Quality Assessment in a Travel Clinic: A Study of Travelers’ Knowledge About Malaria
Part of this work was presented as poster presentation at the 9th Conference of the International Society of Travel Medicine, May 2005, Lisbon, Portugal.
Rosa Teodósio, MD, PhD, Tropical Medicine Unit, Institute of Hygiene and Tropical Medicine, Rua da Junqueira, 96, 1349-008 Lisbon, Portugal. E-mail: email@example.com
Background Quality in health care delivery is considered essential and should be expected for all who deliver health care. We were not able to identify in Portugal any previous studies that assessed the quality of travel medicine consultations. The aims of this study was to assess the impact of travel health advice on travelers’ knowledge and the quality of the outcome of the travel consultations at the Institute of Hygiene and Tropical Medicine, Portugal.
Method We selected the quasi-experimental model “separate-sample pretest–posttest design.” Two random samples were obtained (control and experimental groups). An anonymous self-administered questionnaire was applied during the second half of 2002, until we had received about 200 questionnaires for each group. The questions assessed travelers’ knowledge of malaria, its transmission, prevention, and clinical features.
Results There was a significant improvement of travelers’ knowledge in the postconsultation group, with 98.5% of individuals understanding that malaria is transmitted by mosquito bite (p= 0.005), 91.5% that malaria may be prevented by appropriate prophylactic medication (p= 0.007), and 93% knowing that malaria is prevented by avoiding mosquito bites (p= 0.003). However, almost half of the postconsultation group did not realize that there was no vaccine available for preventing malaria (p < 0.001) or that avoiding unsafe food and drink did not prevent malaria (p= 0.006). About 53% gave correct answers about malaria incubation periods (p < 0.001), and 91.1% were able to identify the initial symptoms of malaria (p < 0.001).
Conclusions Travel medicine consultations increase the knowledge base of travelers but do not achieve 100% correct answers. Our results suggest that during a travel health consultation, critical information is assimilated about the prevention of malaria, but myths and misunderstandings that are held by travelers are not completely dispelled.
According to the International Organization for Standardization, quality is a complex of characteristics of an entity that bestows its capacity to satisfy explicit or implicit needs.1 Quality of care is a multidimensional concept. In Portugal, as elsewhere, quality of health care delivery is considered to be essential and should be the goal of all health care workers.2 The evaluation of quality is a complex process, which involves comparison of a procedure or one of its components, with a pattern or model with predetermined reference values. Evaluation creates an opportunity to make judgments and correct or improve that procedure.1,3
In the speciality of travel medicine, we identified a number of studies regarding specific training or the technical quality of travel advice to travelers given by travel agents, pharmacists, and general practitioners.4–10 Some studies show great variability in the training of doctors in travel medicine consultation,11 while others raise questions about the accessibility and degree of satisfaction with the service provided12,13 or assess the appropriateness of the advice given.14 Studies about the acquisition of knowledge in two different travel medicine consultations concluded that the advice given in these consultations increased the travelers’ level of knowledge.15,16 Some authors studied the impact of pretravel advice on the travelers’ health, while17–19 others studied the structure and process components in travel clinics.20
Each year, many international travelers fall ill with malaria before or after returning home. WHO specifies that travelers and their advisers should note the four principles of malaria protection:21
- 1Be aware of the risk, the incubation period, and the main symptoms.
- 2Avoid being bitten by mosquitoes.
- 3Take chemoprophylaxis.
- 4Immediately seek diagnosis and treatment if suggestive symptoms develop 1 week or more after entering an endemic area.
In Portugal, most travel clinics are located in public health clinics or universities, and the quality of travel medicine consultations have not previously been assessed. Our study aimed:
- 1To determine the impact of the advice given in a travel clinic on the level of travelers’ knowledge.
- 2To assess the quality of the outcome of the consultation with reference to the travelers’ level of knowledge on some important aspects of malaria.
The quasi-experimental model “separate-sample pretest–posttest design” was selected,22 comparing two random samples of travelers. Only travelers advised from our travel clinic, traveling to malaria-endemic areas and aged at least 15 years were included in this study.
Travelers’ identification was made through each doctor’s appointment. Employing a table of random numbers, and agreeing to appointment order, two samples were obtained (control and experimental groups) using alternately, by doctor and day of consultation, even and odd numbers.
During the study, seven doctors advised travelers: five specialists in infectious or tropical diseases, one pediatrician, and one general practitioner.
An anonymous self-administered questionnaire, previously pretested with travelers, was applied. The questions requested information on sociodemographic characteristics (gender, age, level of education, previous travel to tropical countries, and previous travel health advice), data on the journey to take place (country of destination, main reason, and length of stay), and data on knowledge of malaria (transmission, prevention, incubation period, and initial symptoms).
The questionnaire had both closed, single-choice questions and open questions. Closed questions consisted of sentences on each of the themes transmission, prevention, and clinical features of malaria, with the answer options of “yes/no/ignore” or “true/false/ignore.” A total of 22 sentences were included in the questionnaire.
A control group answered the questionnaire before the consultation and the experimental group answered the questionnaire after the consultation. This inquiry was applied during the whole second half of 2002, until we had received about 200 questionnaires for each group.
In this evaluation, the quality criteria were explicit and normative, specifying the conditions of the evaluation and theoretical formulation. These criteria were based in technical orientation provided by the World Health Organization23 and were in agreement with the objectives of our travel clinic for travelers’ knowledge about malaria. The selected evaluation criteria can be found in Table 1.
Table 1. Outcome quality criteria in travel medicine clinic consultation
|1||Every traveler should know how malaria is transmitted|
|2||Every traveler who said that malaria is transmitted by mosquito should know when and where mosquitoes bite|
|3||Every traveler should know how to prevent malaria|
|4||Every traveler should know the chemoprophylactic regimen they have been recommended to use|
|5||Every traveler should know that chemoprophylaxis does not guarantee complete protection|
|6||Every traveler should know antimosquito measures|
|7||Every traveler should know protection time of repellents|
|8||Every traveler should know the incubation period and initial symptoms of malaria|
Data was analyzed using the SPSS package (version 7.5, SPSS Inc., Chicago, IL, USA). We considered the significance level of 5%. A statistical analysis was performed to compare the groups: chi-square test was used for categorical data; Mann–Whitney nonparametric test was an alternative to t-test when the assumptions of this test were not satisfied or if the variable in study was only ordinal.
Travelers’ characteristics; homogeneity between the groups studied
Five travelers selected to be included in the control group and eight travelers selected to be included in the experimental group did not want to participate in this study and were substituted with other randomly selected travelers.
A total of 409 travelers participated in this study, 207 in the control group and 202 in the experimental group. The sex ratio of the two groups was equal. More than half of the travelers traveled for periods of up to 28 days to African countries and indicated leisure/holidays the reason for the journey. More than half the travelers had previously been to tropical countries, and about a quarter of the travelers had previously attended a travel advice consultation. Sociodemographic and travel characteristics are given in Table 2.
Table 2. Demographic and travel characteristics of studied groups
| Male||101 (48.8)||99 (49.0)||0.965†|
| Female||106 (51.2)||103 (51.0)|
| Level I||115 (55.8)||108 (54.8)||0.691†|
| Level II||24 (11.7)||30 (15.2)|
| Level III||55 (26.7)||52 (26.4)|
| Level IV||11 (5.3)||6 (3.0)|
| Level V||1 (0.5)||1 (0.5)|
|Duration of stay|
| <1 week||6 (3.0)||2 (1.0)||0.333†|
| 1 to 2 weeks||36 (17.7)||34 (17.6)|
| 2 to 4 weeks||89 (43.8)||91 (47.2)|
| 4 weeks to 3 months||40 (19.7)||47 (24.4)|
| 3 to 6 months||11 (5.4)||7 (3.6)|
| ≥6 months||21 (10.3)||12 (6.2)|
| Africa||135 (65.2)||122 (60.4)||0.288†|
| Central America||7 (3.4)||3 (1.5)|
| South America||25 (12.1)||25 (12.4)|
| Asia||40 (19.3)||52 (25.7)|
|Reasons for travel|
| Leisure/holidays||120 (58.3)||126 (62.4)||0.267†|
| Professional||56 (27.2)||50 (24.8)|
| VRF||8 (3.8)||13 (6.4)|
| Other||22 (10.7)||13 (6.4)|
| Yes||139 (67.8)||142 (71.7)||0.393†|
| No||66 (32.2)||56 (28.3)|
|Previous travel advice|
| Yes||59 (28.5)||46 (23.1)||0.215†|
| No||148 (71.5)||153 (76.9)|
No significant differences were found between the control and the experimental group regarding those travelers’ characteristics, indicating that the groups were suitable for subsequent analysis.
For all knowledge areas under study in the questionnaire concerning malaria transmission, prevention, and clinical features, the percentage of correct answers increased in the experimental group (Table 3). For some areas, the percentage of correct answers was almost 100%.
Table 3. Outcome quality assessment—questions and answers on the questionnaire
|Malaria transmission||Mosquito (yes)||192 (92.8)||199 (98.5)||0.005|
|Food and beverage (no)||90 (43.7)||112 (57.1)||0.007|
|Sexual (no)||137 (66.5)||157 (79.7)||0.003|
|Anopheles’ biting habits||By day (no)||55 (28.9)||124 (64.9)||<0.001|
|Sunset and sunrise (yes)||145 (76.3)||175 (88.4)||0.002|
|Night (yes)||122 (63.9)||183 (93.8)||<0.001|
|Outside home (yes)||155 (81.2)||187 (96.4)||<0.001|
|Inside home (yes)||136 (71.2)||181 (93.3)||<0.001|
|Malaria prevention||Medication (yes)||170 (82.5)||183 (91.5)||0.007|
|Vaccine (no)||64 (31.5)||104 (52.8)||<0.001|
|Avoid mosquito bites (yes)||171 (83.4)||186 (93.0)||0.003|
|Avoid unsafe food and drink (no)||77 (37.7)||101 (51.3)||0.006|
|How avoid mosquito bites||Repellent (yes)||201 (97.6)||201 (100.0)||—†|
|Protective clothes (yes)||146 (71.2)||188 (94.9)||<0.001|
|Air conditioning (yes)||63 (31.0)||153 (77.3)||<0.001|
|Mosquito bed nets (yes)||185 (89,8)||184 (91.5)||0.547|
|Insecticide (yes)||139 (67,8)||162 (81.0)||0.002|
|Prophylactic regimen||Before, during, and after the journey (yes)||171 (82.6)||196 (97.0)||<0.001|
|The protection conferred is less then 100% (yes)||150 (72.8)||177 (87.6)||<0.001|
|Repellents||Duration of the repellents’ effect (3 to 4 hours) (yes)||87 (42.4)||142 (70.6)||<0.001|
|Malaria incubation period and initial symptoms||Clinical symptoms develop 1 week or more after entering malaria risk area (yes)||66 (32.0)||106 (52.5)||<0.001|
|Initial clinical symptoms are identical to influenza (yes)||147 (71.0)||184 (91.1)||<0.001|
Most of the experimental group answered correctly about malaria transmission and prevention methods (mosquito bite, appropriate prophylactic medication, and protection against Anopheles spp. bites). However, 20.3% of respondents were not sure about whether sexual routes might transmit malaria, 42.9% believed that it could be transmitted via food and beverages, 47.2% that malaria could be prevented by the use of a vaccine, and 48.7% did not understand that avoiding unsafe food and drink would not reduce their risk of acquiring malaria. A small percentage answered incorrectly about chemoprophylactic regimen and the protection conferred by medication. Almost all were correctly able to identify the most frequent malaria initial symptoms, but only 52.5% gave correct answers about the incubation period of malaria (Table 3).
Statistical tests revealed the existence of significant differences on the frequency of correct answers between the control and experimental group (Table 3). The only exception was the question about the use of mosquito bed nets to protect against mosquito bites.
We have assessed the knowledge of travelers about malaria transmission and prevention. It was not possible to evaluate the impact of pretravel advice on travelers’ health because of difficulties related with sampling, control group assignments, control of bias, loss of cases, and available resources.
The selection of our study design allowed us to minimize some threats to validity. If we applied the questionnaire to the same group before and after consultation, the nonresponder rate in the posttest group could increase and the difference between pre- and posttest data might have nothing to do with the consultation. The influence of access to other sources of travel health information on the results was avoided because groups answered the questionnaire just before or after the consultation and because of daily selection of participants. This also avoided a loss of respondents due to a longer time interval between the consultation and completing the questionnaire. The length of time that a traveler might have had to wait before the consultation or factors like increasing tiredness, boredom, or hunger might also have influenced answers, but these we could not influence. Offering travelers yes/no/ignore or true/false/ignore answers allowed us to retain more trustworthy answers. It would have been interesting to assess the knowledge base of travelers a longer interval after the consultation, but we would not have been able to control the other threats to validity we have already alluded to. It would also have been interesting to compare the knowledge of the groups with and without other information sources operating outside the consultation. Our purpose, however, was to assess the knowledge base of travelers under normal conditions of care.
The results of the statistical tests showed significant differences between the control group and the experimental group regarding correct answers to the formulated questions. We have confirmed the findings of others that pretravel consultation will increase the knowledge base of travelers.14,15 For most subjects, we failed to achieve 100% correct answers in the postconsultation, but the knowledge base we achieved was still good. The quality criteria we employed were very ambitious but consistent with the objectives of our travel clinic, although we recognize that 100% accuracy in a posttest consultation will probably never be achieved. In our consultations, the advice was given verbally. The use of video or written advice might have produced even better results.
Before we undertook this study, we knew that some travelers believed that a vaccine could protect against malaria. In Portugal, travelers have access to yellow fever vaccine without medical prescription when they travel to endemic areas, and more than half of Portuguese travelers do not receive any medical advice before travel.24 Our results suggest that during the consultation we gave correct information, but we did not attempt to dispel myths or incorrect assumptions regarding malaria transmission and prevention already held by travelers. We may not have sufficiently emphasized important areas like the incubation period of malaria and the more frequent initial symptoms of malaria. Because travel clinics should be prime credible information sources, it is important for us and others to emphasize these details.
During the consultation, as well as engaging in education on the important central information issues, it is very important avoid the transmission of incorrect information and dispel myths or incorrect assumptions so that travelers achieve real clarity. Guidelines on the ideal knowledge base that travelers should hold should be established. We believe that the knowledge base of travelers should be assessed on a regular basis because only properly informed travelers are likely to comply with the advice they have been given.
We conclude that a good travel medicine consultation will increase the knowledge base of travelers. While we did not achieve total accuracy in the post-travel consultation, our results were good. In our travel health consultations, critical information on malaria prevention is assimilated, but the preexisting myths and incorrect knowledge held by travelers are not completely dispelled.
We thank the medical staff of Institute of Hygiene and Tropical Medicine, Lisbon, for helpful comments.
Declaration of interests
The authors state that they have no conflicts of interest.