Travel Health Survey : Risk Perception , Health-Seeking Behavior , and Subjective Evaluation of Travel Health Services in Egypt

International civilian travel globally has experienced continued growth and expansion since the advent of modern commercial aviation in the 1950s and over the past 6 decades.1 The number of departures from Egypt was 4 863 000 in 2014. The inbound and outbound tourism segments witnessed positive growth in 2014, despite the sluggish growth during the global downturn.2 Outbound travel recovered swiftly in 2011 as many Egyptians who could afford to do so left the country because of the instability. The number of departures was predicted to increase at an average annual rate of 3%.3 Since the 1990s, the number of scientific articles on travel medicine has increased almost threefold compared to the preceding decades, implicating the increase in the importance of and attention given by the medical profession to this discipline of infectious diseases.4 Many studies have highlighted the underutilization of pretravel health advice, the lack of knowledge regarding travel medicine, and the large number of travelers that are unaware of the health risks abroad.5,6 The European Travel Health Advisory Board (ETHAB) utilized a knowledge, attitude, and practice (KAP) survey to assess the KAP associated with travel health. The ETHAB’s study highlighted a lack of knowledge among travelers, even experienced ones, and the poor utilization of the preventive measures.5 http://ijtmgh.com Int J Travel Med Glob Health. 2018 Feb;6(1):16-24 doi 10.15171/ijtmgh.2018.04 TMGH IInternational Journal of Travel Medicine and Global Health J


Introduction
International civilian travel globally has experienced continued growth and expansion since the advent of modern commercial aviation in the 1950s and over the past 6 decades. 1 The number of departures from Egypt was 4 863 000 in 2014.The inbound and outbound tourism segments witnessed positive growth in 2014, despite the sluggish growth during the global downturn. 2Outbound travel recovered swiftly in 2011 as many Egyptians who could afford to do so left the country because of the instability.The number of departures was predicted to increase at an average annual rate of 3%. 3 Since the 1990s, the number of scientific articles on travel medicine has increased almost threefold compared to the preceding decades, implicating the increase in the importance of and attention given by the medical profession to this discipline of infectious diseases. 4any studies have highlighted the underutilization of pretravel health advice, the lack of knowledge regarding travel medicine, and the large number of travelers that are unaware of the health risks abroad. 5,6he European Travel Health Advisory Board (ETHAB) utilized a knowledge, attitude, and practice (KAP) survey to assess the KAP associated with travel health.The ETHAB's study highlighted a lack of knowledge among travelers, even experienced ones, and the poor utilization of the preventive measures. 5everal consecutive studies investigated the KAP of travelers.Most of them used the standardized questionnaire developed by ETHAB.][9] The travel health practice and research in Egypt lag behind both needs and demands.Almost nothing is known about where Egyptian travelers get their travel health knowledge, how they perceive the health risks of travel, or what measures are taken to avoid potential risks.Therefore, this study was done in two parts to assess travel health KAP among Egyptian travelers.In this first part, the current travel health-seeking behavior, risk perception, different pre-travel practices and satisfaction and evaluation of the adequacy of pre-travel health services are described and evaluated.

Methods
This study was conducted at the departure halls of Cairo International Airport.Inclusion criteria included being an Egyptian traveler, at least 18 years of age, and having a final destination of Africa, Southeast Asia, or Latin America.Passengers to North Africa were excluded from the study.
Using a power of 80% to detect a significant level of health knowledge among travelers = 23.1 %, 10 alpha error = 5%, with a precision of 3%, the minimal required sample size was calculated by Epi-Info software to be 756.Because no data for Egyptian travelers was available, it was assumed that Egyptians are less knowledgeable about travel health than Asians (a selected close reference), and the sample size was expanded to 1500 travelers.
The study design was a cross-sectional interview survey using face-to-face interviews.

Study Procedure
Development of the questionnaire: An interview questionnaire that measures the KAP of travelers was developed through an internet-based literature search on worldwide KAP studies, guided by the ETHAB standardized questionnaire, 11 and frequent meetings of the authors.
The questionnaire included 71 questions, 48 of which inquired about socio-demographic data, previous travel history, current journey details, perception of travelassociated risks, presence of risks management plans, details about the received pre-travel health services, and travel health-information seeking behavior.A subjective evaluation of travel health services and suggestions for improvement were also solicited.The remaining questions were related to vaccinations and malaria chemoprophylaxis and are discussed in the second part of this study.

Pilot Study
A pilot testing of the questionnaire was carried out from January to October, 2014, at Alexandria Fever Hospital.The questionnaire was tested on 50 individuals among those being evaluated for blood-borne viral infections (HCV, HBV, and HIV) as a prerequisite for traveling to gulf countries.Accordingly, questionnaire modifications were made including rephrasing and adding or removing some questions.

Data Collection
Data collection continued from November 2014 to October 2015.Passengers were selected using the simple random sampling technique.The time spent for interviewing each participant ranged between 35 to 45 minutes; thus, the researcher was able to interview 10-15 travelers daily.

Statistical Analysis
Data were fed to the computer and analyzed using IBM SPSS software package version 20.0.Categorical data were presented in frequencies.Quantitative data were described using mean/ median and standard deviation.The Kolmogorov-Smirnov test was used to test normality of data.The Mann-Whitney test was used for non-parametric quantitative variables to compare between two groups, while the Kruskal-Wallis test was used when more than two groups were compared.Spearman coefficient was used to correlate between 2 nonparametric quantitative variables.Significance of the obtained results was judged at the 5% level.
A score for perception of travel associated risks was developed by assigning a score of 0 for the answer "not exposed to any risk" and a score of 1 for each possible risk answer, giving a maximum total score of 23.The scores of perceived travel-associated risks were leveled as follows: • Low level of perception of travel associated risks (0-7) • Medium level of perception of travel associated risks (8-15) • High level of perception of travel associated risks (16-23)  A scoring system was also established for each of the travel health-related practices, including risk management plan, carrying protective measures, seeking pre-travel health services and information, receiving vaccines, using malaria prophylaxis, and intent to use prophylactic measures.A Likert-like scale was applied where a score of 0 was given for no or incorrect practices and the highest score was given to the best practice.The total sum of scores for each parameter was grouped into three ranked categories.The lowest was referred to as (poor), the middle was referred to as (fair), and the highest was referred to as (good).

Results
The socio-demographic description of participating travelers is shown in Table 1.The majority of them (78.5%) had no reported chronic medical condition.The distribution of the travelers according to the current journey details is illustrated in Table 2. Africa was the destination for 61.3% of travelers, while Asia accounted for 28.5%.
The mean total score of perceived travel-associated risks was low (2.7).The differences in total score of travelassociated risks perception according to various travelers and travel-related factors are shown in Table 4.
Only 12.1% of travelers sought pre-travel health services, and the mean time between travel and obtaining health services was 1.74 ± 4.8 days.Two main sources for pretravel health services were mentioned by travelers, namely governmental hospitals and malaria prophylaxis centers (40.7% and 78.6%, respectively).About 30.8% sought pretravel health services in traveler's vaccination centers and 13.7% in private hospitals.Only one traveler sought services in a private clinic.
Seeking pre-travel health services was significantly higher among travelers above the age of 40 years (19.2%,P < 0.001).There was no gender or residence predilection for seeking pre-travel health services.Moreover, this practice did not differ significantly among experienced and first-time travelers (11.1% vs. 12.9%, respectively) or by the time of trip preparation.However, it was significantly higher among travelers traveling for seeking medical treatment (P < 0.001).
Regarding the feasibility of obtaining pre-travel health services, 73.6% stated that it was difficult to get pre-travel health services due to distance and inaccessibility (46.7%), lack of specialized travel clinics (33%), overcrowding (16.5%), high cost (1.6%), or lengthy routine procedures (0.5%).Less than half of the studied travelers sought any information before travel; health information accounted for only 11.9% of the general information sought by travelers.The type of information, barriers, sources, and degrees of satisfaction are detailed in Table 5.
Travel health-related practices were described in general as poor.The details are illustrated in Table 6.
Inquiries into the travelers' opinions of the quality of travel health services resulted in 61.3% of travelers stating that the quality of travel health services is very poor and only 0.5% stating that it is of good quality.Their suggestions to improve services are listed in Table 7. tropical countries are usually above the age of 40 years and travel mostly for leisure, 12 travelers from less developed countries 13 including Egypt are young, and their main purpose of travel is for work.This reflects the importance of keeping this productive and active group healthy.5][16] Ear problems represented the second most frequent health problem (one-fifth), which were related mainly to changes in air pressure inside the plane itself rather than being caused by injury or infection acquired at destinations. 17A similar figure (19%) was reported among travelers on a South American expedition. 18None of the experienced travelers in this study reported respiratory infection in their previous travels, and this result disagrees with many studies reporting respiratory infections as a major travel health-associated problem. 19,20However, this may be attributed to recall bias or low perceived importance of the flu/common cold as a respiratory disease.Only 7.9% of experienced travelers mentioned fever as a travel-associated problem.Likewise, in Italy, fever accounted for 7% of health problems in travelers returning from the tropics. 21Fever represented 26% and 29% of travel-associated problems in the GeoSentinel surveillance and in German travelers destined to tropical and subtropical zones, respectively. 22,23Only one third of the present study participants claimed they did not encounter any health problems in their previous travels compared to 74% of American travelers, which could be attributed to better pre-travel health services and awareness in the latter group. 24nly 34% of experienced travelers had received pretravel vaccinations comprised mainly of required or highly recommended vaccines, namely the meningococcal vaccine received by travelers to KSA for pilgrimages and the yellow fever vaccine received by travelers to Africa which represented the most frequent previous travel destination (51.8%).

Unlike most European travelers among whom travelers to
The perceived health risk in the current survey was poor and reflected the absence of a risk management plan for most travelers.Moreover, less than one third of the participants were carrying protective measures.The situation was different in other studies in Spain 25 and Peru, 13 where 91.2% and 47.3% of travelers, respectively, were carrying medications.
Risk perception is a very important safeguard for selfprotection. 26This was higher among the younger age group (<30 years) despite their poor travel health-related knowledge and poor practices.This might be attributed to more apprehension or more concern about the risks and temptations of traveling, which could compel travelers to express more positive attitudes about various hazards in destinations.
Moreover, there was higher perception of travel risks among illiterate travelers, despite having less knowledge about travel-associated risks.This can be explained by hidden fears and the inability to cope with stress and risks. 27Education provides better opportunities and skills to deal with risks, and that might decrease one's perception of endangering risks.However, gender, age, destination, and region-related travel experience had different impacts on the travelers' risk perception. 28Having an older age and a higher level of education were predictors of increased travel risk perception in KSA 29 and Qatar. 30nly 12.1% of travelers sought pre-travel health services, although 83.3% were well educated, 89.1% were urban residents, 72% had a satisfactory income, and 43.9% had a previous travel history.This was far lower than what was reported in South African (86%), 31 Spanish (83.1%), 25 European (40%), 12 American (36%), 32 Australian (32%), 9 Dubaian (22.8%), 33 and Qatari (19%), 30 travelers.
Moreover, in the present study, only 11.9% of travelers sought health information about their destination.This explains in part the low risk awareness and perception.LaRocque et al 34 found that 46% of international travelers in Australia did not pursue health information of any type; a lack of concern about health problems related to the trip was the most commonly cited reason, and this was also the case in the current study.
The internet proved to be the most popular source for health information for more Egyptian travelers (98.6%) than for Japanese (64.1%), 35 European (24%), 12 or US travelers (19%). 32This reflects the unavailability of professional travel health services, and it can be anticipated that the information was unsatisfactory and the quality may vary greatly between and within sources. 12deally, travelers should seek medical advice at least 4-6 weeks before departure.An important factor for inadequate pre-travel-seeking behavior was reported to be the increasing number of last minute travelers who planned their trips in less than 2 weeks. 6,33onversely in the current study, although the majority of travelers had enough time to plan their travel (3 weeks or more), 85% and 93.1% of those who had planned their trip more than one month prior to their trip did not seek pretravel health services or health information, respectively, and the mean time for obtaining health services before travel for those who did was too short (1.74±4.8days).Egyptian travel health services were not satisfactory, as most participants reported them as very bad and one quarter were neutral, unlike elsewhere 9,33 where satisfaction was highly rated.
A high proportion of travelers would like to have information about diseases in their destinations (39.1%), even though 61.7% of them did not know that there are diseases associated with travel.However, some travelers may have been sensitized by the interview questionnaire which may have made them more curious about the importance of getting health information and services before traveling.

Conclusion
Egyptian travelers to tropical areas are usually young educated males traveling for work.They generally have a poor perception of travel-associated health risks and do not have a risk management plan.Travel health awareness is poor regardless of age, education, or any other socio-demographic factor.A minority of travelers seek health information before traveling, and the internet is their main source of information.Their pre-travel practices are poor, and only one eighth seek any pre-travel services.The travel health services in Egypt were evaluated by the travelers as poor and must be improved.

Conflicts of Interest Disclosures
None.

Ethical Approval
The study strictly followed the ethical guidelines of the Helsinki Declaration and was approved by the High Institute of Public Health Ethics Committee.Participation of travelers was voluntarily and a written informed consent was obtained from each participant.

Funding/Support
None.

Figure 1 .
Figure 1.Types of Risks at Destination for Travelers Who Perceived any Travel Health-Related Risks.

Table 2 .
Distribution of the Travelers at Cairo International Airport According to the Journey Details Southeast Asia (Thailand, Malaysia, Indonesia, Singapore, Philippines, Cambodia, Brunei, Vietnam, and Burma), South Asia (Sri Lanka, India, Bangladesh, and Pakistan), other Asian countries (Yemen, Oman, and South Korea), North Latin America (Mexico), Central Latin America (Bahamas, Cuba, Honduras, Haiti, Jamaica, Puerto Rico, Panama, Salvador, and Nicaragua), South Latin America (Brazil, Venezuela, Bolivia, Argentina, Paraguay, Peru, Colombia, and Ecuador).

Table 3 .
Distribution of Travelers at Cairo International Airport According to Travel Risk Management Plans *Multiple response question; **Others= Antipyretics and ear drops.

Table 4 .
Mean (SD) and Median of Studied Travelers' Total Score of Perceived Travel-Associated Risks by Some Socio-demographic and Travel Characteristics

Table 5 .
Distribution of Travelers at Cairo International Airport According to Travel Health-Seeking Information

Table 6 .
Distribution of Travelers at Cairo International Airport According to Level of Travel Health-Related Practices

Table 7 .
Distribution of Travelers at Cairo International Airport According to Evaluation of Travel Health Service and Suggestions About Travel Health * Multiple response question.