Association between divorce and access to healthcare services among married immigrants: propensity score approaches
Archives of Public Health volume 80, Article number: 81 (2022)
While divorce is a social determinant of health among married immigrants in Korea, its association with access to healthcare services is unclear. Given the rapid increase in the number of married immigrants in Korea, research is needed to improve minority groups’ access to healthcare services. Here, we examined healthcare service utilization among married immigrants.
We retrieved 11,778 adults from the 2018 Korea National Multicultural Family Survey. We analyzed whether the sex of divorced immigrants is associated with healthcare access using multivariable logistic regression analysis. Further, we analyzed the association between divorce and access to healthcare services among married immigrants using propensity score matching methods.
There were 691 (5.8%) divorced immigrants in the data set. The married male immigrants had no association between divorce status and healthcare access (adjusted odds ratio [OR] = 1.05, 95% confidence interval [CI] = 0.55–2.03, p = 0.8620). Divorced immigrants were less likely to receive healthcare services than married immigrants (adjusted OR = 1.42, 95% CI = 1.07–1.88).
Our findings revealed that divorce increases the risk of limited access to healthcare services among married immigrants. Policymakers and healthcare providers should be aware of these potential disparities in this vulnerable minority population.
The persistent demand for labor and capital has greatly increased the national mobility of the population. The influx of foreigners into Korea began increasing in the 1990s and continues up to this day . There are several types of immigrants, including those who are coming for international studies, employment, and marriage. Each type of immigrant has distinct characteristics. Notably, unlike those studying abroad or engaged in international employment, those coming for marriage (or “married immigrants”) typically want to become permanent residents . These characteristics have increased the need for specific immigration policies and the welfare of married immigrants.
The health of married immigrants worldwide has become a distinct field of study . Immigrants must live a new life by adapting to a socio-cultural environment that differs from their home country. They experience various challenges such as language problems, economic difficulties, and cultural conflicts . In addition, their health may deteriorate because of difficulties in understanding health insurance and the healthcare system . This can reduce the health of married immigrants and lead to poor health literacy.
Health literacy guides individuals to understand and use information to promote and maintain health. A decline in health literacy is associated with poor disease management. This results in lower health levels and higher healthcare expenditures, as health literacy of married immigrants is a major factor that influences access to health-related services .
The number of married immigrants entering Korea is increasing, and the country is rapidly becoming a multicultural society. According to the 2019 immigration statistics released by the Korea Immigration Service, the number of married immigrants in 2019 was 166,025, an increase of 14,417 from 2015, and an average increase of 3.3% in the last 3 years . To prepare for a multicultural society, Korea has increased the number of welfare policies and educational programs for married immigrants . For instance, depression has increased, and also life satisfaction among married female immigrants has decreased [9, 10]. Married female immigrants living in Korea are also more likely to experience health inequality . In addition, studies on the health-related quality of life and use of healthcare services of married immigrants only target married female immigrants; to the best of our knowledge, there is limited knowledge on the current status of the health of married male immigrants.
As the number of married immigrants is increasing, divorce is becoming a common phenomenon. According to the 2019 Marriage and Divorce Statistics Report, the divorces of married immigrants accounted for 6.2% of all divorces . Divorce is a social determinant of one’s health. Indeed, research on the effect of changing marital status on concomitant changes in health behavior reveals that health disabilities and changes in health promotion were evident in women who experienced divorce or death of a spouse . For married immigrants, divorce leads to social isolation and has a profound impact on their lives . As changes in life may worsen health indicators, we need to understand how divorce affects an individual’s health. However, the link between changes in marital status and changes in health behaviors among married immigrants is unclear.
Our study addresses the limitations of previous studies. First, most studies on married immigrants have been limited to women. According to Statistics Korea, the 2019 population of married male immigrants was 28,931; however, studies including married male immigrants in the literature review were insufficient . Second, divorce is directly related to economic problems, but its relationship with access to healthcare services is unclear. Therefore, this study aims to examine the association between divorce and access to healthcare services among married male and female immigrants while accounting for various socioeconomic factors.
We retrieved the initial sample of 17,073 adults from the 2018 Korea National Multicultural Family Survey. Our final sample included 11,778 ever married immigrants after excluding 5295 cases with missing values on the study variables. The Korea National Multicultural Family Survey is conducted by the Korea Ministry of Gender Equality and Family and targets every married immigrant, their spouses and children. It is implemented to understand the current status of family relations, lifestyles, family problems, economic conditions, and educational support for multicultural families. In this study, the de-identified data were retrieved, and the study has been reviewed and approved by the Yonsei University Institutional Review Board.
Independent and dependent variables
The independent variable was divorce status (yes or no) among married immigrants. The dependent variable was difficulty in accessing healthcare services defined by the question, “Did you have any experiences in the past year where you could not go to the hospital (e.g., inpatient facilities or ambulatory care) when you were sick?” [yes, no].
The confounders were demographics, self-reported social behavior, and economic status characteristics, including experiences participating in meetings, frequency of social services experience, social discrimination, socioeconomic status, sadness or despair, life satisfaction, and self-rated health status (Table 1). The experiences of participating in meetings were divided into various sub-themes such as parents, friends, community society, religion, and civic group meetings. The frequency of social service experience was the number of times an individual received support on economic and psychological consultation from the government agencies. Social discrimination was assessed based on whether the survey participants experienced any type of discrimination in the local community (yes or no). Life satisfaction and self-rated health status were measured using a 5-point Likert scale (1 = very good, 2 = good, 3 = neutral, 4 = poor, and 5 = very poor). Socioeconomic status was measured using a 3-point Likert scale (1 = high, 2 = middle, and 3 = low). Sadness or despair was used to assess the emotional status as a dichotomous category (yes, no).
The study used a retrospective cross-sectional design based on a nationally representative survey database. Descriptive statistics (Chi-squared test and Wilcoxon rank-sum nonparametric test) were used to compare the characteristics of the two comparison groups (divorce vs. non-divorce). Categorical variables were presented as frequency and percentage, whereas numeric variables were presented as mean and standard deviation. We first analyzed whether the sex of divorced immigrants was associated with healthcare access using multivariable logistic regression analysis (divorced male vs. divorced female immigrants). Then, we analyzed whether the divorced status of married immigrants is associated with healthcare access. To assess the robustness of the point estimates, we used three confounders adjustment methods: one based on multivariate logistic regression, and two based on propensity score matching analyses. Regarding the matching methods, we specifically used inverse probability of treatment weighting (IPTW) with average treatment effect (ATE) weight and 1:1 greedy propensity score matching .
The propensity score was calculated using logistic regression analysis that accounted for the study confounders. The most common propensity score matching approaches are 1:1 greedy propensity score matching and IPTW . Divorced and non-divorced immigrant groups were matched based on a propensity score that reflected the distribution of the study confounders. IPTW with ATE was weighted to calculate a generalized estimate of the entire population from which the observed samples were drawn . For the 1:1 greedy propensity score matching approach, we performed diagnostics and checked if the study confounders were balanced across the two comparison groups using the logit propensity score (LPS). LPS represents how well the distribution of variables is balanced . We considered a value between − 0.1 and 0.1 standardized mean difference of all confounders, and LPS (p > 0.05) as a good balance by the 1:1 greedy propensity score matching . The statistical significance level was set at p < 0.05. We calculated the adjusted odds ratio (AOR) as a point estimation with 95% confidence interval (CI). All analyses were performed using the SAS version 9.4 software.
The final sample included 691 (5.9%) divorced and 11,087 (94.1%) non-divorced immigrants. The average age of divorced immigrants was 45.1 years (standard deviation [SD] = 10.9) and that of non-divorced immigrants was 39.1 years (SD = 10.5). Table 1 summarizes the group differences before and after 1:1 greedy propensity score matching. Before matching, 16 of the 19 variables were statistically different between the two groups (all p < 0.05). After matching, all variables and LPS were balanced between the two comparison groups (all p > 0.05); further, the absolute values of the standardized mean differences between divorced and non-divorced immigrants were less than 0.10 .
Table 2 shows the results of the association between divorce status and access to healthcare according to the sex of married immigrants. For married female immigrants, divorce status and healthcare access were associated with access to healthcare (AOR = 1.414, 95% CI = 1.089–1.836, p = 0.0094), but not for married male immigrants (AOR = 1.059, 95% CI = 0.552–2.033, p = 0.8620). Thus, the association between divorce status and access to healthcare differed by sex.
Table 3 presents the association between divorce and difficulties in using healthcare services. In the unadjusted model, divorced immigrants exhibited higher risk of experiencing difficulty in accessing healthcare services than non-divorced immigrants (odds ratio [OR] = 2.323, 95% CI = 1.910–2.826). While the magnitude of risk decreased in the adjusted model (AOR = 1.367, 95% CI = 1.076–1.736) and the two propensity score matching models (IPTW: AOR = 1.147, 95% CI = 1.057–1.243; 1:1 greedy matching: AOR = 1.423, 95% CI = 1.075–1.882; Table 3), the point estimations remained statistically significant (all p < 0.05).
We investigated the association of divorce status with married immigrants’ access to healthcare services by sex. Further, we compared the use of healthcare services by married immigrants according to divorce status. Healthcare service usage differed for married female immigrants according to their divorce status, but not for married male immigrants. Divorced immigrants were more likely to not use healthcare services than non-divorced immigrants. Importantly, our findings could inform clinicians and healthcare policymakers about critical implications for divorced versus non-divorced immigrants’ use of healthcare services.
The number of married immigrants residing in Korea is increasing, along with the divorce rate among them . Divorce is a social determinant of health and has a profound impact on the lives of married immigrants . Research shows that divorce affects the lives of married female immigrants. Notably, their life satisfaction was low; moreover, because of their low income, they experienced difficulty in social adaptation . However, to the best of our knowledge, there is limited research on the association between divorce and healthcare service usage.
Our study attempted to fill this research gap. We find an association between the divorce of married immigrants and their usage of healthcare services. Social determinants of health are important factors for improving the quality of public health . Public health should prevent diseases and promote health; to this end, we need to consider the background and environment of individuals . However, our results suggest an insufficiency of public health policies for married immigrants. Further, our results point to the need for an in-depth study on the effects of the social determinants of married immigrants’ health on public health, and the necessity of establishing a holistic and comprehensive health policy.
Social determinants of health emphasize the importance of the environment in public health . Health-related behavior is influenced by the environment; therefore, an individual’s health may vary depending on the environment . Therefore, it is important to determine how the environment can be modified. For example, the quantity and quality of various social relationships, as well as employment play important roles in attenuating psychological distress among married female immigrants . Moreover, unmet healthcare needs is negatively related to their self-rated health . Our study complements previous studies and suggests that one such social determinant of health, divorce, is related to married female immigrants’ access to healthcare. Recognizing the negative association between health and the social determinants of health, and formulating a solution to this problem is a central tenet of public health initiatives.
The association between divorce and access to healthcare services differed according to sex. Married female immigrants exhibited an association between divorce and access to healthcare services, but not married male immigrants. Studies have also reported that access to healthcare services is influenced by socioeconomic status . Finance is a factor that varies greatly depending on the sex of married immigrants. For example, the employment rate of married male immigrants can be significantly higher than that of married female immigrants . Our results also suggest that financial capability affects access to healthcare services. Notably, Korea is currently conducting several projects to increase the employment rate of married female immigrants . By enhancing their financial capability, increased employment rates may be associated with increased access to healthcare services in married female immigrants. Future studies can analyze the current status of the married immigrant policies in South Korea and examine whether the employment rate of married immigrants indeed affects their access to healthcare services.
In preparation for the expansion of a multicultural society, an increasing number of welfare policies (e.g., multicultural family support projects) for married immigrants residing in South Korea are being implemented . Consequently, the experience of social discrimination and depression among married immigrants has declined. However, the use of healthcare services has remained constant or even decreased . This finding suggests an insufficiency of public health policies which are specifically for married immigrants. The role of public health is to prevent diseases and promote health . For social integration, public health should consider the background and environment of the individuals . Divorce status has been a well-studied factor which influences an individual . However, research on the effects of divorce on healthcare utilization is insufficient. To improve the quality of public health, in-depth research on the association between the social determinants of health and healthcare utilization is needed.
A decrease in access to healthcare services can lead to a decrease in health literacy. Research highlights financial capability and language barriers as reasons for the low use of healthcare services by married immigrants . Immigrants’ health literacy is significantly lower than that of ordinary Koreans, with studies showing that lower health literacy is associated with higher dissatisfaction with life . In addition, although married male immigrants have lower health literacy skills than married female immigrants , few studies have examined the former’s access to healthcare services. South Korea discloses information about the use of healthcare services and the necessary vocabulary for married immigrants; however, we cannot confirm whether they actually use the disclosed information . In addition, married immigrants still have a high demand for healthcare service education, suggesting the need for direct healthcare education services . Therefore, we recommend including healthcare service education in the social integration programs currently being implemented in South Korea. This can help improve the health literacy of married immigrants and their access to healthcare services.
In this study, selection bias, which is a typical limitation of observational research, was addressed by using propensity score matching. Homogeneity verification indirectly confirmed that the statistically analyzed sample was representative of the population. The heterogeneity of variance should be examined for differences in demographics and confounders across the comparison groups . If the homogeneity of each group is not verified, robust results cannot be obtained when determining the effects of the independent variables on the dependent variable. In the case of experimental studies, the effectiveness of the interventions applied by researchers can be questioned . Here, by using propensity score matching methods, we analyzed the association between divorce and access to healthcare services while securing the homogeneity of all demographic characteristics and confounders across comparison groups. We found that access to healthcare services was affected by several factors (e.g., financial support and economic problems). In our analysis, we controlled for variables related to access to healthcare services. The results were robust and divorce was found to be associated with access to healthcare services even after controlling for other variables.
This study has some limitations. First, while various statistical models were utilized to control for selection bias, accurate causal inferences could not be made in this cross-sectional study. In other words, although divorce was associated with the use of healthcare services among married immigrants, it is unclear whether divorce directly restricts access to healthcare. Future studies should examine the causal relationships between divorce and access to healthcare services. Second, the study database did not contain additional factors that may be associated with the use of healthcare services by married immigrants (e.g., occupation or chronic condition). Future studies should verify the study findings by including various health behaviors. Third, among the immigrant types, we focused on healthcare access of married immigrants. Clear participant selection helps in understanding their characteristics; however, as immigrant types vary, we cannot account for the overall characteristics of immigrants and refugees. Therefore, future research should examine access to healthcare according to the type of immigrants and refugees.
This study investigated the association between divorce and use of healthcare services among married immigrants. Divorced immigrants had lower access to healthcare services than non-divorced immigrants. Many welfare policies and adaptation programs are in place for married immigrants, but health programs are still in high demand. Furthermore, there is a lack of adaptation programs for vulnerable subpopulations, such as divorced immigrants. This study suggests the need to establish a healthcare or social program to improve health literacy and access to healthcare services for divorced immigrants.
Availability of data and materials
The datasets analyzed during the current study are available in the Microdata Integrated Service repository https://mdis.kostat.go.kr/index.do.
Inverse probability of treatment weighting
Average treatment effect
Logit propensity score
Adjusted odds ratio
Lim DJ. Performance of social integration programs for immigrants and influential factors: evidence from the Korea immigration and integration program (KIIP). Int J Intercult Relat. 2021;81:108–20.
Seo D, Kim J. A study on the community health and welfare care system in the aged society based on the big data : focused on thecommunity care policy. Acad Korean Social Welfare Adm. 2019;21(1):55–81.
Kang SJ, Hyung NK. Trends and level in health literacy research on immigrants in Korea: a literature review. J Korean Acad Community Health Nurs. 2020;31(3):322–36.
Malmusi D, Palència L, Ikram UZ, Kunst AE, Borrell C. Inequalities by immigrant status in depressive symptoms in Europe: the role of integration policy regimes. Soc Psychiatry Psychiatr Epidemiol. 2017;52(4):391–8.
Yang YM, Wang HH, Lee FH, Lin ML, Lin PC. Health empowerment among immigrant women in transnational marriages in Taiwan. J Nurs Scholarsh. 2015;47(2):135–42.
Kalich A, Heinemann L, Ghahari S. A scoping review of immigrant experience of health care access barriers in Canada. J Immigr Minor Health. 2016;18(3):697–709.
Statistics Korea. Marriage and divorce statistics, vol. 2019. Daejeon: Statistics Korea; 2018.
Lee SY. Social integration of foreigners in local communities: challenges and future directions - focusing on Seoul and Gyeonggi-do. J Multi-Cult Contents Stud. 2017;25:103–136.
Chung KU. An improvement of the citizenship system and the immigration system for social integration. Chung-Ang J Legal Stud. 2016;40(2):279-98.
Ministry of Gender Equality and Family. 2018 National Multicultural Family Survey. Seoul: Ministry of Gender Equality and Family; 2018. http://www.mogef.go.kr/mp/pcd/mp_pcd_s001d.do?mid=plc503&bbtSn=704820.
Choi NY, Lee BS. Health inequality experience of female married immigrants. J Human Soc Sci. 2018;9(2):425–38.
Lee HB. Priority analysis on supporting policy and educational program for the female marital immigrant. Human Res. 2015;50:373–99.
Park MJ, Um MY. A study on the divorce experienced by marriage immigrant women. Korean Acad Soc Welfare. 2015;67(2):33–60.
Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70(1):41–55.
Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivar Behav Res. 2011;46(3):399–424.
SAS Institute Inc. SAS/STAT® 14.2 User’s guide; 2016.
Lanehart RE, Rodriguez de Gil P, Kim ES, Bellara AP, Kromrey JD, Lee RS. Propensity score analysis and assessment of propensity score approaches using SAS procedures. In: Proceedings of the SAS Global Forum 2012 Conference. North Carolina: SAS Institute Inc Cary; 2012. p. 22–5.
Kim TR. A qualitative case study on divorce experience of married immigrant women. Korea Care Manage Res. 2019;20:5–38.
De Graaf PM, Kalmijn M. Change and stability in the social determinants of divorce: a comparison of marriage cohorts in the Netherlands. Eur Sociol Rev. 2006;22(5):561–72.
Stover GN, Bassett MT. Practice is the purpose of public health. Am J Public Health. 2003;93(11):1799–801.
Graham H, White PCL. Social determinants and lifestyles: integrating environmental and public health perspectives. Public Health. 2016;141:270–8.
Bircher J, Kuruvilla S. Defining health by addressing individual, social, and environmental determinants: new opportunities for health care and public health. J Public Health Policy. 2014;35(3):363–86.
Lee Y, Park S. The mental health of married immigrant women in South Korea and its risk and protective factors: a literature review. Int J Soc Psychiatry. 2017;64(1):80–91.
Kim B, Son KB. Factors affecting the self-rated health of immigrant women married to native men and raising children in South Korea: a cross-sectional study. BMC Womens Health. 2020;20(1):210.
Song HY, Choi JW, Park EC. The effect of economic participatory change on unmet needs of health care among Korean adults. Health Policy Manage. 2015;25(1):11–21.
Choi S, Kim C, Lee H. A customer-tailored social support for the employment of married immigrant women - application of qualitative study based on grounded theory to employment process. J Korean Policy Stud. 2018;18(2):107–25.
Shin YJ, Lee K. A status diagnosis and improvement of women marriage immigrant policy. Korea Crim Intell Rev. 2019;5(2):63–84.
Fisher MP, Elnitsky C. Health and social services integration: a review of concepts and models. Soc Work Public Health. 2012;27(5):441–68.
Yoo SH, Ryu J. Intermarriage and divorce in South Korea. Korea J Popul Stud. 2019;42(2):25–50.
Yang SJ. Health status, health care utilization and related factors among asian immigrant women in Korea. Korean Soc Public Health Nurs. 2010;24(2):323–35.
Lee SH, Chang KH, Han HS, Park BK, Kim SS. The relationship of health literacy of female married migrants in Busan with their attitudes toward health. PNU J Womens Stud. 2012;22(1):165–200.
Kim JK, Lee SH. Administration service related to health literacy in emigrants, north Korean refugees. Seoul: National Assembly Research Service; 2016.
Kim CM, Park MS, Kim EM. Married immigrant women’s utilization of health care and needs of health services. J Korean Acad Community Health Nurs. 2011;22(3):333–41.
Brown MB, Forsythe AB. Robust tests for the equality of variances. J Am Stat Assoc. 1974;69(346):364–7.
Glass GV. Testing homogeneity of variances. Am Educ Res J. 1966;3(3):187–90.
This research was supported by BK21 FOUR (Fostering Outstanding Universities for Research) funded by the Ministry of Education (MOE) of the Republic of Korea and the National Research Foundation of Korea (NRF) (Big data specialized education and research team for cognitive health and social integration of community-dwelling older adults).
Ethics approval and consent to participate
The study has been reviewed and approved by the Yonsei University Institutional Review Board.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Bae, S., Graham, J.E., Nam, S. et al. Association between divorce and access to healthcare services among married immigrants: propensity score approaches. Arch Public Health 80, 81 (2022). https://doi.org/10.1186/s13690-022-00840-3
- Health services accessibility
- Health services research