Scandinavian Journal of Infectious Diseases
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Travel health advice: Benefits, compliance, and outcome Martin Angelin, Birgitta Evengård & Helena Palmgren To cite this article: Martin Angelin, Birgitta Evengård & Helena Palmgren (2014) Travel health advice: Benefits, compliance, and outcome, Scandinavian Journal of Infectious Diseases, 46:6, 447-453 To link to this article: http://dx.doi.org/10.3109/00365548.2014.896030
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Date: 05 November 2015, At: 14:09
Scandinavian Journal of Infectious Diseases, 2014; 46: 447–453
ORIGINAL ARTICLE
Travel health advice: Benefits, compliance, and outcome
MARTIN ANGELIN, BIRGITTA EVENGÅRD & HELENA PALMGREN
Scandinavian Journal of Infectious Diseases 2014.46:447-453.
From the Division of Infectious Diseases, Department of Clinical Microbiology, Umeå University, Umeå, Sweden
Abstract Background: Travel health advice is an important and difficult part of a pre-travel consultation. The aim of this study was to determine whether the travel health advice given is followed by the traveller and whether it affects disease and injury experienced during travel. Methods: A prospective survey study was carried out from October 2009 to April 2012 at the Travel Medicine Clinic of the Department of Infectious Diseases, Umeå University Hospital, Umeå, Sweden. The Travel Medicine Clinic in Umeå is the largest travel clinic in northern Sweden. Results: We included 1277 individuals in the study; 1059 (83%) responded to the post-travel questionnaire. Most visitors (88%) remembered having received travel health advice; among these, 95% found some of the health advice useful. Two-thirds (67%) claimed to have followed the advice, but fell ill during travel to the same extent as those who did not. Younger travellers (⬍ 31 y) found our travel health advice less beneficial, were less compliant with the advice, took more risks during travel, and fell ill during travel to a greater extent than older travellers. Conclusions: Helping travellers stay healthy during travel is the main goal of travel medicine. Younger travellers are a risk group for illness during travel and there is a need to find new methods to help them avoid illness. Travellers find travel health advice useful, but it does not protect them from travel-related illness. Factors not easily influenced by the traveller play a role, but a comprehensive analysis of the benefits of travel health advice is needed.
Keywords: Travel health advice, illness during travel, risk behaviour during travel, risk groups in travel medicine, compliance with travel health advice
Introduction International travel is constantly increasing. Departures from Swedish airports reached 11.8 million in 2012 compared to around 3 million in 1970 [1]. In 2002–2003, an airport survey at several European airports showed that 52% of passengers departing for developing countries had sought travel health advice prior to travel [2]. Travel health advice is a difficult part of a pretravel consultation. There are a number of areas related to travel health advice in need of further study, such as the content of the advice and the methods and time used to give the advice; a better understanding of differences in traveller risk assessment is also needed [3–5]. Umeå is the most northern university city of Sweden and has a population of 112,000. During the study period (y 2009–2011), an average 1140 appointments with doctors and 7050 appointments
with nurses took place at the Travel Medicine Clinic in Umeå annually. The clinic is a part of the public healthcare service in Sweden and is administered by the County Council of Västerbotten. Visitors to the clinic pay a consultation fee (approximately 46 USD) and vaccines are provided at cost price. In a previous study at the Travel Medicine Clinic in Umeå we examined the demographics of travellers, their travel destinations, and their levels of vaccination [6]. We found sex differences in vaccinations received and a difference in inclination to seek a pre-travel consultation depending on the travel destination. In the present study we were interested to learn how our health advice is received by our visitors. The aim of this study was to determine whether the health advice given is relevant to the travellers’ experiences during travel and if they comply with the advice. A third objective was to investigate if compliance with
Correspondence: M. Angelin, Department of Infectious Diseases, University Hospital of Umeå, SE-901 85 Umeå, Sweden. Tel: ⫹ 46 90 7852306. Fax: ⫹ 46 90 133006. E-mail: [email protected] (Received 30 November 2013 ; accepted 22 January 2014 ) ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.896030
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health advice is related to a lower rate of travelrelated illness.
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Materials and methods This was a prospective survey study carried out from October 2009 to April 2012 at the Travel Medicine Clinic of the Department of Infectious Diseases, Umeå University Hospital, Umeå, Sweden. Inclusion criteria were the following: Swedish speaking, aged 18 y or older, and scheduled to see a doctor. Visitors seeing a doctor during their visit are embarking on trips for which multiple vaccines and/or malaria prophylaxis may be needed. In seeing a doctor they receive both oral and written health advice. This includes advice on hygiene and food security, travel diarrhoea, malaria, skin afflictions, animal bites, traffic accidents, drowning, sexually transmitted diseases (STDs), and recommendations for appropriate medications to take with them. The duration of a Travel Medicine Clinic visit is 15 min. During the study period, 15 different doctors delivered health advice to travellers. All doctors are trained in giving travel health advice according to the same educational protocol. Upon inclusion in the study, all participants filled out a short pre-travel questionnaire with details concerning their trip, such as duration of travel, travel destination, and type of travel. Two weeks after they returned home from the trip in question, they received a post-travel questionnaire with questions regarding their perceptions of and compliance with the health advice they had received, any travelrelated illness, and risk behaviours during travel. This second questionnaire was available both in printed form and as a web survey constructed using the software Lime Survey [7]. In order for the study participants to respond anonymously, the questionnaires were coded. The questions on illness and compliance with malaria prophylaxis during travel have been validated in a previous study by Ahlm et al. [8]. We added questions regarding opinions of and compliance with health advice, sexual behaviour during travel, and protective measures against accidents and crime. Before the start of the study, the questionnaire was tested on a control group of 10 travellers and some of the wording was changed. Most questions were quantitative, with response alternatives given; psychometric scales were not used. Openended questions regarding health advice and protective measures against accidents and crime were also included. The content of these latter questions was analysed quantitatively. A power analysis was performed before the start of the study. In order to identify differences of 3% in
the data, we needed to include 1068 individuals in the analysis. Informed consent was obtained from all study participants. Approval from the Umeå University ethics board was obtained before the start of the study.
Data analysis Data processing and statistical analysis were carried out in Microsoft Office Excel 2007 and IBM SPSS version 21.0 (IBM Corp., Armonk, NY, USA). The Chi-square test was used for categorical data. Regression analysis was carried out using binary logistic regression. A p-value of ⱕ 0.05 was considered statistically significant.
Results During the study period, 2596 individuals were eligible for participation. In total 1277 individuals were included in the study. Reasons for not participating in the study were either logistical inclusion problems at the clinic, or that the potential participant declined to participate. The proportions in these 2 groups are not known. Of those included in the study, 1059 (83%) responded to the post-travel questionnaire; among these, 79% (n ⫽ 835) responded to the web format questionnaire. There was no statistically significant difference in age or sex distribution between study participants, those who chose not to participate in the study, and those lost to follow-up. All results were tested for differences related to the sex and age of the travellers.
Demographics The demographics of the study participants can be found in Table I. Women had a lower median age than men. Younger travellers undertook longer trips than older travellers. Although most travelled for tourism, 40% travelled for study or work. Before travel Most visitors (77%, 789/1029) had sought travel health information, mainly on the internet (89%, 704/789), prior to their visit to the travel clinic. Women sought travel health information to a greater extent than men: 81% (500/614) compared to 70% (289/415); p ⬍ 0.001. Previous experience of travel to Asia, Africa, and/or South America was reported by 76% (790/1033).
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Table I. Demographics of study participants. Sex (n ⫽ 1059)
Female 59% (n ⫽ 630) Male 41% (n ⫽ 429) 31 y (range 18–85 y), quartiles 24, 31, 51 y Men 40 y, women 27 y 28 days (range 4–365 days), quartiles 15, 28, 50 days 18–23 y, 42 days; 24–30 y, 35 days; 31–50 y, 21 days; ⱖ 51 y, 18 days Tourism 59% (n ⫽ 629), work 20% (n ⫽ 211), studies 20% (n ⫽ 215), visiting friends and relatives 2% (n ⫽ 17) Thailand 14% (n ⫽ 151), Tanzania 14% (n ⫽ 150), India 13% (n ⫽ 140), Malaysia 10% (n ⫽ 105), Vietnam 8% (n ⫽ 86)
Median age (n ⫽ 1035) Median travel duration (n ⫽ 1059) Reason for travela (n ⫽ 1059) Five most popular destinationsb (n ⫽ 1057) aMultiple
answers allowed. Africa was the most popular continent (49%, n ⫽ 410), followed by Southeast Asia (28%, n ⫽ 297).
bSub-Saharan
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Health advice and illness during travel Among the respondents, 88% (930/1052) remembered having received health advice at their pre-travel clinic visit. Younger travellers felt that they benefited less from our health advice and fell ill to a greater extent than older travellers; these differences were statistically significant (Table II; p ⬍ 0.001). Missing advice. In response to an open-ended question about travel advice, 12% (113/930) reported advice they felt was not addressed during their pre-travel consultation. The responses included: more accurate information on the local malaria risk (n ⫽ 22), better information on malaria prophylaxis (side effects/alternative therapies) (n ⫽ 13), gastrointestinal illness and risk (n ⫽ 27), vaccines and vaccine-preventable diseases (n ⫽ 14), rabies risk (n ⫽ 12), what to bring in a travel pharmacy (n ⫽ 10), self-treatment/quality of medical care at travel destination (n ⫽ 8), parasitic infections (n ⫽ 6), and traffic risks (n ⫽ 4). Risks during travel. Table III shows the results of binary logistic regression analysis with variables showing a significant association. Young age, longer duration of travel, and travel to India were associated with increased risks during travel. The sex of the traveller and traveller compliance with health advice showed a significant association in a bivariate analysis (Chi-square test) but not in the regression analysis. Parameters included in the analysis were sex, age, travel duration, type of travel, 10 most
popular travel destinations, and compliance with travel health advice. Skin infection affected 3% (28/1046) and urinary tract infection 2% (18/1046); ⬍ 1% (6/1046) were diagnosed with malaria (3/6 reported that they took their prophylaxis as instructed). An animal bite with a potential rabies risk was stated by ⬍ 1% (7/1041). Involvement in a traffic accident was reported by 2% (18/1041): 3% (16/503) of those aged ⬍ 31 y and ⬍ 1% (2/514) of those aged ⬎ 30 y (p ⫽ 0.001). Theft/robbery was experienced by 7% (71/1041) during travel. Travel ⬎ 1 month had an increased risk, with an odds ratio (OR) of 5.7 (95% confidence interval (CI) 3.1–10.6; p ⬍ 0.001), as did age ⬍ 31 y, with OR 2.1 (95% CI 1.2–3.9, p ⬍ 0.05).
Behaviour during travel Malaria prevention. Out of the 1059 individuals included in the study, 61% (645) visited a malaria endemic area and were prescribed malaria chemoprophylaxis. Travellers to malaria endemic areas stated similar reasons for travel as the whole study population (Table I). Only 1% (8/645) were visiting friends and relatives in their country of origin (VFR). Self-reported adherence to chemoprophylaxis was 67% (435/645). Adherence was correlated to the age of the traveller (58% (88/153) in the youngest quartile compared to 88% (149/169) in the oldest quartile), travel duration (76% (263/344) for trips shorter than 1 month compared to 57% (172/301) for trips longer than 1 month), and travel to malaria
Table II. Health advice and illness during travel.
Age quartiles (y) 18–23 24–30 31–50 ⱖ 51
Advice helped to Always Found advice Found advice avoid illness and/or followed advice helpful (n ⫽ 855) relevant (n ⫽ 829) accident (n ⫽ 800) (n ⫽ 905) 42% 45% 61% 64%
(84/202) (103/227) (127/207) (141/219)
64% 67% 76% 79%
(129/202) (149/223) (151/199) (161/205)
33% 31% 39% 54%
(62/189) (68/220) (73/189) (110/202)
57% 64% 70% 76%
(123/216) (154/241) (153/219) (174/229)
Illness (n ⫽ 1029) 52% 46% 34% 30%
(127/243) (122/263) (87/259) (79/264)
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M. Angelin et al. Table III. Illness during travel. All illness 40% (424/1053) Travellers’ diarrhoea 33% (342/1046) Respiratory tract infection 13% (133/1046) Skin wound 14% (148/1041)
Age ⬍ 31 y Travel to India Age ⬍ 31 y Travel to India Age ⬍ 31 y Travel ⬎ 1 month Age ⬍ 31 y Travel ⬎ 1 month
OR OR OR OR OR OR OR OR
1.6 (95% CI 1.1–2.4)a 1.9 (95% CI 1.2–3)b 1.7 (95% CI 1.2–2.6)b 2.5 (95% CI 1.6–3.9)c 2.1 (95% CI 1.2–3.8)a 2 (95% CI 1.2–3.4)a 2.4 (95% CI 1.6–3.6)c 1.8 (95% CI 1.2–2.6)a
OR, adjusted odds ratio; 95% CI, 95% confidence interval. ap ⬍ 0.05.
bp ⬍ 0.01.
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cp
⬍ 0.001.
endemic regions in Sub-Saharan Africa (78% (294/ 376) compared to 52% (141/269) for travel to other malaria endemic regions where chemoprophylaxis is recommended). Correlations remained significant after analysis with binary logistic regression; p ⬍ 0.001 for all correlations. Reasons for non-adherence were the following: did not experience malaria as a risk at the travel destination (24%, 51/210), felt it was unnecessary (23%, 48/210), forgetfulness (20%, 43/210), and side effects (17%, 35/210). One of 4 drugs was prescribed: atovaquone/proguanil (68%, 444/645), mefloquine (18%, 118/645), chloroquine (4%, 24/645), and doxycycline (1%, 8/645); 9% (55/645) did not remember which drug they had been prescribed. No significant difference in relation to cessation of prophylaxis because of side effects was seen between the different anti-malarials. For personal protection against malaria, 63% (409/645) stated that they used bed nets, 76% (493/645) mosquito repellents, 47% (300/645) long sleeved clothing, and 48% (311/645) slept with the windows closed. In total, 77% (496/645) used either bed nets or slept with the windows closed. Personal protection was assessed for those who were prescribed chemoprophylaxis. Traffic. Only half of the travellers (50%, 527/1048) used seat belts during travel, however 40% (420/1048) stated that this was because of non-availability. Renting of a motorcycle during travel was reported by 13% (138/1042); 70% of these used a helmet (96/138). Younger travellers were significantly more likely to rent a motorcycle: 21% (103/499) if aged ⬍ 31 y compared to 7% (34/519) aged ⬎ 30 y; p ⬍ 0.001. Accidents and personal security. Answers to the openended question on accidents and personal security fell into the following behavioural categories: (1) was careful with valuables, 41% (424/1035); (2) watchful behaviour after dark, 21% (216/1035); (3) avoided
walking alone, 14% (147/1035); (4) tried to minimize risks in traffic, 12% (121/1035); (5) was generally attentive, 10% (103/1035). In total, 62% (639/1035) reported that they had taken action regarding accidents and personal security. This was more common among women (69%, 430/620) than men (50%, 209/415); p ⬍ 0.001. Sexual behaviour. One in 10 (9%, 94/1045) met a new sexual partner during travel and 53% (50/94) found their new partner among the local population at the travel destination. The likelihood of meeting a new sexual partner was related to duration of travel (16% (78/484) for trips ⬎ 1 month compared to 3% (16/561) for trips ⬍ 1 month) and the age of the traveller (15% (76/502) for travellers aged 18–30 y and 3% (17/519) for travellers aged ⬎ 30 y) (p ⬍ 0.001 for both correlations). Only 53% (50/94) always used a condom. Women were as likely as men to meet a new sexual partner during travel. Discussion In order to prepare the traveller in the best way, it is important to obtain feedback from the travellers themselves. We could find little data in the literature on feedback from travellers on the health advice received. This study was also designed to identify areas of pre-travel health advice in need of improvement. The number of travellers visiting friends and relatives in their country of origin (VFRs), a risk group for travel-related illness [9], was small in this study, mainly because the survey was only available in Swedish. Previous studies have shown that this group also seeks travel health advice to a lesser extent [2,9]. A majority of our visitors had previously travelled to countries in Asia, Africa, or South America and the majority sought health information prior to their visit to our travel clinic. Meeting travellers with previous knowledge of travel health makes it necessary to adapt the travel health information given. Verifying
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Evaluating travel health advice the traveller’s knowledge and correcting any misinformation is important. Pre-existing knowledge and beliefs can affect the traveller’s perception of risk and the likelihood of the health advice given being followed; if not addressed, this will often result in partial adherence [3]. Our results show that 67% (618/929) reported having fully adhered to the health advice given. Suboptimal adherence can be due to factors other than choice, such as not being able to use a seatbelt because there are none. Another factor affecting adherence to health advice discussed by Bauer [5] is poor recall. We found that 12% of respondents did not remember any advice at all. Studies on health advice show that individuals forget half of the message in a consultation in 5 minutes and by best remember the first one-third of the information provided [5]. This is important to consider when delivering travel health advice. We also learned that younger travellers found our health advice less beneficial and followed the advice to a lesser extent. Reported compliance with travel health advice was not shown to be protective against travel-related illness in this study. It is probable that risk factors not easily influenced by the traveller are important in travel-related illness, for example factors such as hygiene standards in restaurants [10–12], droplet spread of respiratory tract infections, and the local traffic situation. That travellers, despite following advised hygiene precautions, contracted travellers’ diarrhoea, confirms previous findings [10–15]. Hygiene precautions can also be difficult to follow [10,12,16]. Very few study participants stated that they did not benefit at all from our health advice. So it appears that the travellers found our advice helpful but that it did not protect them from falling ill during travel. Infections with longer incubation periods could have been missed in this study since the second questionnaire was administered 2 weeks after travel. Our visitors requested more advice on local malaria risk. Available malaria prevalence data are often not geographically and seasonally precise. Discrepancies in the advised and actual malaria risk are also mentioned as a reason for cessation of malaria prophylaxis. Younger travellers fell ill to a greater extent than older travellers. The fact that younger travellers are a risk group for travel-related illness confirms the results of previous studies [8,10,14,16–18]. Aro et al. showed that younger travellers are more willing to take health-related risks during travel [4] and thus have a greater need for health advice. Younger travellers seek travel health advice to the same extent as older travellers [19–22]. Among the participants in our study, younger travellers demonstrated lower adherence to malaria chemoprophylaxis, were more
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likely to rent a motorcycle during travel, and had a higher probability of meeting a new sexual partner during their trip. They were also more likely to be involved in a traffic accident and to face theft/ robbery during their trip. Lower adherence to malaria prophylaxis for younger travellers was seen by Alon et al. [18] and Sagui et al. [23], but Pistone et al. [24] found younger travellers to have higher adherence to prophylaxis. In their review from 2010, Vivancos et al. found that young age was correlated to an increased likelihood of meeting a new sexual partner during travel [25]. These findings highlight the importance of risk communication in a travel health consultation. If the traveller does not perceive the topic discussed in the pre-travel consultation to be a risk that requires avoidance, it is unlikely that the advice given will be followed [3,5]. Women were more likely to take steps to reduce the risk of accidents, theft, and/or assault. The overall number of travellers who took these steps was lower than desired and this aspect should be stressed in the travel health consultation. Unfortunately evidence-based advice in this respect is scarce and common sense advice is usually used [26]. Among those who experienced theft/robbery during their trip, 79% (49/62) reported taking some of these steps compared to 65% (414/642) for those who were not robbed. This may reflect differences in travel characteristics. The strongest correlation with increased risk of theft/robbery was travel duration. Previous data on this topic are difficult to obtain. A 2003–2004 study on humanitarian relief expatriates showed that 3.5% were involved in a traffic accident and 4% were robbed during their stay abroad [27]. We found that 2% of travellers were involved in a traffic accident. Travellers engaging in sexual contact with new partners during travel practiced safe sex to the same extent as shown previously [28,29]. No reduction in this risk behaviour was seen. We found that women were as likely as men to meet a new sexual partner during travel, in contrast to previous findings in a review by Vivancos et al. [28]. Casual travel sex as compared to casual sex at home is correlated with a 3-fold increased risk of contracting an STD [28]. A 3.4% risk of primary HIV associated with unprotected casual travel sex has been reported [30]. It is important to communicate the risks involved in unprotected casual sex to travellers. Older age, shorter trip, and travel to a high-risk area for severe malaria (Sub-Saharan Africa) were related to increased self-reported compliance with malaria chemoprophylaxis. The level of compliance with chemoprophylaxis found in this study is lower than desired but in line with previous findings. Previous studies have shown varying compliance levels regarding malaria chemoprophylaxis, ranging from
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47% to 89% [15,18,31–34]. Malaria is responsible for most of the deaths due to infectious diseases among travellers [29]. In this study we identified a need for new methods to help younger travellers avoid illness during travel. To approach this need, we must learn more, for example through the help of age-specific focus group discussions. The use of modern technology, such as new forms of communication, has to our knowledge not been evaluated in pre-travel advice. The use of smart phone applications as a support for changing health behaviour may be a method of interest to young people, in addition to the use of text messaging-delivered interventions [35]. Internet-delivered interventions with regular updates by phone or e-mail could also be used [36]. Helping travellers stay healthy during travel is the main goal of travel medicine. The value of travel health advice should be investigated further since reported adherence was not associated with a lower rate of illness during travel. When advice is given, it needs to be evidence-based and tailored to the recipient with respect to both their background and their travel itinerary.
Acknowledgements We would like to thank Maria Casserdahl and Madelaine Sillfors for their work with data processing. We also thank Klara Brändström, Maria Casserdahl, Ulla Gunnarsson, Linda Olsson, Ann Catrin Tegenfeldt, and Anna Wännman for their invaluable help with the inclusion of study participants. Declaration of interest: This study was funded solely by the Division of Infectious Diseases, Department of Clinical Microbiology, Umeå University, Umeå, Sweden. References [1] Swedish Transport Agency. Available at: http://www. transportstyrelsen.se/sv/Luftfart/Statistik/Flygplatsstatistik-/ (in Swedish) (accessed 14 November 2013). [2] Van Herck K, Castelli F, Zuckerman J, Nothdurft H, Van Damme P, Dahgren AL, et al. Knowledge, attitudes and practices in travel-related infectious diseases: the European airport survey. J Travel Med 2004;11:3–8. [3] Noble LM, Willcox A, Behrens RH. Travel clinic consultation and risk assessment. Infect Dis Clin North Am 2012;26: 575–93. [4] Aro AR, Vartti AM, Schreck M, Turtiainen P, Uutela A. Willingness to take travel-related health risks—a study among Finnish tourists in Asia during the avian influenza outbreak. Int J Behav Med 2009;16:68–73. [5] Bauer IL. Educational issues and concerns in travel health advice: is all the effort a waste of time? J Travel Med 2005; 12:45–52.
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ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Travel health advice: Benefits, compliance, and outcome Martin Angelin, Birgitta Evengård & Helena Palmgren To cite this article: Martin Angelin, Birgitta Evengård & Helena Palmgren (2014) Travel health advice: Benefits, compliance, and outcome, Scandinavian Journal of Infectious Diseases, 46:6, 447-453 To link to this article: http://dx.doi.org/10.3109/00365548.2014.896030
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Date: 05 November 2015, At: 14:09
Scandinavian Journal of Infectious Diseases, 2014; 46: 447–453
ORIGINAL ARTICLE
Travel health advice: Benefits, compliance, and outcome
MARTIN ANGELIN, BIRGITTA EVENGÅRD & HELENA PALMGREN
Scandinavian Journal of Infectious Diseases 2014.46:447-453.
From the Division of Infectious Diseases, Department of Clinical Microbiology, Umeå University, Umeå, Sweden
Abstract Background: Travel health advice is an important and difficult part of a pre-travel consultation. The aim of this study was to determine whether the travel health advice given is followed by the traveller and whether it affects disease and injury experienced during travel. Methods: A prospective survey study was carried out from October 2009 to April 2012 at the Travel Medicine Clinic of the Department of Infectious Diseases, Umeå University Hospital, Umeå, Sweden. The Travel Medicine Clinic in Umeå is the largest travel clinic in northern Sweden. Results: We included 1277 individuals in the study; 1059 (83%) responded to the post-travel questionnaire. Most visitors (88%) remembered having received travel health advice; among these, 95% found some of the health advice useful. Two-thirds (67%) claimed to have followed the advice, but fell ill during travel to the same extent as those who did not. Younger travellers (⬍ 31 y) found our travel health advice less beneficial, were less compliant with the advice, took more risks during travel, and fell ill during travel to a greater extent than older travellers. Conclusions: Helping travellers stay healthy during travel is the main goal of travel medicine. Younger travellers are a risk group for illness during travel and there is a need to find new methods to help them avoid illness. Travellers find travel health advice useful, but it does not protect them from travel-related illness. Factors not easily influenced by the traveller play a role, but a comprehensive analysis of the benefits of travel health advice is needed.
Keywords: Travel health advice, illness during travel, risk behaviour during travel, risk groups in travel medicine, compliance with travel health advice
Introduction International travel is constantly increasing. Departures from Swedish airports reached 11.8 million in 2012 compared to around 3 million in 1970 [1]. In 2002–2003, an airport survey at several European airports showed that 52% of passengers departing for developing countries had sought travel health advice prior to travel [2]. Travel health advice is a difficult part of a pretravel consultation. There are a number of areas related to travel health advice in need of further study, such as the content of the advice and the methods and time used to give the advice; a better understanding of differences in traveller risk assessment is also needed [3–5]. Umeå is the most northern university city of Sweden and has a population of 112,000. During the study period (y 2009–2011), an average 1140 appointments with doctors and 7050 appointments
with nurses took place at the Travel Medicine Clinic in Umeå annually. The clinic is a part of the public healthcare service in Sweden and is administered by the County Council of Västerbotten. Visitors to the clinic pay a consultation fee (approximately 46 USD) and vaccines are provided at cost price. In a previous study at the Travel Medicine Clinic in Umeå we examined the demographics of travellers, their travel destinations, and their levels of vaccination [6]. We found sex differences in vaccinations received and a difference in inclination to seek a pre-travel consultation depending on the travel destination. In the present study we were interested to learn how our health advice is received by our visitors. The aim of this study was to determine whether the health advice given is relevant to the travellers’ experiences during travel and if they comply with the advice. A third objective was to investigate if compliance with
Correspondence: M. Angelin, Department of Infectious Diseases, University Hospital of Umeå, SE-901 85 Umeå, Sweden. Tel: ⫹ 46 90 7852306. Fax: ⫹ 46 90 133006. E-mail: [email protected] (Received 30 November 2013 ; accepted 22 January 2014 ) ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.896030
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health advice is related to a lower rate of travelrelated illness.
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Materials and methods This was a prospective survey study carried out from October 2009 to April 2012 at the Travel Medicine Clinic of the Department of Infectious Diseases, Umeå University Hospital, Umeå, Sweden. Inclusion criteria were the following: Swedish speaking, aged 18 y or older, and scheduled to see a doctor. Visitors seeing a doctor during their visit are embarking on trips for which multiple vaccines and/or malaria prophylaxis may be needed. In seeing a doctor they receive both oral and written health advice. This includes advice on hygiene and food security, travel diarrhoea, malaria, skin afflictions, animal bites, traffic accidents, drowning, sexually transmitted diseases (STDs), and recommendations for appropriate medications to take with them. The duration of a Travel Medicine Clinic visit is 15 min. During the study period, 15 different doctors delivered health advice to travellers. All doctors are trained in giving travel health advice according to the same educational protocol. Upon inclusion in the study, all participants filled out a short pre-travel questionnaire with details concerning their trip, such as duration of travel, travel destination, and type of travel. Two weeks after they returned home from the trip in question, they received a post-travel questionnaire with questions regarding their perceptions of and compliance with the health advice they had received, any travelrelated illness, and risk behaviours during travel. This second questionnaire was available both in printed form and as a web survey constructed using the software Lime Survey [7]. In order for the study participants to respond anonymously, the questionnaires were coded. The questions on illness and compliance with malaria prophylaxis during travel have been validated in a previous study by Ahlm et al. [8]. We added questions regarding opinions of and compliance with health advice, sexual behaviour during travel, and protective measures against accidents and crime. Before the start of the study, the questionnaire was tested on a control group of 10 travellers and some of the wording was changed. Most questions were quantitative, with response alternatives given; psychometric scales were not used. Openended questions regarding health advice and protective measures against accidents and crime were also included. The content of these latter questions was analysed quantitatively. A power analysis was performed before the start of the study. In order to identify differences of 3% in
the data, we needed to include 1068 individuals in the analysis. Informed consent was obtained from all study participants. Approval from the Umeå University ethics board was obtained before the start of the study.
Data analysis Data processing and statistical analysis were carried out in Microsoft Office Excel 2007 and IBM SPSS version 21.0 (IBM Corp., Armonk, NY, USA). The Chi-square test was used for categorical data. Regression analysis was carried out using binary logistic regression. A p-value of ⱕ 0.05 was considered statistically significant.
Results During the study period, 2596 individuals were eligible for participation. In total 1277 individuals were included in the study. Reasons for not participating in the study were either logistical inclusion problems at the clinic, or that the potential participant declined to participate. The proportions in these 2 groups are not known. Of those included in the study, 1059 (83%) responded to the post-travel questionnaire; among these, 79% (n ⫽ 835) responded to the web format questionnaire. There was no statistically significant difference in age or sex distribution between study participants, those who chose not to participate in the study, and those lost to follow-up. All results were tested for differences related to the sex and age of the travellers.
Demographics The demographics of the study participants can be found in Table I. Women had a lower median age than men. Younger travellers undertook longer trips than older travellers. Although most travelled for tourism, 40% travelled for study or work. Before travel Most visitors (77%, 789/1029) had sought travel health information, mainly on the internet (89%, 704/789), prior to their visit to the travel clinic. Women sought travel health information to a greater extent than men: 81% (500/614) compared to 70% (289/415); p ⬍ 0.001. Previous experience of travel to Asia, Africa, and/or South America was reported by 76% (790/1033).
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Table I. Demographics of study participants. Sex (n ⫽ 1059)
Female 59% (n ⫽ 630) Male 41% (n ⫽ 429) 31 y (range 18–85 y), quartiles 24, 31, 51 y Men 40 y, women 27 y 28 days (range 4–365 days), quartiles 15, 28, 50 days 18–23 y, 42 days; 24–30 y, 35 days; 31–50 y, 21 days; ⱖ 51 y, 18 days Tourism 59% (n ⫽ 629), work 20% (n ⫽ 211), studies 20% (n ⫽ 215), visiting friends and relatives 2% (n ⫽ 17) Thailand 14% (n ⫽ 151), Tanzania 14% (n ⫽ 150), India 13% (n ⫽ 140), Malaysia 10% (n ⫽ 105), Vietnam 8% (n ⫽ 86)
Median age (n ⫽ 1035) Median travel duration (n ⫽ 1059) Reason for travela (n ⫽ 1059) Five most popular destinationsb (n ⫽ 1057) aMultiple
answers allowed. Africa was the most popular continent (49%, n ⫽ 410), followed by Southeast Asia (28%, n ⫽ 297).
bSub-Saharan
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Health advice and illness during travel Among the respondents, 88% (930/1052) remembered having received health advice at their pre-travel clinic visit. Younger travellers felt that they benefited less from our health advice and fell ill to a greater extent than older travellers; these differences were statistically significant (Table II; p ⬍ 0.001). Missing advice. In response to an open-ended question about travel advice, 12% (113/930) reported advice they felt was not addressed during their pre-travel consultation. The responses included: more accurate information on the local malaria risk (n ⫽ 22), better information on malaria prophylaxis (side effects/alternative therapies) (n ⫽ 13), gastrointestinal illness and risk (n ⫽ 27), vaccines and vaccine-preventable diseases (n ⫽ 14), rabies risk (n ⫽ 12), what to bring in a travel pharmacy (n ⫽ 10), self-treatment/quality of medical care at travel destination (n ⫽ 8), parasitic infections (n ⫽ 6), and traffic risks (n ⫽ 4). Risks during travel. Table III shows the results of binary logistic regression analysis with variables showing a significant association. Young age, longer duration of travel, and travel to India were associated with increased risks during travel. The sex of the traveller and traveller compliance with health advice showed a significant association in a bivariate analysis (Chi-square test) but not in the regression analysis. Parameters included in the analysis were sex, age, travel duration, type of travel, 10 most
popular travel destinations, and compliance with travel health advice. Skin infection affected 3% (28/1046) and urinary tract infection 2% (18/1046); ⬍ 1% (6/1046) were diagnosed with malaria (3/6 reported that they took their prophylaxis as instructed). An animal bite with a potential rabies risk was stated by ⬍ 1% (7/1041). Involvement in a traffic accident was reported by 2% (18/1041): 3% (16/503) of those aged ⬍ 31 y and ⬍ 1% (2/514) of those aged ⬎ 30 y (p ⫽ 0.001). Theft/robbery was experienced by 7% (71/1041) during travel. Travel ⬎ 1 month had an increased risk, with an odds ratio (OR) of 5.7 (95% confidence interval (CI) 3.1–10.6; p ⬍ 0.001), as did age ⬍ 31 y, with OR 2.1 (95% CI 1.2–3.9, p ⬍ 0.05).
Behaviour during travel Malaria prevention. Out of the 1059 individuals included in the study, 61% (645) visited a malaria endemic area and were prescribed malaria chemoprophylaxis. Travellers to malaria endemic areas stated similar reasons for travel as the whole study population (Table I). Only 1% (8/645) were visiting friends and relatives in their country of origin (VFR). Self-reported adherence to chemoprophylaxis was 67% (435/645). Adherence was correlated to the age of the traveller (58% (88/153) in the youngest quartile compared to 88% (149/169) in the oldest quartile), travel duration (76% (263/344) for trips shorter than 1 month compared to 57% (172/301) for trips longer than 1 month), and travel to malaria
Table II. Health advice and illness during travel.
Age quartiles (y) 18–23 24–30 31–50 ⱖ 51
Advice helped to Always Found advice Found advice avoid illness and/or followed advice helpful (n ⫽ 855) relevant (n ⫽ 829) accident (n ⫽ 800) (n ⫽ 905) 42% 45% 61% 64%
(84/202) (103/227) (127/207) (141/219)
64% 67% 76% 79%
(129/202) (149/223) (151/199) (161/205)
33% 31% 39% 54%
(62/189) (68/220) (73/189) (110/202)
57% 64% 70% 76%
(123/216) (154/241) (153/219) (174/229)
Illness (n ⫽ 1029) 52% 46% 34% 30%
(127/243) (122/263) (87/259) (79/264)
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M. Angelin et al. Table III. Illness during travel. All illness 40% (424/1053) Travellers’ diarrhoea 33% (342/1046) Respiratory tract infection 13% (133/1046) Skin wound 14% (148/1041)
Age ⬍ 31 y Travel to India Age ⬍ 31 y Travel to India Age ⬍ 31 y Travel ⬎ 1 month Age ⬍ 31 y Travel ⬎ 1 month
OR OR OR OR OR OR OR OR
1.6 (95% CI 1.1–2.4)a 1.9 (95% CI 1.2–3)b 1.7 (95% CI 1.2–2.6)b 2.5 (95% CI 1.6–3.9)c 2.1 (95% CI 1.2–3.8)a 2 (95% CI 1.2–3.4)a 2.4 (95% CI 1.6–3.6)c 1.8 (95% CI 1.2–2.6)a
OR, adjusted odds ratio; 95% CI, 95% confidence interval. ap ⬍ 0.05.
bp ⬍ 0.01.
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cp
⬍ 0.001.
endemic regions in Sub-Saharan Africa (78% (294/ 376) compared to 52% (141/269) for travel to other malaria endemic regions where chemoprophylaxis is recommended). Correlations remained significant after analysis with binary logistic regression; p ⬍ 0.001 for all correlations. Reasons for non-adherence were the following: did not experience malaria as a risk at the travel destination (24%, 51/210), felt it was unnecessary (23%, 48/210), forgetfulness (20%, 43/210), and side effects (17%, 35/210). One of 4 drugs was prescribed: atovaquone/proguanil (68%, 444/645), mefloquine (18%, 118/645), chloroquine (4%, 24/645), and doxycycline (1%, 8/645); 9% (55/645) did not remember which drug they had been prescribed. No significant difference in relation to cessation of prophylaxis because of side effects was seen between the different anti-malarials. For personal protection against malaria, 63% (409/645) stated that they used bed nets, 76% (493/645) mosquito repellents, 47% (300/645) long sleeved clothing, and 48% (311/645) slept with the windows closed. In total, 77% (496/645) used either bed nets or slept with the windows closed. Personal protection was assessed for those who were prescribed chemoprophylaxis. Traffic. Only half of the travellers (50%, 527/1048) used seat belts during travel, however 40% (420/1048) stated that this was because of non-availability. Renting of a motorcycle during travel was reported by 13% (138/1042); 70% of these used a helmet (96/138). Younger travellers were significantly more likely to rent a motorcycle: 21% (103/499) if aged ⬍ 31 y compared to 7% (34/519) aged ⬎ 30 y; p ⬍ 0.001. Accidents and personal security. Answers to the openended question on accidents and personal security fell into the following behavioural categories: (1) was careful with valuables, 41% (424/1035); (2) watchful behaviour after dark, 21% (216/1035); (3) avoided
walking alone, 14% (147/1035); (4) tried to minimize risks in traffic, 12% (121/1035); (5) was generally attentive, 10% (103/1035). In total, 62% (639/1035) reported that they had taken action regarding accidents and personal security. This was more common among women (69%, 430/620) than men (50%, 209/415); p ⬍ 0.001. Sexual behaviour. One in 10 (9%, 94/1045) met a new sexual partner during travel and 53% (50/94) found their new partner among the local population at the travel destination. The likelihood of meeting a new sexual partner was related to duration of travel (16% (78/484) for trips ⬎ 1 month compared to 3% (16/561) for trips ⬍ 1 month) and the age of the traveller (15% (76/502) for travellers aged 18–30 y and 3% (17/519) for travellers aged ⬎ 30 y) (p ⬍ 0.001 for both correlations). Only 53% (50/94) always used a condom. Women were as likely as men to meet a new sexual partner during travel. Discussion In order to prepare the traveller in the best way, it is important to obtain feedback from the travellers themselves. We could find little data in the literature on feedback from travellers on the health advice received. This study was also designed to identify areas of pre-travel health advice in need of improvement. The number of travellers visiting friends and relatives in their country of origin (VFRs), a risk group for travel-related illness [9], was small in this study, mainly because the survey was only available in Swedish. Previous studies have shown that this group also seeks travel health advice to a lesser extent [2,9]. A majority of our visitors had previously travelled to countries in Asia, Africa, or South America and the majority sought health information prior to their visit to our travel clinic. Meeting travellers with previous knowledge of travel health makes it necessary to adapt the travel health information given. Verifying
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Evaluating travel health advice the traveller’s knowledge and correcting any misinformation is important. Pre-existing knowledge and beliefs can affect the traveller’s perception of risk and the likelihood of the health advice given being followed; if not addressed, this will often result in partial adherence [3]. Our results show that 67% (618/929) reported having fully adhered to the health advice given. Suboptimal adherence can be due to factors other than choice, such as not being able to use a seatbelt because there are none. Another factor affecting adherence to health advice discussed by Bauer [5] is poor recall. We found that 12% of respondents did not remember any advice at all. Studies on health advice show that individuals forget half of the message in a consultation in 5 minutes and by best remember the first one-third of the information provided [5]. This is important to consider when delivering travel health advice. We also learned that younger travellers found our health advice less beneficial and followed the advice to a lesser extent. Reported compliance with travel health advice was not shown to be protective against travel-related illness in this study. It is probable that risk factors not easily influenced by the traveller are important in travel-related illness, for example factors such as hygiene standards in restaurants [10–12], droplet spread of respiratory tract infections, and the local traffic situation. That travellers, despite following advised hygiene precautions, contracted travellers’ diarrhoea, confirms previous findings [10–15]. Hygiene precautions can also be difficult to follow [10,12,16]. Very few study participants stated that they did not benefit at all from our health advice. So it appears that the travellers found our advice helpful but that it did not protect them from falling ill during travel. Infections with longer incubation periods could have been missed in this study since the second questionnaire was administered 2 weeks after travel. Our visitors requested more advice on local malaria risk. Available malaria prevalence data are often not geographically and seasonally precise. Discrepancies in the advised and actual malaria risk are also mentioned as a reason for cessation of malaria prophylaxis. Younger travellers fell ill to a greater extent than older travellers. The fact that younger travellers are a risk group for travel-related illness confirms the results of previous studies [8,10,14,16–18]. Aro et al. showed that younger travellers are more willing to take health-related risks during travel [4] and thus have a greater need for health advice. Younger travellers seek travel health advice to the same extent as older travellers [19–22]. Among the participants in our study, younger travellers demonstrated lower adherence to malaria chemoprophylaxis, were more
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likely to rent a motorcycle during travel, and had a higher probability of meeting a new sexual partner during their trip. They were also more likely to be involved in a traffic accident and to face theft/ robbery during their trip. Lower adherence to malaria prophylaxis for younger travellers was seen by Alon et al. [18] and Sagui et al. [23], but Pistone et al. [24] found younger travellers to have higher adherence to prophylaxis. In their review from 2010, Vivancos et al. found that young age was correlated to an increased likelihood of meeting a new sexual partner during travel [25]. These findings highlight the importance of risk communication in a travel health consultation. If the traveller does not perceive the topic discussed in the pre-travel consultation to be a risk that requires avoidance, it is unlikely that the advice given will be followed [3,5]. Women were more likely to take steps to reduce the risk of accidents, theft, and/or assault. The overall number of travellers who took these steps was lower than desired and this aspect should be stressed in the travel health consultation. Unfortunately evidence-based advice in this respect is scarce and common sense advice is usually used [26]. Among those who experienced theft/robbery during their trip, 79% (49/62) reported taking some of these steps compared to 65% (414/642) for those who were not robbed. This may reflect differences in travel characteristics. The strongest correlation with increased risk of theft/robbery was travel duration. Previous data on this topic are difficult to obtain. A 2003–2004 study on humanitarian relief expatriates showed that 3.5% were involved in a traffic accident and 4% were robbed during their stay abroad [27]. We found that 2% of travellers were involved in a traffic accident. Travellers engaging in sexual contact with new partners during travel practiced safe sex to the same extent as shown previously [28,29]. No reduction in this risk behaviour was seen. We found that women were as likely as men to meet a new sexual partner during travel, in contrast to previous findings in a review by Vivancos et al. [28]. Casual travel sex as compared to casual sex at home is correlated with a 3-fold increased risk of contracting an STD [28]. A 3.4% risk of primary HIV associated with unprotected casual travel sex has been reported [30]. It is important to communicate the risks involved in unprotected casual sex to travellers. Older age, shorter trip, and travel to a high-risk area for severe malaria (Sub-Saharan Africa) were related to increased self-reported compliance with malaria chemoprophylaxis. The level of compliance with chemoprophylaxis found in this study is lower than desired but in line with previous findings. Previous studies have shown varying compliance levels regarding malaria chemoprophylaxis, ranging from
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47% to 89% [15,18,31–34]. Malaria is responsible for most of the deaths due to infectious diseases among travellers [29]. In this study we identified a need for new methods to help younger travellers avoid illness during travel. To approach this need, we must learn more, for example through the help of age-specific focus group discussions. The use of modern technology, such as new forms of communication, has to our knowledge not been evaluated in pre-travel advice. The use of smart phone applications as a support for changing health behaviour may be a method of interest to young people, in addition to the use of text messaging-delivered interventions [35]. Internet-delivered interventions with regular updates by phone or e-mail could also be used [36]. Helping travellers stay healthy during travel is the main goal of travel medicine. The value of travel health advice should be investigated further since reported adherence was not associated with a lower rate of illness during travel. When advice is given, it needs to be evidence-based and tailored to the recipient with respect to both their background and their travel itinerary.
Acknowledgements We would like to thank Maria Casserdahl and Madelaine Sillfors for their work with data processing. We also thank Klara Brändström, Maria Casserdahl, Ulla Gunnarsson, Linda Olsson, Ann Catrin Tegenfeldt, and Anna Wännman for their invaluable help with the inclusion of study participants. Declaration of interest: This study was funded solely by the Division of Infectious Diseases, Department of Clinical Microbiology, Umeå University, Umeå, Sweden. References [1] Swedish Transport Agency. Available at: http://www. transportstyrelsen.se/sv/Luftfart/Statistik/Flygplatsstatistik-/ (in Swedish) (accessed 14 November 2013). [2] Van Herck K, Castelli F, Zuckerman J, Nothdurft H, Van Damme P, Dahgren AL, et al. Knowledge, attitudes and practices in travel-related infectious diseases: the European airport survey. J Travel Med 2004;11:3–8. [3] Noble LM, Willcox A, Behrens RH. Travel clinic consultation and risk assessment. Infect Dis Clin North Am 2012;26: 575–93. [4] Aro AR, Vartti AM, Schreck M, Turtiainen P, Uutela A. Willingness to take travel-related health risks—a study among Finnish tourists in Asia during the avian influenza outbreak. Int J Behav Med 2009;16:68–73. [5] Bauer IL. Educational issues and concerns in travel health advice: is all the effort a waste of time? J Travel Med 2005; 12:45–52.
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