Internationalisation is a vital activity for universities these days and it is often used as a tool to increase the quality of the education, university status, and academic recognition, and exchange studies and mobility programmes play a natural and important role in this process (1). For university students, this means the opportunity to spend a semester abroad as exchange students. Approximately 24,000 Swedish students from different universities spent a semester abroad, and approximately 38,000 exchange students from different countries travelled to Sweden in the 2018/2019 school year (2).

Even though many Swedish students choose to spend a semester abroad (hereafter referred to as Swedish exchange students), there has been limited research on this group. The few studies that have been carried out, have focused on risky behaviour, which seems to be prominent amongst Swedish exchange students (3, 4).

It has been shown that 36% of Swedish exchange students consume alcohol in a way that could be associated with increased risks for ill-health (3). This is higher than the general Swedish population between the ages of 16 and 29, where approximately 21% have a risky consumption of alcohol (5). However, lower then Swedish university students in general, where 46.1% of male and 44% of female students between the ages of 18 and 24 consume alcohol at a risky level (6). In addition, 43% of male and 23% of female Swedish university students between the years 21 to 25 years binge drink alcohol at least once per week (7).

Even though it is common to quantify alcohol into risky and non-risky consumption for research purposes, the use of alcohol is always associated with an increased risk for ill-health and there is no such thing as risk-free alcohol consumption. However, four or more glasses at a single occasion or 10 glasses per week is associated with significantly increased risks for ill-health, not only the development of addiction, but also accidents and diseases (8).

Swedish exchange students’ risky alcohol consumption is also associated with having sex with a new partner; 20% met a new partner whilst abroad but only 65% used a condom at every sexual encounter (3). It has also been shown that 51% of Swedish exchange students have had sex with a new partner during their exchange studies, and 87% of them had engaged in risky sexual behaviour, such as sex together with alcohol and sex without protection (4).

A risky sexual behaviour can have several components, but common definitions are sex that increases the risk of sexually transmitted infection (STI), such as sex with multiple partners, sex without protection, and/or sex together with drugs and alcohol (9). The use of protection seems to be higher for exchange students (3), than for the Swedish population in general, where 50% of women and 46% of men between the ages of 20 and 24 years did not use a condom the last time they had sex with a new, unknown partner. Common reasons for not using condoms were alcohol use, no condoms available, that they reduce sensitivity, and unplanned sexual activities (9–11).

Swedish exchange students rate their mental health as good (4), however, research on non-Swedish exchange students shows that exchange studies might be an overwhelming experience because the students might not be fully prepared for the journey, and this can have a negative effect on their mental health (12). A number of symptoms were identified in Asian exchange students, including sleeping problems, depressive symptoms (13), anxiety, stress (14), and psychological distress (15). Common causes for decreased mental health in Asian exchange students were lack of social contacts, homesickness (16), academic stress, and social isolation (17). Examples of decreased mental health have also been shown amongst exchange students from the US, where 44% experienced reduced well-being due to stress or emotion-related problems (18). Both a high alcohol consumption and mental ill-health can also lead to lower levels of academic functioning amongst exchange students (19, 20).

Studies on Swedish exchange students suggest that they indulge in sexually risky behaviour and use alcohol in a risky way, which might lead to an increased risk for accidents and diseases (8, 9). In addition, studies on non-Swedish exchange students suggest that there is a risk for mental ill-health whilst abroad (12–18, 20). These risk factors could possibly be enhanced due to exchange students being in an unknown environment, with limited knowledge of the native language and healthcare access. In order to adjust measures to better fit the majority of the Swedish exchange students and design proactive measures to ensure academic performance, good health, and decreased risky sexual behaviour and alcohol consumption, it could be fruitful to investigate whether, and if so how, students who intend to spend a semester abroad differ from students who remain on campus. Students who intend to spend a semester abroad are hereafter referred to as prospective exchange students. Students in the comparison group are hereafter referred to as campus students.

The response rate for the survey that was sent out in May was 24.5% (n = 49) for the prospective exchange students and 23.1% (n = 231) for the campus students. In the survey that was sent out in November the response rate was 36.1% (n = 66) for the prospective exchange students and 24.5% (n = 224) for the campus students. Five students who had responded as gender other than male or female were excluded because there were too few of them to form a separate group. The mean ages of the male prospective exchange students, female prospective exchange students, male campus students, and female campus students were 25, 24.3, 26.4, and 28 years, respectively.

Male prospective exchange students rated their mental health as being better and had used cannabis more often compared with female prospective exchange students. More female prospective exchange students had sex with a new partner during the last six months and drank higher levels alcohol on the same occasion compared to female campus students. Male prospective exchange students had had more sex together with alcohol, and rated their mental health and health as better than male campus students. Female students rated their mental health as worse than male students. A higher number of male prospective exchange students had used cannabis, amphetamines, GHB, cocaine, spice, or other drugs than male campus students.

There were no significant statistical differences in alcohol consumption between the groups, with the exception that female prospective exchange students drank more alcohol per occasion than female campus students; however, the overall use of alcohol was high in comparison with the general Swedish population between the ages of 16 and 29 (5), but similar to exchange students in the US where 31% of the exchange students drank alcohol weekly (30). Previous research has also shown that at least one-third of Swedish exchange students drink alcohol in a way that could be associated with increased risks for ill-health (3). Moreover, Swedish university students in general consume alcohol at a high level (31–34), as well as Norwegian students (35, 36). Binge drinking is also common for Swedish university students in general (7).

Exchange students in Europe and Australia reported that both general use of alcohol and binge drinking increased to a level higher than local students whilst abroad (37, 38). It was also shown that exchange students may adapt to the country’s local drinking culture in order to be included in social life (37). Therefore, it is possible that Swedish students will also increase their alcohol consumption, from an already high level. Moreover, frequent drinking and binge drinking have been shown to increase the risk for anxiety and depression amongst students in general (36, 39).

However, previous research on exchange students show that they experience both good mental health and high self-esteem (4). This could indicate that when the prospective exchange students go on their exchange trip, generally, their mental health is not negatively affected. However, there are still risk factors that could potentially lead to a decrease in mental health (12, 13, 15, 17), which should be considered when preparing to go on an exchange trip.

The female students in our study rated their mental health as worse than male students. This is in line with current statistics from the general Swedish population between 16 and 29 years, where it was shown that 20% of women and 10% of men experienced severe worry and/or anxiety (40). There is an increasing demand from society that women should be successful in school and work, which contributes to stress (25, 41). Swedish women also use social media more frequently than men and are exposed to cyber bullying to a higher degree (41). Women between 18 and 34 years who regularly use social media report significantly lower mental health than women who do not use or rarely use social media (42). It is possible that the use of social media could increase further whilst abroad, in attempt to stay in contact with family, friends and cope with loneliness. These additional risk factors (25, 41, 42) may indicate that female students are at a higher risk of worsening mental ill-health whilst abroad.

Although female students did not report worse self-rated health than male students, there are factors that might negatively affect self-rated health whilst abroad. Previous research has shown that academic pressure and being behind in school work has a negative effect on self-rated health (43). Self-rated health also has a general tendency to reduce after starting at a university, with increased stress as a contributing factor (44). The unavailability of healthcare services has also been shown to have a negative effect on students self-rated health (45). This, combined with academic pressure (43–45), could possibly be associated with a semester in a foreign country, and lead to reduced self-rated health amongst exchange students.

Our results showed that a higher proportion of the female prospective exchange students had had sex with a new partner at least once over the last six months; it was also shown that only about half of them used a condom whilst having sex with a new partner. Moreover, previous research on Swedish exchange students showed one-third did not use a condom whilst having sex with a new partner whilst abroad (4). The frequency of prospective exchange students condom-use is higher than in the general Swedish population between the ages of 20 and 24 (9). However, it is similar to other students in Greece (46), but differs somewhat from students in China, where only one-quarter always use a condom (47). Students in South Africa, however, did use condoms whilst having sex with a new partner more often than Swedish prospective exchange students (48).

A common reason for not using condoms whilst having sex is the perception that condoms reduce sensitivity (9–11). Other factors are unplanned sexual activity (10), no condoms available (9), and embarrassment at obtaining condoms (49). Alcohol also seems to be a factor in reducing willingness to use condoms. Research suggests that heavy use of alcohol is strongly associated with decreased intentions of using a condom whilst having sex (50), and there is a link between alcohol use and casual sexual encounters amongst university students (51). Research on tourists suggests that sex together with alcohol or other drugs whilst abroad decreases the likelihood of using protection (52). In our study, the use of condoms whilst having sex together with alcohol was low. This is similar to a university in Greece, where students who used alcohol also showed a lower tendency to use a condom whilst having casual sex (46). Research also suggests that whilst abroad, Swedish exchange students indulge in sexually risky behaviour, such as sex together with alcohol and sex without using a condom (3, 4).

The high degree of sexually risky behaviour, such as more sexual partners and sex together with alcohol, may be due to Swedish exchange students having high self-esteem (4). A high level of self-esteem can bolster the desire to experiment with sex, alcohol, and drugs, which could lead to risky sexual behaviour (53). It has also been shown that low-self-esteem, anxiety and phobic anxiety is associated with a lower intention to use a condom amongst students (11, 54). The results also showed that male prospective exchange students had used cannabis more frequently, and previous research has shown that students who use cannabis have sex without protection more frequently than students who abstain from cannabis (55). There is also a social expectation for university students to drink alcohol and indulge in risky sexual behaviour (56).

For many students, exchange studies might be a totally new experience that can be challenging but also an opportunity for personal growth. However, exchange studies require commitment and a willingness to take risks, which may discourage many students (57). This could suggest that prospective exchange students are a select group of individuals who are resourceful in many ways but who are also not afraid to take risks. It is, however, possible that the exchange students’ risky behaviour could lead to more negative consequences whilst abroad compared to being at home, due to an unknown environment, new culture and social contacts.

As our result showed that sexually risky behaviour and high alcohol consumption were prominent amongst prospective exchange students, it could be beneficial to address these areas before departure. All Swedish universities have an established student health department, with a unique possibility to reach out to prospective exchange students to provide support and proactive measures to ensure good health. Examples of proactive measures from the student health department could be to; distribute free condoms, encourage students to look up locations for sexual health clinics in advance, and distribute preventive information about STI and safe sex prior to departure. Other examples could be to encourage prospective exchange students to investigate the local norms and cultural views on alcohol before departure and to locate healthcare facilities and police stations in advance. This includes learning the name of said facilities in the local language.

Generally, it can be difficult to prevent sexually risky behaviour by providing written information about safe sex, especially for exchange students (4). Further research is needed on how to reach out to prospective exchange students about safe sex and alcohol consumption.

The results show that risky alcohol use and sexually risky behaviour is prominent amongst prospective exchange students. It is possible that they will continue, and even increase, their risky behaviour whilst abroad as they find themselves in a new social context, and free from influence of the rules and restrictions they might have back home. With limited knowledge of the local culture, native language, and in an unfamiliar environment, it is possible that the risks will be enhanced and possibly decrease their health. This highlights the need for proactive interventions, conceivably with some variations in content between sexes.

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found at: https://snd.gu.se/sv/catalogue/study/2020-68.

The studies involving human participants were reviewed and approved by Regional Ethical Review Board, Linköping (Dnr 2017/504-3). Written informed consent was not provided because detailed information about the content of the survey as well as the aim of the study were included in the information letter and survey instructions. We therefore assumed that those who, for any reason, did not want to participate in the survey, abstained from participating. Completing and submitting the online questionnaire was considered informed consent according to the approved protocol by the Regional Ethical Review Board.

All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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