We interviewed 19 Canadian international retirement migrants wintering in Yuma, Arizona, most of whom were women (n = 12). The majority of participants had spent multiple winter seasons in Yuma, and some had visited other popular retirement migrant destinations in the US and Mexico. Participants ranged in age from 63 to 86 and had travelled from several Canadian provinces, including: British Columbia (n = 8), Alberta (n = 6), Manitoba (n = 2), Saskatchewan (n = 2), and Yukon (n = 1). While most considered themselves to be in good health overall, many had experienced health exacerbations while abroad ranging from developing influenza to requiring hospitalization and ultimately repatriation due to diverticulitis. Participants drew on their deep lived experiences of this transnational practice during the interviews to reflect on how they managed their health while abroad and their plans for doing so prior to departing for Yuma. These plans included actions such as preparing to access health care before departure from and upon return home to Canada, accessing health care while in Yuma, filling prescriptions in advance or planning for renewals while abroad, purchasing travel health insurance, making copies of health records, and undertaking other similar activities that may facilitate care continuity and health management in this transnational context.
Through independent and triangulated transcript review and thematic analysis we identified four distinct preparatory strategies that together form a typology of how Canadian international retirement migrants planned for managing their health while abroad. First, there were those who chose to become thoroughly prepared for a range of potential outcomes by undertaking extensive, and often well-informed, research and preparatory activities. Second, some participants were highly preparation-adverse and opted to not prepare at all for the possibility of needing to access health care or have to take on any active health management while abroad. A third group characterized themselves as well informed, and as a result of what they had learned had opted to not undertake any preparatory actions that required financial investment (e.g., purchasing travel health insurance). Finally, a fourth group prepared in a haphazard way, often acting on information and advice that was obtained in a non-systematic way. In the remainder of this section we expand on these four distinct preparatory strategies, drawing on verbatim quotes from participants to support interpretation.
Becoming thoroughly prepared
Participants who characterized themselves as thoroughly prepared for a range of potential health and health care access outcomes while abroad relied upon extensive information gathering prior to, and during, their time away. In particular, they typically spent numerous hours researching different options for travel health insurance, often obtaining multiple quotes and speaking with a range of brokers. For example, as one participant explained “…we had Manulife recommended to us [by friends] and we thought, ‘well it’s a big company.’ So, we checked them out and decided to try it out and they were absolutely great.” Word-of-mouth was an important way to learn about travel health insurance plans for those wanting to prepare for their time abroad in such a way. Another participant described changing travel health insurance providers “…after we’d heard so many complaints on [provider] about rejecting [health] claims” from other retirement migrants. Others’ experiential knowledge also informed many participants’ decisions regarding where to access prescriptions while abroad. For example, participants received advice on whether or not buying pharmaceuticals across the border in Mexico (a very short drive from Yuma) was thought to be a safe option, or whether or not prescriptions should be filled in Canada before departing for the US. Participants’ own histories as international retirement migrants also shaped the preparatory activities they undertook. For example, while in Canada prescriptions cannot often be written for longer than a two- or three-month supply of a drug, some participants had identified creative solutions: “I need six months [worth of prescriptions] … So, I called the doctor [before departure], and said, ‘I want you to double the dosage.’ She said, ‘I’ll give you prescription for twice a day’ and I just take it once.”
The preparatory planning of thoroughly prepared participants extended into the period after returning to Canada from Yuma. “Your annual physical, you get ‘em done as soon as you go home, you get all the doctor stuff out of the way when you get home, because you need six months clear when you return.” Signaled by this quote, many travel health insurance providers required a period of many months with no major health episodes or new prescriptions in order to issue policies for future travel. Thoroughly prepared travellers thus planned in advance to receive their annual physical exam from their family physicians shortly after returning home from Yuma so that they would have the health history record needed to purchase a travel medicine policy for the next winter season. From when to get their flu shot to when to start calling potential travel medicine insurers, and everything in between, we learned that many thoroughly prepared participants diarized specific preparatory activities so that they could create a sound plan for managing their health while abroad and act in the event they needed to access health care while in Yuma. These planned and diarized activities also extended to health-related events including attending free screenings and educational workshops, known as the Silver Care program, offered by the Yuma Regional Medical Center.
Those who were preparation-adverse actively avoided preparing for the potential of having to manage health-related issues while living abroad for the winter. Although there were a variety of reasons given for why some participants were preparation-adverse, they all focused on a desire to not have to plan for some of the complexities of transnational living prior to arriving in Yuma. In some instances, participants lacked technological skills and were not confident in their abilities to get details from websites and apps, which they explained were key informational platforms for preparatory strategies (e.g., cost comparing travel health policies, reading information in online forums, looking up details of health service availability in Yuma). Instead, they opted to not seek out information or prepare for eventualities. In other instances, some of those who were preparation-adverse firmly believed that if they developed an acute or exacerbated chronic health condition, they would be stable enough to return home without needing to access care in Yuma. As one participant explained: “My goal is to just try to stay healthy down here and not need any healthcare, because really I’d rather deal with it at home.” Others still had a firm belief that if they needed prescriptions refilled, had an emergency situation develop that required going to the hospital, or required some other form of medical intervention they would be able to easily make arrangements to do so while in Yuma without preparing in advance.
Unlike their more prepared counterparts, preparation-adverse participants did not spend time researching or purchasing travel health insurance prior to arriving in Yuma, nor did they worry about having checkups or physicals with their physicians at home prior to travel or upon return to Canada. These choices were often presented in a manner that suggested participants were resigned to the fact that travel health insurance would either be too costly, or that they would be ineligible. “Some of us [Canadian international retirement migrants] do come without it [travel health insurance] … If you’ve got all kinds of health issues, it’s gonna cost you more and they just figure they’ll go take the chance.” For those for whom travel health insurance was too costly, the belief was: “If you have a pain, get on a plane.” Interestingly, many preparation-adverse participants discussed the importance of using their social networks as a buffer against the potential negative consequences of their lack of preparation. For example, some believed that they could rely on other members of their residential communities in Yuma to offer recommendations for where to purchase pharmaceuticals, advise them on regulatory matters regarding accessing emergency medical care without travel health insurance, and the like.
Preparing by becoming informed yet not taking action
Unlike those who were thoroughly prepared to manage their health while in Yuma for the winter, there was another group of participants who had become well informed about a range of health matters but had chosen not to undertake any specific preparatory actions. Participants who undertook this strategy were generally knowledgeable about things such as travel health insurance, when and where to get prescription refills, and health care facilities in Yuma, but did not use this knowledge to guide any preparatory actions. Such research led many of those who opted not to purchase a policy to find the application process to be complex and criteria for approval to be restrictive, which is why this particular preparatory action was not adopted. As one participant explained: “They [insurance providers] do that [make the approval process complex] on purpose so they can screw you later” in terms of the lack of clarity regarding which pre-existing conditions may lead to non-coverage in the case of medical treatment while abroad. Phrases such as “scam” and “cartel” were commonly used by these participants when describing what they had learned about the travel insurance sector and policy options. Participants in this group shared a commonly held belief that unfortunate events would happen to other people, but not themselves, and used such beliefs to inform decisions regarding not purchasing travel health insurance.
The tendency to become informed, yet avoid taking action, was motivated by a strong sense of self-reliance. This strategy resulted in these participants’ conscious decisions to avoid taking actions that others, and especially those who were thoroughly prepared, identified as beneficial. For example, despite knowing the benefits of regular visits with their doctor after returning home, many simply chose not to: “No we don’t [visit our doctor after returning home]. Why would we? Our meds aren’t going to change.” Another element of self-reliance was these participants’ common believe that they were “in good enough health” to take the risk of opting not to purchase travel medicine insurance for their time in Yuma, despite having done some research into the options available.
Becoming haphazardly prepared
A haphazard preparatory strategy was employed by participants who did not take a systematic or comprehensive approach to informing their decisions regarding which preparatory activities to undertake, or who undertook preparatory actions without becoming extensively informed. Much of their information gathering was done in situ through talking with friends and neighbours while already abroad. As one participant explained: “I mean I think that’s how snowbirds operate a bit. It’s, it’s so much as word of mouth.” While thoroughly prepared participants also cited the importance of experiential knowledge as an information gathering and knowledge building tool, those who prepared haphazardly relied on it as their primary source and so only received information that others chose to share. Because much information was gathered once having arrived in the destination, in many cases critical preparatory steps were missed. For example, some participants discussed carrying copies of recent medical records with them to Yuma, but not a full list of their prescriptions. In another instance, a participant had a complete list of their medications, but only learned of the advantages of having their annual physical exam with their family doctor upon return to Canada through word-of-mouth.
As with most other participants who had purchased travel health insurance, those who prepared haphazardly typically hoped they would not need to use their policies. “We’re kinda desperate not to use it [travel health insurance]. We pay all this money for it in case you’re in a car accident or have something major.” There were also those who opted not to purchase travel health insurance at all. Many haphazardly prepared individuals reported learning through their social networks about the seemingly affordable pharmaceuticals and medical care available just across the border in Los Algodones, Mexico. They viewed it as a reliable alternative to using travel health insurance policies:
We don't have extended health care; we don't even have a pension. We, neither one of us, all we have is our [national contributory pension] and, well she gets [national old age security pension]. I don't get that yet. And so, we don't have pensions, we don't have extended health plan, so we do go to [Los] Algodones.
By relying heavily on others in their residential communities for health-related information in lieu of doing their own information gathering, in many ways these participants were also listening to others’ risk assessments regarding accessing care and purchasing pharmaceuticals in Los Algodones.