- Split View
-
Views
-
Cite
Cite
Gerard T. Flaherty, Bingling Chen, Gloria Avalos, Individual traveller health priorities and the pre-travel health consultation, Journal of Travel Medicine, Volume 24, Issue 6, November-December 2017, tax059, https://doi.org/10.1093/jtm/tax059
- Share Icon Share
Abstract
The purpose of this study was to examine the principal travel health priorities of travellers. The most frequently selected travel health concerns were accessing medical care abroad, dying abroad, insect bites, malaria, personal safety and travel security threats. The travel health risks of least concern were culture shock, fear of flying, jet lag and sexually transmitted infections. This study is the first to develop a hierarchy of self-declared travel health risk priorities among travellers.
Introduction
The pre-travel health consultation is a central element of travel medicine practice. This encounter is a time-limited contact which requires an efficient approach in order to maximise its utility in transmitting preventive advice to the intending traveller. The outcome of the pre-travel consultation may be influenced by traveller engagement and the extent to which the clinician recognises the traveller's personal health priorities. Given the diverse nature of travel health risks and the need in most cases to administer travel vaccinations as part of the first clinic visit, it is possible that personal traveller health concerns may be overlooked and not given specific attention by the travel health provider.
A standardised approach to travel health consultations, while time efficient, is not in keeping with a patient-centred travel healthcare paradigm and does not take due account of the traveller’s unique profile, including previous medical history,1 previous travel experiences, and proposed itinerary, which may be very uncertain.2 Travellers may not be afforded the opportunity to express their individual concerns regarding the travel health risks which they anticipate, thus compromising the clinician–patient relationship and impeding information gathering. This exposes the traveller to clinical risks and the clinician to medicolegal risks3 should an important discussion of health risk fail to occur in the pre-travel consultation. The issue of patient-centred travel healthcare has not been adequately researched. We aimed to describe the travel health priorities of international travellers and to determine the extent to which the pre-travel consultation addresses these individual concerns.
Methods
Travellers attending a specialist travel health clinic (Tropical Medical Bureau, Galway, Ireland) between June and August 2016 were invited to participate in the study. In advance of their consultation with the travel medicine physician, subjects were asked by an independent research assistant to rank order the top 5 (1–5, in descending order) travel health risks of greatest importance to them from a list of 20 major risks. The research assistant observed the consultation which followed and recorded whether the traveller raised the issue and/or if the physician addressed the particular risk during the consultation. The physician was blinded to the declared health priorities of the travellers until the study was concluded. Demographic data were documented for each participant, including gender, age, destinations, duration of travel, accommodation and purpose of travel. Statistical analysis was performed using SPSS version 22.0.
Results
Of the 148 travellers who participated in this study, 89 (60%) were female and 59 (40%) were male. The majority of subjects (53%, n = 79) were younger than 30 years. The most common type of accommodation was hotels (60%, n = 119) and the most frequent purpose of travel was for leisure (89%, n = 132). The most frequent duration of travel was 3–5 weeks (52%, n = 77). Over two-thirds of travellers (68%, n = 100) were expected to depart in fewer than 4 weeks from the date of the consultation. Only a minority of travellers (18%, n = 27) were travelling alone on their next international journey. Sixty percent (n = 88) had at least one item in their past medical history although the details of their history were not recorded for the purpose of this study. Asia was the most frequently visited destination in this study (66%, n = 98), followed by Africa (13%, n = 19) and North America (10%, n = 15).
The most frequently selected travel health concerns were accessing medical care abroad (58.8%, n = 87), dying abroad (26.4%, n = 39), receiving insect bites (56.1%, n = 83), contracting malaria (52.7%, n = 78), personal safety (58.8%, n = 87), travel security threats (48%, n = 71), natural disasters (23.6%, n = 35), rabies infection (24.3%, n = 36), and travellers' diarrhoea (35.8%, n = 53). The travel health risks of least concern to travellers in this study were altitude illness (9.5%, n = 14), culture shock (9.5%, n = 14), fear of flying (9.5%, n = 14), jet lag (6.1%, n = 9) and sexually transmitted infections (8.1%, n = 12). Females were more likely than males to be concerned about accessing medical care abroad (P = 0.042 by Pearson Chi-square test) but no other significant gender differences were recorded. Of the travel health priorities ranked in the travellers’ top two most significant concerns, accessing medical care (17.2%, n = 51), personal safety (16.2%, n = 48), malaria (12.2%, n = 36), insect bites (8.8%, n = 26) and death abroad (8.4%, n = 25) featured most frequently (Figure 1). Only 1 traveller selected the ‘other’ category of travel health risk and cited homophobia as a concern which was not in the list provided.
Table 1 presents data relating to the frequency with which traveller-expressed concerns were addressed in the ensuing travel consultation by the clinician and/or by the traveller. The clinician was most likely to discuss insect bite avoidance, malaria prevention, rabies infection, accessing medical care and sexually transmitted infections and least likely to raise the issues of security, dying abroad, natural disasters, deep vein thrombosis and jet lag. The traveller was most likely to address vaccine needle phobia, altitude illness, wild animal attacks, insect bites and malaria.
Travel health risk . | Ranked in top 5 priorities (n) . | Addressed by clinician (n, %) . | Addressed by Traveller (n, %) . |
---|---|---|---|
Accessing medical care | 87 | 81 (93%) | 7 (8%) |
Personal safety | 87 | 72 (83%) | 5 (6%) |
Insect bites | 83 | 83 (100%) | 15 (18%) |
Malaria | 78 | 78 (100%) | 13 (17%) |
Security | 71 | 11 (16%) | 0 (0%) |
Travellers’ diarrhoea | 53 | 52 (98%) | 5 (9%) |
Dying abroad | 39 | 0 (0%) | 0 (0%) |
Rabies infection | 36 | 36 (100%) | 5 (14%) |
Natural disasters | 35 | 0 (0%) | 0 (0%) |
Sun exposure | 31 | 17 (55%) | 1 (3%) |
Deep vein thrombosis | 26 | 4 (15%) | 0 (0%) |
Adventure activities | 20 | 16 (80%) | 1 (5%) |
Wild animal attacks | 16 | 5 (31%) | 3 (19%) |
Fear of flying | 14 | 2 (14%) | 1 (7%) |
Altitude illness | 14 | 5 (36%) | 3 (21%) |
Culture shock | 14 | 3 (21%) | 1 (7%) |
Vaccine needle phobia | 13 | 4 (31%) | 3 (23%) |
Sexually transmitted infections | 12 | 11 (92%) | 1 (8%) |
Jet lag | 9 | 5 (6%) | 0 (0%) |
Travel health risk . | Ranked in top 5 priorities (n) . | Addressed by clinician (n, %) . | Addressed by Traveller (n, %) . |
---|---|---|---|
Accessing medical care | 87 | 81 (93%) | 7 (8%) |
Personal safety | 87 | 72 (83%) | 5 (6%) |
Insect bites | 83 | 83 (100%) | 15 (18%) |
Malaria | 78 | 78 (100%) | 13 (17%) |
Security | 71 | 11 (16%) | 0 (0%) |
Travellers’ diarrhoea | 53 | 52 (98%) | 5 (9%) |
Dying abroad | 39 | 0 (0%) | 0 (0%) |
Rabies infection | 36 | 36 (100%) | 5 (14%) |
Natural disasters | 35 | 0 (0%) | 0 (0%) |
Sun exposure | 31 | 17 (55%) | 1 (3%) |
Deep vein thrombosis | 26 | 4 (15%) | 0 (0%) |
Adventure activities | 20 | 16 (80%) | 1 (5%) |
Wild animal attacks | 16 | 5 (31%) | 3 (19%) |
Fear of flying | 14 | 2 (14%) | 1 (7%) |
Altitude illness | 14 | 5 (36%) | 3 (21%) |
Culture shock | 14 | 3 (21%) | 1 (7%) |
Vaccine needle phobia | 13 | 4 (31%) | 3 (23%) |
Sexually transmitted infections | 12 | 11 (92%) | 1 (8%) |
Jet lag | 9 | 5 (6%) | 0 (0%) |
Travel health risk . | Ranked in top 5 priorities (n) . | Addressed by clinician (n, %) . | Addressed by Traveller (n, %) . |
---|---|---|---|
Accessing medical care | 87 | 81 (93%) | 7 (8%) |
Personal safety | 87 | 72 (83%) | 5 (6%) |
Insect bites | 83 | 83 (100%) | 15 (18%) |
Malaria | 78 | 78 (100%) | 13 (17%) |
Security | 71 | 11 (16%) | 0 (0%) |
Travellers’ diarrhoea | 53 | 52 (98%) | 5 (9%) |
Dying abroad | 39 | 0 (0%) | 0 (0%) |
Rabies infection | 36 | 36 (100%) | 5 (14%) |
Natural disasters | 35 | 0 (0%) | 0 (0%) |
Sun exposure | 31 | 17 (55%) | 1 (3%) |
Deep vein thrombosis | 26 | 4 (15%) | 0 (0%) |
Adventure activities | 20 | 16 (80%) | 1 (5%) |
Wild animal attacks | 16 | 5 (31%) | 3 (19%) |
Fear of flying | 14 | 2 (14%) | 1 (7%) |
Altitude illness | 14 | 5 (36%) | 3 (21%) |
Culture shock | 14 | 3 (21%) | 1 (7%) |
Vaccine needle phobia | 13 | 4 (31%) | 3 (23%) |
Sexually transmitted infections | 12 | 11 (92%) | 1 (8%) |
Jet lag | 9 | 5 (6%) | 0 (0%) |
Travel health risk . | Ranked in top 5 priorities (n) . | Addressed by clinician (n, %) . | Addressed by Traveller (n, %) . |
---|---|---|---|
Accessing medical care | 87 | 81 (93%) | 7 (8%) |
Personal safety | 87 | 72 (83%) | 5 (6%) |
Insect bites | 83 | 83 (100%) | 15 (18%) |
Malaria | 78 | 78 (100%) | 13 (17%) |
Security | 71 | 11 (16%) | 0 (0%) |
Travellers’ diarrhoea | 53 | 52 (98%) | 5 (9%) |
Dying abroad | 39 | 0 (0%) | 0 (0%) |
Rabies infection | 36 | 36 (100%) | 5 (14%) |
Natural disasters | 35 | 0 (0%) | 0 (0%) |
Sun exposure | 31 | 17 (55%) | 1 (3%) |
Deep vein thrombosis | 26 | 4 (15%) | 0 (0%) |
Adventure activities | 20 | 16 (80%) | 1 (5%) |
Wild animal attacks | 16 | 5 (31%) | 3 (19%) |
Fear of flying | 14 | 2 (14%) | 1 (7%) |
Altitude illness | 14 | 5 (36%) | 3 (21%) |
Culture shock | 14 | 3 (21%) | 1 (7%) |
Vaccine needle phobia | 13 | 4 (31%) | 3 (23%) |
Sexually transmitted infections | 12 | 11 (92%) | 1 (8%) |
Jet lag | 9 | 5 (6%) | 0 (0%) |
Discussion
The effectiveness of the pre-travel health consultation in preventing travel-related illness has been demonstrated.4 Key travel health messages are adequately assimilated following a pre-travel consultation, although the large volume of material transmitted impedes the immediate recollection of all information.5 In a recent insightful editorial on the pre-travel health consultation, McIntosh advocates the provision of customised information which is delivered concisely and supplemented by written and electronic instructions.6 The complexities and limitations of providing numerical risk data to travellers during the pre-travel consultation have previously been discussed.7 A study of 130 travellers in the UK implicated low quality clinician-traveller communication as a significant predictor of non-adherence to malaria chemoprophylaxis.8 The authors advanced specific verbal communication strategies as a means of improving the effectiveness of clinician-traveller communication.
This study is the first to develop a hierarchy of self-declared travel health priorities among travellers and to identify travel health risks which may be neglected in the pre-travel consultation. The findings may be of value in improving our understanding of traveller behaviour and our capacity to provide more targeted travel health information. While pre-travel assessment and consultation is one of the seven domains of the ISTM Body of Knowledge, traveller risk perception is not currently listed in this comprehensive curricular document. A recent bibliometric analysis proposed that risk perception should be included as a sub-domain in the Body of Knowledge in future revisions.9
It was of interest to observe that the single greatest source of concern for travellers in our sample was accessing medical care overseas. While our study did not collect detailed information on past medical history, the presence or absence of even minor clinical conditions as listed on the travellers’ self-completed clinic registration card was captured. It would be of interest in a larger study to examine whether travellers with more challenging chronic medical illnesses were more likely to be concerned about access to competent medical care. A previous study found that 40.5% of 391 travellers reporting a chronic illness sought pre-travel advice from their general practitioner,10 reinforcing the need to develop standardised approaches to conducting a patient-centred travel consultation across the professional spectrum of travel health advisers. The high level of traveller concern towards personal safety and the limited extent to which the topic was addressed by the clinician was also noteworthy. Although road traffic accidents are the leading cause of death in younger travellers, there are multiple other traumatic challenges to traveller safety, such as the risk of sexual assault,11 which may not be given due attention in a pressurised consultation.
While some of the travel health concerns considered by the travellers in this study may not have been deemed relevant to their immediate travel plans, it was surprising that jet lag was regarded as the health risk of least priority as the majority of travellers in the study were predictably subject to jet lag given their proposed destinations. Unfamiliarity with jet lag from previous east-west travel or failure to appreciate its potential to disrupt travel activities,12 or expose the traveller to accidental injury may account for the limited value attached to this phenomenon in the current study. The clinician who conducted the pre-travel consultation in this study did not routinely discuss all facets of travel health risk based on the traveller profile and characteristics of the itinerary and destination, but it was surprising that the sensitive issue of death abroad and the distressing subject of natural disasters were not raised in a single consultation by the physician. In spite of the fact that all travellers would be airline passengers at some stage during their upcoming trip, deep vein thrombosis was selectively discussed with only 15% of travellers. Further research is indicated to explore these trends and to better understand the reasons for experienced clinician reticence towards potentially fatal travel health risks.
Limitations of this study include its single clinical site, the risk of observer bias, and the possibility that the travel health priority list may not be definitive. Furthermore, our study did not document the detailed country-specific itineraries of the travellers, but rather the continental destinations. Future studies may reasonably investigate associations between physician-determined travel health risk levels based on detailed geographic itineraries and the health priority profile expressed by individual travellers. It would be of interest to observe if travellers to high-risk destinations had similar or different concerns compared to travellers to low-risk countries, acknowledging that a gradient of risk exists in individual countries, depending on the traveller’s specific exposures. Notwithstanding these limitations, our findings suggest that travellers should be invited to nominate their principal travel health priorities on the travel health record prior to the subsequent pre-travel consultation. Furthermore, travel health advisers should specifically contextualise and address the traveller’s individually nominated concerns. Uncomfortable topics, such as death abroad and repatriation, should be discussed where appropriate and these may require to be instigated by the clinician.13
In line with the recommendations of a recent perspective article from a group of travel medicine professionals practicing in the Asia-Pacific region,14 we recommend that this study be extended to multiple centres in diverse regions of the world in an attempt to better understand the varying perspectives of the global travelling community. It would be of interest to study the effect of the travel consultation on the travellers’ stated priorities and whether particular risks were magnified or diminished from the traveller’s perspective following an explanation of the true risks associated with their proposed travel itinerary. Such studies would allow an assessment of the impact of a more patient-centred consultation on the travellers’ knowledge, anxiety levels and travel health outcomes.
This study is the first to establish a hierarchy of self-declared travel health risk priorities among travellers. It may help to inform our understanding of traveller psychology and our capacity to provide a more patient-centred and more customised pre-travel health consultation.
Funding
Bingling Chen was supported by an unrestricted travel research bursary from the Travel Medicine Society of Ireland.
Conflict of interest: None declared.