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Chapter 8 Advising Travelers with Specific Needs

Study Abroad & Other International Student Travel

Gary Rhodes, Inés DeRomaña, Bettina N. Pedone

Study abroad can be a life-changing and positive experience. However, with increasing numbers of students choosing to study in regions where health and safety concerns differ from those in the United States, students and their families must plan for and understand the risks of such travel. This planning should include researching the policies of the study-abroad program administrator, learning about health and safety risks at the destination, making plans to mitigate those risks, and obtaining advice from a health care professional before departure.

Study-abroad programs vary in structure and staffing, the support provided by the program, and obligations placed on students. Some institutions have several employees dedicated to supporting study-abroad programs while others have no full-time staff members. Some hire specialized professionals to focus on health and safety issues; others have no staff dedicated to such support. Some institutions require students to carry insurance that includes accident and illness coverage, 24-hour emergency assistance, emergency medical evacuation, and repatriation. Other institutions may recommend obtaining travel insurance for study abroad but may provide limited or no information about available options.

Whether or not a university offers pretravel health clinic support, students should consult with a medical professional as a part of the planning process. This consultation should include information on endemic health issues in the host country, travel vaccinations, availability and legality of medications commonly prescribed in the United States, and information on how to obtain medical care abroad.

PREDEPARTURE PLANNING

Program professionals should collaborate with institutional health practitioners to provide students with comprehensive pretravel consultations that include an assessment of the student’s health and immunization history, length of program, destination country, activities, and other travel the student will undertake while abroad. The consultation should also cover the following:

  • Country- and region-specific health and environmental information
  • A plan for continued treatment while abroad
  • Gender-specific health information
  • Required, recommended, and routine vaccinations
  • Recommended prophylactic and self-treatment medications and first aid kit (see Chapter 2, Travel Health Kits)
  • Advice and resources for students with special needs, including specific plans for students with preexisting conditions that include provisions for medications, ongoing care, and emergency treatment
  • Information about physiologic and psychological consequences students may encounter as a result of culture shock or changes in routine
  • General advice on nutrition and dietary deficiencies
  • Cautions about alcohol and drug use and a specific plan for those with preexisting dependency issues
  • Rabies education (avoid feeding or petting animals, and postexposure measures)
  • Bloodborne pathogens precautions (needles, blood products, tattoos, piercing, surgeries, acupuncture) and safe sex (including emergency contraception)
  • General instructions for emergency medical situations, including locating a physician abroad (see Chapter 2, Obtaining Health Care Abroad)
  • Illness and accident insurance policies and emergency assistance coverage information, including medical and evacuation insurance
  • Pretravel medical and dental exams and treatment as indicated

Before departure, program professionals and health practitioners should encourage students to learn about the countries they will visit to better understand the health and safety issues there, as well as the cultural and political climate. The information in the Humanitarian Aid Workers section earlier in this chapter can be useful for students participating in study abroad, internships, field studies, community service projects, or research in the developing world.

The Department of State’s online resource for students (http://studentsabroad.state.gov) includes information to help students plan healthy and safe experiences abroad. Their travel website (http://travel.state.gov) provides country-specific information, including guidance on crime and transportation safety. Advise students to be aware of possible travel warnings or travel alerts and to consider this information when making travel decisions. Students also should know how to get help from a US embassy or consulate in an emergency. Encourage students who are not US citizens to contact their country’s embassy or consulate in the United States and in the countries where they will be traveling to find out what support their country may provide.

Before departure, students should register with the Department of State’s Smart Traveler Enrollment Program (STEP, https://step.state.gov/step). Program professionals may be able to register their students as a group with STEP.

The CDC Travelers’ Health website (www.cdc.gov/travel) contains advice for travelers on the most current health recommendations for international destinations. Other resources for study abroad are provided in Table 8-07.

HEALTH AND SAFETY WHILE ABROAD

Food and Water Safety

Food and water contamination is one of the leading causes of illness for travelers. Basic precautions can minimize the risk of diarrhea and other illnesses. Specific food and water recommendations depend on the destination country. In most developing countries, the only safe sources of water are factory-sealed bottles or water that has been purified (see Chapter 2, Water Disinfection for Travelers). Advise students to avoid ice in drinks, as the ice may have been made with unsafe water.

Cooked foods should be eaten hot; raw fruits and vegetables should be eaten only if they have been washed in clean water or peeled by the traveler. Poor refrigeration, undercooked meat, and food purchased from street vendors could pose problems related to food contamination. See Chapter 2, Food and Water Precautions for more information. Travelers may also wish to download CDC’s Can I Eat This? app (wwwnc.cdc.gov/travel/page/apps-about) for on-the-go safe food and water guidance.

Adherence to Host Country Laws and Codes of Conduct

The rules and regulations of the host country, city, region, and institution may differ from those at home. Students should be counseled that they must abide by the legal system of their host country. Additional information on host country laws may be found on the Department of State website (http://travel.state.gov).

Mental and Physical Health

International travel can be stressful for many reasons. Dealing with stressful situations abroad may be difficult for students away from their familiar support systems and could trigger mental and physical issues. Existing health conditions can be made worse when adjusting to unfamiliar food, a different climate, and different time zones. To minimize potential problems, students must consider their own mental and physical well-being when deciding on an experience abroad and discuss their destination, local resources, and any existing medical or mental health issues with their families and health professionals.

The NAFSA: Association of International Educators’ publication, “Best Practices in Addressing Mental Health Issues Affecting Education Abroad Participants” (www.nafsa.org/mentalhealth) encourages study-abroad programs “to sensitively offer support that connects the student to professional help before a problem reaches a crisis state or seriously derails the student’s academic and career plans.”

Students should be encouraged to disclose any chronic physical or mental health conditions or accommodation needs before departure. Program professionals can encourage students’ disclosure by assuring confidentiality and explaining that the information is needed to facilitate a safe experience while abroad—not to prevent them from going.

Once a student has disclosed a chronic or mental health condition, health care professionals can assist with planning for care while abroad. Engaging students in a discussion about potential scenarios they may encounter can help determine their acumen for problem solving and can reveal areas that need further attention before departure. Mobility International USA (www.miusa.org) provides information and resources to support study abroad by students with special needs and can be contacted directly for assistance.

Prescription Medication

Medications commonly prescribed in the United States may not be legal or available in the host country. Well before departure, students should check with the US embassy or consulate in the host country or the International Narcotics Control Board (https://www.incb.org) regarding the legality of their prescription medications— particularly if they take narcotic or psychotropic drugs. They also should discuss with their health care providers whether some medications should be changed, and allow sufficient time to make adjustments before departure. Students should avoid switching medications immediately before departure and should not discontinue prescribed medications while abroad unless instructed by a health care professional.

Students must travel with a signed prescription for all medications. The prescription must indicate the name of the student, the name of the medication (both brand name and generic), and the dosage and quantity prescribed. The student should also have a letter from the US treating physician explaining the recommended dosage, the student’s diagnosis, and the treatment. This is especially important for controlled substances and injectable medications. Translations of these documents to the host country language may be helpful. It is a good idea to leave copies of prescriptions with a family member or friend at home. In most countries, arriving with quantities exceeding those prescribed for personal use is prohibited. Students should pack all medications in the original, labeled containers in their carry-on baggage.

Many countries consider marijuana to be illegal. A student possessing marijuana, even with a valid US prescription, may be arrested, prosecuted, and jailed or deported.

If the anticipated term of study exceeds 90 days, students should ask if their doctor can write prescriptions for more than 90 days of medication and should fill all prescriptions before departure, if possible. This reduces the need to purchase medication overseas and lowers the risk of exposure to counterfeit or poor-quality medications abroad (see Chapter 2, Perspectives: Pharmaceutical Quality & Falsified Drugs).

US prescriptions are not accepted by pharmacies overseas. Shipping or mailing medications may not be viable options because many countries’ laws prohibit the mailing of drugs, including prescription medicines. Students who anticipate the need to refill a prescription while abroad must plan to be assessed by a local doctor to obtain a local prescription. Students need to determine whether these appointments will be covered by their insurance policy, as they may be considered preventive care and thus not covered by the policy.

How to Access Medical Care Abroad

Adequate medical care may not be available at all destinations. Providing information to students about quality-of-care issues abroad is important. Serious medical problems may require emergency medical evacuation, which is why students should have accident and illness travel insurance that includes medical evacuation coverage. Many foreign doctors and hospitals may require full cash payment in advance of treatment, as they do not accept US insurance policies. Insurance requirements and limitations may reduce reimbursements. Many students who will need ongoing care while abroad may have to make special arrangements with their insurance travel assistance provider before departure, particularly if the continued care will be expensive. Frank discussions about these issues should take place well in advance of departure.

If the student is covered by travel insurance while abroad, the plan provider may be able to issue a referral for a local doctor. US embassies and consulates maintain a list of doctors and medical facilities in the regions they serve. To locate a US embassy or consulate, visit www.usembassy.gov. Once on the website, look for the lists under the US Citizens Services section of the embassy or consulate website.

For more detailed information, consult Chapter 2: Obtaining Health Care Abroad and Travel Insurance, Travel Health Insurance, & Medical Evacuation Insurance.

Emergency Contacts and Emergency Preparedness

Instruct students to print and fill out an emergency information card with contact numbers and personal information and carry a copy with them at all times. If one is not provided by the program, a sample can be found at http://studentsabroad.com/emergencycard.asp. Students should provide friends and family members at home with emergency contact information for their destination, and should provide study-abroad program officials and the host school with their emergency contacts at home. Students may want to consider programming emergency contact information into their smartphones, if available.

Students should keep program staff and home emergency contacts informed of their whereabouts and activities and provide them with copies of their travel documents (passport, visa, plane tickets, prescriptions) and itinerary. Developing an emergency plan and testing it soon after arrival abroad can help students respond more effectively if a health or safety incident occurs. Resources to help develop and implement an emergency action plan can be found at http://studentsabroad.com/handbook/crisis-management.php.

Sexual Harassment and Sexual Violence

Student travelers will need predeparture information about sexual harassment and assault abroad. Sexual assault can happen to anyone and at any time and any place. Encourage students to watch out for one another and to get advice and information from program administrators.

Transportation and Pedestrian Safety

Traffic crashes are a major cause of injury to students while traveling abroad. Vehicular traffic is not always regulated to the extent it is in the United States, and traffic laws may differ. For instance, students should be made aware of countries where traffic travels on the left side of the road instead of the right as in the United States. If not aware, students may look in the wrong direction for oncoming traffic and risk being hit by a car.

Students should also be counseled to choose safe and legitimate modes of travel in their destination countries. Each US Department of State country information sheet includes “Traffic Safety and Road Conditions” content to help assess conditions in a specific country. A good source of information on transportation safety is the Association for Safe International Road Travel at www.asirt.org.

Water and Swimming Safety

Students must be careful and informed about water safety before approaching unfamiliar bodies of water. Warn students not to swim alone or on beaches where there are no lifeguards or warning signs.

Swimming in contaminated water can put students at risk for contracting certain infectious diseases. Inform students about common waterborne pathogens, especially those in freshwater.

Building and Fire Safety

Students should think about building safety at their destination, including the potential impact of earthquakes, wind damage or flooding, and substandard building standards or maintenance practices. Fire safety is of particular concern. Students should evaluate buildings for the presence of functioning smoke alarms, fire extinguishers, emergency ladders, and fire exits.

Air Pollution

Air pollution is a problem in many cities around the world and can exacerbate symptoms for students with chronic health conditions. Even if students are healthy, they may experience temporary symptoms such as irritation of the eyes, nose, and throat; coughing; phlegm; chest tightness; and shortness of breath.

Alcohol and Drugs

The misuse of alcohol and drugs can increase the risk of accidents, injury, unwanted attention, and theft. Being in a foreign environment requires the ability to respond to new and changing circumstances, which can be impaired under the influence of drugs or alcohol. Many students are not of legal drinking age in the United States but are in the host country. Many do not receive adequate alcohol- and drug-prevention education explaining the consequences of risky drinking and drug abuse before departure. Violating drug laws abroad may result in serious consequences. In some countries, being found guilty of violating drug laws can lead to life in prison or the death penalty. Study-abroad professionals, in collaboration with institutional experts, should conduct a proper orientation about the risks associated with drinking and using drugs abroad.

Bloodborne Pathogens and Safe-Sex Precautions

Advise students on risk factors associated with the use of needles, blood products, tattoos, piercing, surgeries, and acupuncture. Most people are aware of the risk of contaminated needles, but students also need to know that the water used to create tattoo ink is often shared and can be contaminated with bloodborne pathogens.

Students should be encouraged to be prepared. Have frank conversations about safe sex (bring adequate condoms, birth control, and emergency contraception) and encourage students to educate themselves on social customs of their host city and country with regard to dating, public displays of affection, and sexual intimacy.

Table 8-07. Study-abroad resources

ORGANIZATION DESCRIPTION

NAFSA: Association of International Educators, www.nafsa.org

Useful information for institutions implementing studyabroad programs, as well as information for students to support their health and safety
Responsible Study Abroad: Good Practices for Health & Safety, by the Interorganizational Task Force for Safety and Responsibility in Study Abroad http://www.nafsa.org/Find_Resources/Supporting_Study_Abroad/Network_Resources/Education_Abroad/Responsible_Study_Abroad__Good_Practices_for_Health___Safety/ Advice for developing plans and procedures to implement good practices for program sponsors, students, and parents/guardians/families, especially those pertaining to health and safety issues

Council on Standards for International Educational Travel (CSIET), www.csiet.org/

Standards for exchange programs for US high-and middle-school students going abroad
Health and safety good practices
Center for Global Education, SAFETI (Safety Abroad First–Educational Travel Information) Clearinghouse
http://globaled.us/safeti
Resources to support study-abroad program development and implementation, emphasizing health and safety issues and resources for US colleges and universities supporting study abroad
SAFETI Program Audit Checklist
http://globaled.us/SAFETI/program_audit_checklist.asp
http://studentsabroad.com
List of health and safety and study-abroad issues to guide institutions’ policies and procedures
Resource website for students that includes a country-specific handbook
GlobalScholar and GlobalStudent: Online Learning for Study Abroad
http://globalscholar.us
http://globalstudent.us
University- and high school-level online courses that provide students with helpful information, including health and safety information before, during, and after study abroad
Forum on Education Abroad www.forumea.org Standards of good practice, a code of ethics, and resources for institutions and organizations that sponsor and support study-abroad programs
Federal Bureau of Investigation https://www.fbi.gov/file-repository/student-travel-brochure-pdf.pdf A brochure that introduces students to threats they may face and provides tips on avoiding unsafe situations

BIBLIOGRAPHY

  1. Forum on Education Abroad. Code of ethics for education abroad. Carlisle, PA: Forum on Education Abroad; 2008 [cited 2016 Sep. 27]; Available from: https://forumea.org/resources/standards-of-goodpractice/code-of-ethics/.
  2. Gore J, Green J. Issues and advising responsibilities. NAFSA’s Guide to Education Abroad for Advisors and Administrators. 3rd ed. Washington, DC: NAFSA Association of International Educators; 2005. p. 261.
  3. Institute of International Education. Americans study abroad in increasing numbers. New York: Institute of International Education; 2009 [cited 2016 Sep. 27]; Available from: http://www.iie.org/en/Who-We-Are/News-and-Events/Press-Center/Press-Releases/2009/2009-11-16-Americans-Study-Abroad-Increasing.
  4. Institute of International Education. Host regions of US study abroad students, 2012/13-2013/14. New York: Institute of International Education; 2013 [cited 2016 Sep. 27]; Available from: http://www.iie.org/Research-and-Publications/Open-Doors/Data/USStudy-Abroad/Leading-Destinations/2012-14.
  5. Interorganizational Task Force on Safety and Responsibility in Study Abroad. Responsible study abroad: good practices for health and safety. Washington, DC: NAFSA: Association of International Educators; 2002 [cited 2016 Sep. 27]; Available from: http://www.nafsa.org/Find_Resources/Supporting_Study_Abroad/Network_Resources/Education_Abroad/Responsible_Study_Abroad__Good_Practices_for_Health___Safety/.
  6. NAFSA: Association of International Educators. Best practices in addressing mental health issues affecting education abroad participants. Washington, DC: NAFSA: Association of International Educators; 2006 [cited 2016 Sep. 27]; Available from: http://www.nafsa.org/mentalhealth.
  7. Pedersen ER, LaBrie JW, Hummer JF. Perceived behavioral alcohol norms predict drinking for college students while studying abroad. J Stud Alcohol Drugs. 2009;70(6):924–8.
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