Assessment of Knowledge, Attitude and Practice in Relation to Travel Health among Travelers in Qassim Region

Introduction

The international traveling is annually growing and is expected to reach 1.6 billion travelers in 2020. The risk of infectious diseases during traveling are not only related to the destination and duration of the trip, also the personal health. The risk of these diseases not limited to the traveler, it’s also a risk for the community. The risk can be reduced by taking some pre-traveling, during and post-traveling precautions. In general, only 10% of the participants have seen a travel-health specialist. Aim To determine the level of travel health knowledge, attitude and practice (KAP) among Saudi travelers at Prince Nayef international airport and to identify their source of travel health-related information. With comparing with other studies in different countries we’ll find the need of establishment of travel-health clinics in Saudi Arabia. Methods A cross sectional study conducted at Prince Nayef International Airport in Qassim Region from 10-17 January 2018. A total of 535 travelers aged 18-60 years old had been voluntarily recruited in this study. We used the questionnaires regarding the knowledge, attitude and practices of travel health among travelers published by Neika Vendetti (17). Results Males were dominated the females with 62.8% versus 37.2%. Family and friends are the main source of general travel advice (64.5%). Poor knowledge and good knowledge constituted 84.3% and 15.7% respectively while attitude were closed in ratings as 50.3% for positive and 49.7% were negative whereas poor practices had 86.0% against 14.0% for good practices. Conclusion This study found out the majority of travelers were having poor knowledge and practices toward pre-travel medical advice. Many of them didn’t seek medical advice prior to departure which is quite alarming due to the threat pose of some diseases while in the travel.

Keywords

Knowledge, attitude, practices, travelers, travel health, medical advice

الملخص

خلفية

يزداد معدل السفر الدولي بشكل سنوي ونتوقع أن يصل إلى 1.6 مليار مسافر في عام 2020. لا يرتبط خطر الأمراض المعدية أثناء السفر بوجهة الرحلة ومدة الرحلة فقط ولكنه يرتبط بالصحة الشخصية ايضاً. لا يقتصر خطر هذه الأمراض على المسافر وحده بل هو يشكل خطراً على المجتمع ككل. يمكن تقليل المخاطر من خلال اتخاذ بعض الاحتياطات قبل وأثناء وبعد السفر. وبصفة عامة فإن نسبة 10بالمائة فقط من المشاركين قد زاروا أخصائي صحة السفر. الهدف هو تحديد مستوى المعرفة الصحية، السلوك والممارسة الصحية الصحيحة (KAP) للمسافرين السعوديين في مطار الأمير نايف الدولي وتحديد مصدر معلوماتهم الصحية المتعلقة بالسفر بشكل صحيح. بمقارنة هذه الدراسة بدراسات أخرى بدول مختلفة سوف نجد هل هناك حاجة لإنشاء عيادات خاصة بصحة المسافرين في المملكة العربية السعودية أم لا. طريقة البحث اعتمد البحث على اجراء دراسة مقطعية في مطار الأمير نايف الدولي في منطقة القصيم من 10 إلى 17 يناير 2018 وتمت دراسة عينة لعدد 535 مسافر تتراوح أعمارهم بين 18-60 سنة والذين اشتركوا في هذه الدراسة بشكل طوعي. تم استخدام الاستبيانات المتعلقة بالمعرفة والسلوك والممارسات المتعلقة بصحة السفر بين المسافرين التي نشرها نيكا فينديتيNeika Vendetti (17). النتائج: زاد عدد الذكور على الإناث بنسبة 62.8٪ مقابل 37.2٪. حيث أن المصدر الرئيسي للنصائح العامة للسفر هو العائلة والأصدقاء بنسبة (64.5٪). أظهر انتشار الثقافة المتعلقة بالمعرفة والسلوك والممارسات الخاصة بمجال صحة المسافرين أن ضعف المعرفة غلب بنسبة 84.3 ٪ مقابل 15.7 ٪ للمعرفة الجيدة في حين كانت السلوكيات الصحية للمسافرين 50.3 ٪ للنتائج الإيجابية و 49.7 ٪ للنتائج السلبية بينما كانت نسبة الممارسات السيئة 86 ٪ مقابل 14.0 ٪ للممارسات الجيدة. الاستنتاج: وجدت هذه الدراسة أن غالبية المسافرين كانوا يعانون من ضعف المعرفة والممارسات الصحيحة للحصول على المشورة الطبية قبل السفر. لم يهتم العديد منهم بطلب المشورة الطبية قبل المغادرة وهو أمر ينذر بالخطر بسبب وجود تهديد لبعض الأمراض أثناء السفر.

الكلمات المفتاحية:

المعرفة والسلوك والممارسات والمسافرين والصحة أثناء السفر والمشورة الطبية

Introduction

The international traveling is annually growing and is expected to reach 1.6 billion travelers in 2020.1 And in 2030, traveling to developing countries is expected to reach 57% of the international destinations.² The risk of infectious diseases during traveling are not only related to the destination and duration of the trip, also the personal health. 1 The risk of these diseases not limited to the traveler, it’s also a risk for the community and relatives whom in contact with the traveler. 1 The risk can be reduced by taking some pre-traveling, during and post-traveling precautions. 3

Traveling history can be the cornerstone in identifying the cause of such a disease.⁴ Some studies reported that most of the travelers are unaware about the prophylaxis and standby treatment measures which needed in their trips.⁵ In general, only 10% of the participants have seen a travel-health specialist.

The aim of this study is to determine the level of travel health knowledge, attitude and practice (KAP) among Saudi travelers at Prince Nayef international airport and to identify their source of travel health-related information. With comparing with other studies in different countries we’ll find the need of establishment of travel-health clinics in Saudi Arabia.

Methods

A cross sectional design used for International travelers aged ≥18 years at Prince Nayef International Airport in Qassim Region (ELQ) On Jan 10th to Jan 17th 2018 with exception of those don’t speak Arabic or English languages or younger than 18 years old. The data collected randomly from different flights and different times of airplanes departures.

Methods of data collection

Of the 600 participants 535 responded to this study; self-administered pre-exiting questionnaire covering the following aspects: demographic data, pre-travel questions and travel health part. The questionnaire validity is approved by a study conducted by Neika Vendetti, May 2010 with a valid translation to Arabic.^6,17 The questionnaire delivered by trained medical students and written consent is taken from the participants, also the data kept confidential and only used for the purpose of the study.

Data entry and analysis

The data had been gathered through Microsoft Excel and after data cleaning and data re-coding, it was then exported to Statistical Packages for Social Sciences (SPSS) version 20 for further tabulation and subsequently for statistical data analyses. Both descriptive and inferential statistics were performed where numbers and percentages were used to presents all categorical variables. A p-value cut off point of 0.05 at 95% CI used to determine statistical significance. The analyses measured the relationship between socio-demographic and knowledge, attitude and practices of travelers regarding health pre-travel advice by using chi square test.

The evaluation of attitude of travelers’ toward health pre-travel advice which comprised of 2 questions where “yes” coded as 1, “no” coded 0 were the answer options and the total score had been calculated by adding the 2 questions. The minimum score was 0 and the maximum was 2, score of 1 – 2 were classified as positive attitude while no score (0) were classified as negative attitude.

The assessment of practices of travelers toward health pre-travel advice which composed of 5 questions and the answers has been coded as 2 (most appropriate answer) or 1 (least appropriate answer) and for “yes” as 1, and “no” coded as 0 were the answer options and the total score had been calculated by adding all 5 questions. The minimum score was 0 and the maximum was 7. Score of 0 – 3 had been classified as poor practices while score of 4 – 7 were classified as good practices.

The measurement of travelers knowledge toward health pre-travel advice which comprised of 8 questions and “yes” coded as 1, “no” and “I don’t know” coded 0 were the answer options and the total score had been calculated by adding all 8 questions. The minimum score was 0 and the maximum score was 8. Score of 0 – 4 had been classified as poor knowledge and score of 5 – 8 were classified as good knowledge.

Results

The socio demographic data of 535 travelers who were voluntarily enrolled in this study. Of the 535 participants, 412 (77.0%) were Saudis and 123 (23.0%) were non-Saudis. Age ranged was from 18 to 60 years old of whom 295 (55.1%) were in the age group of 18 – 25 years old, 125 (23.4%) were in the age group of 26 – 35 years old, 79 (14.8%) were in the age group of 36 – 45 years old, 31 (05.8%) were in the age group of 46 – 60 years old and 05 (0.9%) participants were in the age group of more than 60 years old. Males were dominated the females with 336 (62.8%) males while 199 (37.2%) were females. Nearly all travelers were living in Saudi Arabia (95.0%) with only 27 participants were living outside Saudi Arabia while most of them (89.7%) had already been traveled outside of Saudi Arabia and few of them don’t (10.3%). Majority of the travelers had 1 – 2 companion during the travel (40.6%), 27.9% traveled with 3 – 5 companions, 11.2% traveled with more than 5 companions while 20.4% preferred to travel alone. Many participants already been traveled to their preferred destination (79.8%) whilst 20.2% only first time while more travelers preferred to stay by days only (48.6%), 36.6% by months, 10.5% by weeks and 4.3% by years. Most of the travelers were going to tourist spot country (87.7%) while few of them on the opposite (12.3%). More than 60% were planning to visit rural area or countryside and 38.5% preferred not to visit. About a half of them (49.5%) planned the trip at least one month prior to travel, 15.6% 2 to 4 weeks prior to travel, 14.5% during 1 to 2 weeks and 20.4% during the week of the trip. Nearly all travelers debriefed toward the general travel information of destination prior to the trip and only 11.2% don’t. Table1

Table 1: Demographic data and travel characteristics of participants
Study Variables	N (%)(n=535)
Nationality
Saudi	412 (77.0%)
Non Saudi	123 (23.0%)
Age group in years
18 – 25 years old	295 (55.1%)
26 – 35 years old	125 (23.4%)
36 – 45 years old	79 (14.8%)
46 – 60 years old	31 (05.8%)
>60 years old	05 (0.9%)
Gender
Male	336 (62.8%)
Female	199 (37.2%)
Is Saudi Arabia your country of residence?
Yes	508 (95.0%)
No	27 (05.0%)
Have you ever traveled to country outside of Saudi Arabia?
Yes	480 (89.7%)
No	55 (10.3%)
Number of companions during the travel
Alone	109 (20.4%)
1 – 2 persons	217 (40.6%)
3 – 5 persons	149 (27.9%)
>5 persons	60 (11.2%)
Is this your first time traveling to this country?
Yes	108 (20.2%)
No	427 (79.8%)
How long are you staying at your destination?
Days	260 (48.6%)
Months	196 (36.6%)
Weeks	56 (10.5%)
Years	23 (04.3%)
Is your primary destination a tourist/vacation area?
Yes	469 (87.7%)
No	66 (12.3%)
Do you plan on visiting rural area/countryside?
Yes	329 (61.5%)
No	206 (38.5%)
When did you begin planning this trip prior to your departure date?
At least one-month prior	260 (49.5%)
2 to 4 weeks prior	82 (15.6%)
1 – 2 weeks prior	76 (14.5%)
During the week of the trip	107 (20.4%)
Did you get general travel information about your destination prior to your trip?
Yes	475 (88.8%)
No	60 (11.2%)

Figure 1: Distribution of the favorite travel destination

Figure 1 shows the distribution of the favorite travel destination, majority of them preferred both Middle East and Asia (31.4%), 31% preferred Africa, 6.2% likes North America and very few likes South America (0.6%).

The distribution of sleeping arrangement of trip. Among the travelers, 64.5% of them choose hotel or resorts, 25.2% like private home, and 2.8% preferred dorm or youth hostel with very few like camping and 3% with other staying arrangements.

Many travelers do not seek travel health medical advice prior to departure with 71.2% contrary to those who seek with 28.8% while more of the travelers do not have health insurance (68.8%) compared to those with travel insurance (31.2%). About 80 percent of the travelers do not purchase nor receive any preventive medications prior to trip while 20.8% of them were having preventive medication for the trip where more than a half of them (54.3%) were having non-prescription medicine while on the other hand, 45.7% have vaccine. Only 14 participants adhere to anti-malaria medicine. 33.1% of them were planning to participate in any outdoor activities such as running or walking (72.3%), swimming and other water sports (17.5%) with 10.2% of them planned to participate both activities. For health safety during the travel, 40.4% of them preferred to cover arms or legs while outside at night, 18.3% will use bug repellant and 17.6% will close windows or might use mosquito nets. The following food might cause illness according to travelers such as; food from street vendor’s (71.2%), tap water (32.9%), raw fruits or vegetables (25.5%), sushi/shellfish (19.5%), ice cream (15.5%), ice cubes (13.3%) and milk (09.2%) (Table 2).

Table 2: Attitude and practices of travelers toward health pre-travel advice
Statement	N (%)(n=535)
Attitude
Q1. Did you seek travel health or medical advice prior to departure
Yes	154 (28.8%)
No	381 (71.2%)
Q2. Do you have health insurance
Yes	167 (31.2%)
No	368 (68.8%)
Practices
Q1. Prior to your travel date did you receive or purchase any preventative medications for this trip specifically (including vaccine)?
Yes	109 (20.8%)
No	414 (79.2%)
Q1a. If yes to question, What type of preventative medication did you receive?
Vaccines	43 (45.7%)
Non-prescription medicine	51 (54.3%)
Q2. If you received anti-malarial medicine, did you begin taking them?
Yes	14 (02.8%)
No	483 (97.2%)
Q3. Do you plan on participating in any outdoor activities?
Yes	177 (33.1%)
No	358 (66.9%)
Q3a. If yes, what kind of outdoor activities?
Walking and running	128 (72.3%)
Swimming and other water sports	31 (17.5%)
Both	18 (10.2%)
Q4. Do you plan on doing any of these things while on your trip?
Using bug repellant	98 (18.3%)
Covering arms/legs while outside at night	216 (40.4%)
Sleeping with windows closed or under mosquito nets	94 (17.6%)
Q5. Food that might cause illnesses if eaten while traveling outside of the Saudi Arabia
Food from street vendor’s	381 (71.2%)
Tap water	176 (32.9%)
Raw fruit or vegetables	136 (25.5%)
Sushi/shellfish	104 (19.5%)
Ice cream	83 (15.5%)
Ice cubes	71 (13.3%)
Milk	49 (09.2%)

Figure 2: Sources of information about medical advice prior to departure

Majority of them obtained information about medical advice prior to departure from pharmacist (40.6%), followed by primary doctor (23.9%), next travel health clinic (12.2%) and health department (2.2%) with 21.1% from mixed sources (Figure 3).

The reason for not seeking pre-travel medical advice were 37% who were not seeking pre-travel medical advice because they knew already the necessary information, 24.2% were too busy, 21.7% had no idea where to find information, 8.1% without health problems, 1.4% were concerned about the cost of pre-travel medical advice and 7.5% had other reason for not seeking pre-travel advice.

The Percentage of knowledge, attitude and practices toward health travel has been presented at table 3. Poor knowledge dominated the good knowledge with 451 (84.3%) as poor while only 84 (15.7%) were having good knowledge while attitude shows, half of the participants were having positive attitude as 269 (50.3%) and 266 (49.7%) were having negative attitude. Poor practices were more on travelers with 460 (86.0%) with relatively low ratings on good practices with 75 (14.0%).

Table 3: Percentage of knowledge, attitude and practices toward travel health
Factor	N (%)(n=535)
Knowledge
Poor	451 (84.3%)
Good	84 (15.7%)
Attitude
Negative	266 (49.7%)
Positive	269 (50.3%)
Practices
Poor	460 (86.0%)
Good	75 (14.0%)

There was significant difference on nationality against attitude (p-<0.001) while both knowledge and practices have no significant difference. Age group in years were not statistically significant for all the dependent variables while gender was statistically significant at knowledge (p-<0.001). Saudi Arabia residency also shows negative relationship and travel to country outside Saudi Arabia shows the same. Number of companions during the travel was statistically significant at knowledge (p-<0.001) and on the other hand plan on visiting rural area or countryside was statistically significant at attitude (p-0.010) .

Discussion

Pre-travel seeking advice

In this study, despite that fact that many of the travelers were visiting high risk countries for some serious diseases still majority of them did not seek any pre travel medical advice (71.2%). This number is quite alarming since some of these diseases are endemic for those high risk countries. Obtaining medical advice prior to travel is as necessary as the travel. This is in order to obtain general information about the disease which is prevalent in the planned country to visit. Generally, the medical advisor would suggest what is necessary to bring and avoid in the planned country of destination. Incidentally, several of the published articles locally and internationally showed that travelers were not accustomed to getting pre-travel medical advice. 6,7,16,19,20,21,22 However, studies suggest that Europeans were more aware of the danger of diseases from those high risk countries as many of them sought medical advice prior to the travel. 5,12,15

Reason for not seeking pre-travel health advice

The most common reason for not seeking pre-travel health advice as the travelers remarked was about “they already knew” others indicated busy schedules. In Oman, Al-Jabri et al (3), among travelers who did not seek pre-travel advice, they stated that “having no time” was the main the reason for not seeking and another reason traveler’s elaborated was about “having no idea about it” whereas in UAE (20), travelers stated that the most common reason for not seeking pre-travel health advice was about “not seeing the importance of pre-travel health advice.” On the other hand, In Asia Pacific, Wilder-Smith et al (22), reported that the main reason of the travelers regarding the subject was the perception of not being at risk and short duration of travel.

Source of pre-travel medical advice

Moreover, our study suggest that many of the travelers who sought pre-travel medical advice considered pharmacist and medical doctor as the best sources of information. This finding is consistent from most of the published articles in the same subject where either general practitioner or other health care providers were the most sought for sources of information about pre-travel medical advice. 5,7,12,15,16,19,20,21,22 However, Al-Abri and his associates provided otherwise where majority of the travelers preferred internet as the sources of health advice prior to departure rather than healthcare providers. 6

Preventive Vaccination

Vaccination prior to travel was the least importance for the travelers in this study. Only 20.8% of the travelers received or purchased preventative medications including vaccination. We further observed that the most common preventive vaccination against communicable disease was in regards to polio and MMR with relatively few cases on Hepatitis virus (A or B). Low adherence to pre-travel vaccination was also determined from the studies published regionally and internationally. 16,19,21,22 However, this is contrary from the studies conducted by Al-Jabri et al as well as Alghamdi and associates. 6,7 Both studies exhibited a relatively higher prevalence of adherence to pre-travel vaccination (52.7% and 57.1% respectively). Moreover, in regards to preventive vaccination of communicable disease our report was not in agreement from most of the published articles in the same subject, where we observed that the most common pre-travel vaccination of the travelers from the previous articles was in regards to Hepatitis virus. 6,7,8,16,19,21,22

Anti-malarial behavior

Traveling to countries classified as high risk of Malaria infection had also been noted in this study. This project reported that those travelers who were taking anti-malarial medicine revealed relatively low (02.8%).

Vaccination prior to travel was the least importance for the travelers in this study. Only 20.8% of the travelers received or purchased preventative medications including vaccine with very few of them were taking anti-malarial medicine (02.8%). They also considered covering arms or legs while outside at night to be the most effective way to prevent from malaria followed by bug repellant and mosquito nets while food from vendors and tap water were the most common food to be shunned while traveling outside Saudi Arabia. These findings were in congruent from other published articles. 5,6,7,16,19,22 Although some studies differed on the application of anti-malarial medication most especially if the travelers were departed to those countries with high risk of malaria infection. 5,12,15

Prevalence of KAP

The prevalence of knowledge, attitude and practices (KAP) of regarding health travel shows, poor knowledge dominated the good knowledge with (84.3%) versus (15.7%) while attitude shows, half of the participants were having positive (50.3%) and (49.7%) were negative. More travelers were having poor practices toward health travel with (86.0%) with relatively low ratings on good practices (14.0%). Regarding relationship between knowledge, attitude and practices versus socio demographic characteristics of travelers it was revealed that there was significant difference on nationality against attitude while gender was statistically significant at knowledge whilst number of companions during travel was statistically significant at knowledge and on the other hand plan on visiting rural area or countryside was statistically significant at attitude. Results published by Alghamdi et al was slightly higher in prevalence although it needs to be considered the number of studied population where their sample size was more than doubled from our study participants. They also showed more significant results when comparing KAP to the socio demographics characteristics. 7 In Oman, majority of travelers were having good knowledge too and symmetric findings in attitude while the correlation between KAP and socio demographic data viewed to be consistent also from our study findings. 6 We further observed that the knowledge and practices of travelers in our study were lower than the previous mentioned studies. This signifies the need to educate Saudi Arabian travelers more about the importance of pre-travel health advice

Determinants of KAP

The present study also measured the determinants of KAP among the socio demographic characteristics of travelers. We found out that the determinants of knowledge in this study was gender and companions to travel while the determinants of attitude was nationality and planned to visit rural area whereas practices showed no determinants. Al Jabri et al, reported that the determinants of knowledge was gender while attitude was travel destination. 6 On the other hand, Alghamdi and colleagues 7, revealed that the KAP was statistically significant at age, education, companions settings and chronic diseases.

Limitation

Just like any other study, this paper is also subjected to some limitations such as; Self-administered questionnaire could contain bias. Another was about limited destinations that departed directly from Prince Nayef International Airport.

Conclusion

This study found out that the majority of travelers were having poor knowledge and practices toward pre-travel medical advice. Many of them did not seek medical advice prior to departure which is quite alarming due to the threat pose of some diseases while in the travel. Concerning this, travel clinics and continuous campaign are needed about the importance of getting pre-travel medical advice. Travel agency as well as general practitioner should educate more the travelers about the danger of diseases in the chosen country of destination. Proper medications and awareness to country of destination should be well taught prior to departure by the concerned parties.

Acknowledgment

At the end of our research, we would like to thank our data collectors:

• Saleh Ali Alghafis

• Abdullah Mohammad Alsalameh

• Abdurahman Abdullah Aldubaikhi

• Maram Ibrahim Altami

• Albatoul Abdulaziz Alluhaida

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