with Korean doctors, unfamiliar medical jargon in Korean) as one of the greatest concerns preventing them from accessing healthcare services. To overcome these language barriers, some interviewees attempted to “Search for Korean words that describe symptoms in advance via the internet or a dictionary or seek assistance from a Korean friend and a Chinese friend who has visited the hospital they are trying to visit.” A few stated that they had tried to use interpreter services at the hospitals, but none of them did because those were not affordable. One female interviewee who had been in Korea 3 to 4 years reported how financial and language barriers intersected:

I felt a language barrier when I used medical services. For foreign students, because we cannot join the Korean national health insurance, we cannot claim reimbursement and must pay the full cost of the examination. To overcome the language barrier, we should ask for assistance from medical interpreters at our own expense.

Need Factors

One’s health status as a need factor was the least frequently mentioned factor for healthcare utilization in Korea among interviewees. All perceived themselves as young and healthy and not having any issues.

Broad and Narrow Types of Medical Transnational Ties With the Home Country

In addition to the factors suggested by Andersen, broad and narrow types of medical transnational ties with the home country were related to Chinese international students’ healthcare utilization in Korea. Compared to the broad type of medical transnational ties, a narrow type of medical transnational ties (i.e., visiting the home country for medical care during the break) was less frequent. Most interviewees mentioned that they had visited China for healthcare about once or twice a year (usually during the break) to receive healthcare services because services were cheaper there, and they could get support from their family members. However, during the COVID-19 pandemic, only a few students had visited China for dental care, and the majority expressed their regret about not being easily able to visit the home country for medical care as they did before COVID-19.

While narrow medical transnational ties with the home country played a role as a safety net among Chinese international students, broad medical transnational ties with the home country were negatively related to healthcare utilization in Korea. Most interviewees brought various kinds of medications (e.g., cold, diarrhea, anti-inflammatory, allergy, and digestive medicines; fever reducers; pain relievers; and antibiotics) from the home country to treat any possible difficulties they might face when utilizing healthcare in Korea. For example,

I brought all kinds of medicine - cold medicine, anti-inflammatory drugs, and gastrointestinal medicine - from China…these drugs can work in part even when I get sick suddenly and can’t go to the hospital… The medicines prescribed by a doctor may work similarly to those I have brought. I had a stomachache, but the doctor didn’t know the cause of the disease clearly, but it got better after taking the medicine I brought.

Discussion

The present study sheds light on the perceptions and experiences of Chinese international students in Korea regarding healthcare utilization. It confirms that, similar to other international students in the U.S. (Jang, 2023a), they perceive the Korean healthcare system as complicated and expensive, and tend not to actively seek healthcare, often delaying it (Masai et al., 2021; Skromanis et al., 2018). It also reveals the importance of campus health centers and language interpretation services in clinics and hospitals in promoting access to healthcare. By identifying predisposing factors such as negative perceptions of the Korean healthcare system and enabling factors such as language barriers and lack of social support, this study highlights the need for policy changes that address these issues.

One of the most notable findings of the present study is the role of transnational ties with the home country in healthcare utilization. While previous studies have indicated that international students tend not to actively seek healthcare (Masai et al., 2021; Skromanis et al., 2018), relying instead on self-medication, this study found that transnational ties can serve as a coping strategy against barriers to healthcare utilization in Korea. However, this strategy also poses potential risks to students’ health in the long term due to misdiagnosis, overdose, or prolonged medication duration (Hughes et al., 2001). Therefore, policymakers should take steps to promote access to healthcare while also educating international students on the potential dangers of self-medication.

This study has considerable policy implications that could help reduce health inequalities among vulnerable populations like Chinese international students. First, the primary healthcare source for many Chinese international students is the campus health center, which should be expanded and emphasized. Previous studies have discussed that international students tend to seek university health centers first or more often than off-campus health services due to their accessibility and affordability (Carmack et al., 2016; Ebbin & Blankenship, 1986; Lederer et al., 2021; J. Lee et al., 2021). Providing health services through these accessible and frequently visited centers is the most effective way to cater to the students’ needs. To maximize the advantages of university health centers, institutional stakeholders such as the university, student union, or international student offices should advocate for policies or legislation that support international student health services, as sustained financial and technical support is necessary (Lederer et al., 2021). The campus health center’s crucial role as the first point of contact for international students highlights the need for educating students on how to use their health insurance in Korea, finding doctors and nearby hospitals, and overcoming language barriers.

Second, language interpretation services in clinics and hospitals should be made easily accessible and affordable, allowing international students to access healthcare services in Korea with fewer language barriers. Finally, expanding social support for international students in Korea could be beneficial in their healthcare utilization, with universities hosting events where international students can interact with native-born students on campus or their neighbors in the community.

While the present study focused specifically on Chinese international students, there is a need for further research on healthcare utilization among international students from diverse ethnic groups. Although Chinese students comprise the largest international student group in Korea (Ministry of Education, 2020), as researchers have pointed out, there are likely to be disparities in and different factors related to healthcare utilization among different ethnic groups in the host country (Richardson & Norris, 2010). While Chinese and Koreans share many cultural similarities under the same umbrella of East Asian culture (Huat, 2015), international students from Western countries, including the U.S. and European countries, might experience more cultural differences and barriers to accessing health care in Korea. Additionally, future studies could address the limitations of the present study, which relied on a self-selected sample of volunteers.

In conclusion, the present study highlights the significance of improving healthcare availability for international students in Korea and recognizing the essential policy changes that can enhance their access to healthcare. Policymakers should focus on resolving issues such as negative perceptions, language obstacles, and inadequate social support to ensure that international students receive appropriate healthcare during their stay in Korea. Implementing such measures can help promote health equity and bridge the gap in healthcare access between international students and domestic students.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This work was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea(NRF-2023S1A5A2A01081240).

ORCID iDs

Sou Hyun Jang

Yong Jeong Yi

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

References

Akresh

I. R.

(2009). Health service utilization among immigrants to the United States. Population Research and Policy Review, 28, 795–815.

Andersen

R. M.

(1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36(1), 1–10.

J. H.

Ahn

Woo

S. I.

Song

M. R.

Sohn

(2016). International students’ use of a university health center. Child Health Nursing Research, 22(1), 29–36.

Araujo

A. A. D.

(2011). Adjustment issues of international students enrolled in American colleges and universities: A review of the literature. Higher Education Studies, 1(1), 2–8.

Babitsch

Gohl

von Lengerke

(2012). Re-revisiting Andersen’s behavioral model of health services use: A systematic review of studies from1998-2011. GMS Psycho-Social-Medicine, 9, Doc11.

Carmack

H. J.

Bedi

Heiss

S. N.

(2016). International students, university health centers, and memorable messages about health. Journal of International Students, 6(1), 52–72.

Cho

S. Y.

Kim

E. H.

(2013). The factors leading to the use of Korean health services among international college students, their future intention to use, and recommendation intention to others. The Journal of Korean Society for Journalism & Communication Studies, 57(5), 78–112.

Ebbin

A. J.

Blankenship

E. S.

(1986). A longitudinal health care study: International versus domestic students. Journal of American College Health, 34(4), 177–182.

Glaser

B. G.

Strauss

A. L.

Strutzel

(1968). The discovery of grounded theory; strategies for qualitative research. Nursing Research, 17(4), 364.

10.

Jiawen

Ting

(2020). Study on medical behavior of international students and its influencing Factors------Taking Jiangsu University as an example. Academic Journal of Medicine & Health Sciences, 1(1), 1–8.

11.

Huat

C. B.

(2015). Conceptualizing an East Asian popular culture. In The Inter-Asia cultural studies reader (pp. 131–155). Routledge.

12.

Hughes

C. M.

McElnay

J. C.

Fleming

G. F.

(2001). Benefits and risks of self medication. Drug safety, 24, 1027–103

13.

Jang

S. H.

(2018). Medical transnationalism: Korean immigrants’ medical tourism to South Korea. Rowman & Littlefield.

14.

Jang

S. H.

(2021b). Logging in for medical transnationalism-transnational health information seeking among Korean immigrant women. Journal of Diaspora Studies, 15(1), 183–209.

15.

Jang

S. H.

(2023a). “I can wait until I return home”: Healthcare utilization among Korean international students in the US. Journal of American College Health, 71, 1804–1814.

16.

Jang

S. H.

(2023b). Political transnationalism: Factors associated with immigrants’ voting in their home country elections. Political Studies Review, 21, 593.

17.

Kim

Kwon

Lee

(2021). A study on the willingness to pay for NHI among international students in Korea - using double-bounded choice contingent valuation method. The Korean Journal of Health Economics and Policy, 27(3), 21–60.

18.

Kim

Lee

(2021). A study on the mediating effect of acculturation stress in the relationship between discrimination experience and mental health of international students: A comparison between Vietnamese and Chinese students in Daegu and Gyeongbuk region. Journal of Diaspora Studies, 15(1), 141–181.

19.

Kwon

T. H.

Chung

H. H.

(2020). A meta-analysis on variables related to university life adaptation of Chinese students. Korean Journal of Youth Studies, 27(12), 187–215.

20.

Leclere

F. B.

Jensen

Biddlecom

A. E.

(1994). Health care utilization, family context, and adaptation among immigrants to the United States. Journal of Health and Social Behavior, 35, 370–384.

21.

Lederer

A. M.

Hoban

M. T.

Lipson

S. K.

Zhou

Eisenberg

(2021). More than inconvenienced: The unique needs of US college students during the COVID-19 pandemic. Health Education & Behavior, 48(1), 14–19.

22.

Lee

Kim

K. K.

Kwon

(2021). The determinants of health care utilization of international students in Korea. The Korean Journal of Health Economics and Policy, 27(2), 121–148.

23.

Lee

Jeong

H. J.

Kim

(2021). Stress, anxiety, and depression among undergraduate students during the COVID-19 pandemic and their use of mental health services. Innovative Higher Education, 46, 519–538.

24.

Masai

A. N.

Güçiz-Doğan

Ouma

P. N.

Nyadera

I. N.

Ruto

V. K.

(2021). Healthcare services utilization among international students in Ankara, Turkey: A cross-sectional study. BMC Health Services Research, 21(1), 311–318.

25.

McKinley

M. T.

(2019). Supervising the sojourner: Multicultural supervision of international students. Training and Education in Professional Psychology, 13(3), 174–179.

26.

Migration Data Portal. (2020). International students. Accessed March 20, 2022, from https://www.migrationdataportal.org/themes/international-students

27.

Ministry of Education. (2020). Overseas education. Accessed March 20, 2022, from https://www.moe.go.kr/boardCnts/view.do?boardID=350&lev=0&statusYN=W&s=moe&m=0309&opType=N&boardSeq=82916

28.

Portes

(2003). Conclusion: Theoretical convergencies and empirical evidence in the study of immigrant transnationalism. International Migration Review, 37(3), 874–892.

29.

Portes

Fernández-Kelly

(Eds.) (2015). The state and the grassroots: Immigrant transnational organizations in four continents. Berghahn Books.

30.

Portes

Guarnizo

L. E.

Landolt

(1999). The study of transnationalism: Pitfalls and promise of an emergent research field. Ethnic and Racial Studies, 22(2), 217–237.

31.

Read

J. G.

Smith

P. B.

(2018). Gender and national origin differences in healthcare utilization among US immigrants from Mexico, China, and India. Ethnicity and Health, 23(8), 867–883.

32.

Richardson

L. D.

Norris

(2010). Access to health and health care: how race and ethnicity matter. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine: A Journal of Translational and Personalized Medicine, 77(2), 166–177.

33.

Schiller

N. G.

Basch

Blanc

C. S.

(1995). From immigrant to transmigrant: Theorizing transnational migration. Anthropological Quarterly, 68, 48–63.

34.

Shafeek Amin

Driver

. (2022). Health care utilization among Middle Eastern, Hispanic/Latino, and Asian immigrants in the United States: An application of Andersen’s behavioral model. Ethnicity and Health, 27(4), 858–876.

35.

Skromanis

Cooling

Rodgers

Purton

Fan

Bridgman

Harris

Presser

Mond

(2018). Health and well-being of international university students, and comparison with domestic students, in Tasmania, Australia. International Journal of Environmental Research and Public Health, 15(6), 1147.

36.

Surood

Lai

D. W.

(2010). Impact of culture on use of western health services by older South Asian Canadians. Canadian Journal of Public Health, 101, 176–180.

37.

Zhou

A. Q.

Sun

(2022). Prevalence of common mental concerns and service utilization among international students studying in the US. Counselling Psychology Quarterly, 35(3), 483–502.