Korean Travelers’ Knowledge, Attitudes, and Practices Regarding the Prevention of Malaria: Measures Taken by Travelers Departing for India From Incheon International Airport
Ji-Ho Choi, MD, PhD, Department of Family Medicine, Inha University Hospital, 7-206, 3-Ga, Sinheung-Dong, Jung-Gu, Incheon 400-711, Korea. E-mail: firstname.lastname@example.org
Background Although many Koreans travel each year to countries where malaria is present, few data are available on the knowledge, attitudes, and practices of Koreans with regards to malaria.
Methods The study was conducted in the departure lounge of Incheon International Airport in May 2006. A 22-item questionnaire was administered to Korean travelers whose travel destination was India.
Results Of 188 respondents, 24% had sought pretravel health information. Independent predictors for seeking pretravel health information were the following: being a Korean woman, longer duration of travel, planning to travel independently or to a rural area, and perceived risk of malaria. A total of 47% of travelers answered that they had not perceived any risk of malaria, and only 7% of travelers carried malaria prophylaxis.
Conclusions There is an urgent need for increased awareness about travel-related infectious diseases (especially malaria) among Korean travelers, and they should be encouraged to seek pretravel health information.
Improved standards of living and globalization have resulted in an increase in the number of people traveling abroad. Moreover, as people travel to a variety of destinations, there has been a dramatic increase in the number of travelers going to tropical regions, which in turn has resulted in a proportionate increase in the risk of malaria infection.
About 30,000 travelers each year worldwide are infected with malaria during a trip abroad.1 According to the Korea Center for Disease Control and Prevention, about 50 Korean travelers are infected with malaria every year when abroad.2 Between 2002 and 2005, the regional distribution of the origin of malarial infection in all 184 cases in Korean travelers was 92 from Asia, 79 from Africa, 10 from Oceania, 2 from America, and 1 of unknown origin (Table 1). Types of imported malaria in Korea are listed in Table 2.
Table 1. Regional distribution of origin of imported malaria in Korea (2002–2005)
|Total, n (%)||79 (42)||92 (50)||10 (5)||0 (0)||2 (1)||1 (0)||184|
Table 2. Types of imported malaria in Korea (2002–2005)
|Plasmodium falciparum||58||19||4||0||0||0||81 (44)|
|Plasmodium malaria||3||2||0||0||0||0||5 (3)|
|Plasmodium vivax||10||53||4||0||1||0||68 (37)|
|P vivax + P falciparum||3||7||1||0||1||0||12 (6)|
|Plasmodium ovale||1||1||0||0||0||0||2 (1)|
|Total, n (%)||79 (42)||92 (50)||10 (5)||0 (0)||2 (1)||1 (0)||184|
Most cases from an individual country were from India (n= 27), followed by Nigeria (n= 21), Indonesia (n= 18), and East Timor (n= 11). India is a country of particularly high malaria risk, including both metropolitan and rural areas;3 travelers who only visit large cities are also at risk of malaria infection. Although travelers from Nigeria or Indonesia may have a higher individual risk of importing malaria into Korea, because of the relatively small number of travelers from these destinations, they were excluded from the study. Countries from which there is no direct flight to Korea were also excluded. Therefore, India was selected as the study destination. According to the Korean Society of Infectious Disease, mefloquine or doxycycline is recommended for travelers to India.
The family doctor of those who plan to travel to malaria-risk countries should be able to evaluate relative risk of the disease, conduct counseling and education on how to reduce this risk, and provide proper preventive vaccination and medication.3–5 There have been studies carried out on travelers’ knowledge, attitude, and practice at various airports, including those in Australia, America, Europe, and Canada, to provide the basic material for counseling and education.6–9 However, there are insufficient travel-related medical data from Korea, as pretravel health information provision is relatively new in this country.10
Therefore, this study attempted to investigate the knowledge, attitude, and practice regarding malaria of those traveling to India, which is one of the major malaria-risk areas for Korean travelers. An additional objective of this study was to provide basic information to primary care and pretravel health specialists to encourage them to emphasize the importance of pretravel health.
Study subject and methods
This study was conducted from May 1 to 31, 2006, at Incheon International Airport, Korea. The study was restricted to Korean passengers older than 18 years who were leaving for India. Among the 30 flights per month, which fly directly to India from Incheon International Airport, 10 were randomly chosen, and all passengers who arrived at the lounge at least 30 minutes before departure were included in the study. One family medicine practitioner distributed questionnaires to the travelers leaving for India in the departure lounge of the airport and collected them immediately after completion. Passengers who did not have Korean nationality were excluded. The questionnaires were distributed to 201 passengers in total. Among them, 13 (6%) passengers who refused to participate or who did not complete the questionnaire were excluded. For the analyses, 188 questionnaires were used.
The study protocol was approved by the chief of the Incheon International Airport Medical Center.
The research tool used in this study was based on published studies related to travelers’ knowledge, attitudes, and practice regarding pretravel health carried out at several airports6–9 in Australia, America, and Europe. The questionnaire consisted of 22 items including 3 on the individual’s socioeconomic status; 5 on travel-related characteristics; 7 on general travel information and pretravel health information collection; and 7 on the participants’ knowledge, attitude, and practice regarding malaria infection.
Statistical Package for the Social Science Program for Windows v.11.5 (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis. Descriptive statistics were obtained for the socioeconomic factors and travel-related characteristics of the subjects. Bivariate logistic regression analysis was carried out with the data on knowledge, attitude, and practice regarding malaria infection. Factors related to pretravel health information–seeking behavior were independent of each other, and the test for possible interactions was done. Results were taken to be statistically significant at p < 0.05.
General characteristics of the subjects
There were 188 subjects in total. Mean age was 39.02 years (SD = 12.1); 137 (72.9%) were men and 51 (27.1%) women. Most of the participants (75.5%) were at least college graduates (Table 3).
Table 3. General characteristics of study subjects
|Age||Mean (SD)||39.02 (12.1)|
|Sex, n (%)||Male||137 (72.9)|
|Education, n (%)||Elementary school educated||1 (0.5)|
|Middle school educated||3 (1.6)|
|High school educated||42 (22.3)|
|College educated or higher||142 (75.5)|
|Regular hospital visiting for chronic disease, n (%)||Yes||13 (6.9)|
Among travel-related characteristics, most of the individuals (38.8%) planned to travel for less than a week. The purpose of their travel was business (53.2%), personal leisure (17.6%), or a group tour (15.1%). A total of 72 (38.3%) had planned their travel 2 weeks to a month and 53.7% planned to travel outside large cities (Table 4).
Table 4. Characteristics associated with traveling
|The purpose of traveling||Business||100 (53.2)|
|Private trip||33 (17.6)|
|Group tour||29 (15.4)|
|Length of stay (d)||Within 7||73 (38.8)|
|More than 30||55 (29.3)|
|When plans were made for traveling||Within 7 d before departure date||34 (18.1)|
|7–14 d before||40 (21.3)|
|14–30 d before||42 (22.3)|
|More than 30 d before||72 (38.3)|
|First visiting to India||Yes||109 (58)|
|Plan to travel outside city||Yes||101 (53.7)|
Knowledge, attitude, and practice regarding pretravel health information
Among the 188 travelers, 136 (72%) had acquired general information about their trip prior to departure. They had acquired information from the Internet (43%), travel guidebooks (22%), coworkers (13%), or a travel agency (12%). (Multiple selections were possible.)
Only 23.9% of participants had looked for pretravel health information. Most (25%) of those who did not look for medical information answered that “We did not see the necessity of medical information” (Table 5). While most participants obtained pretravel health information from the Internet, only 5% of all participants got the information from their doctor and none from a travel medicine specialist.
Table 5. Travel health–seeking behavior
|Seek general information before departure|| ||136 (72)|
|Seek travel health advice before departure|| ||45 (24)|
|Reasons for not seeking travel health advice||Not necessary||47 (32)|
|No time||41 (28)|
|No knowledge how to get medical information||18 (12)|
|Already have got||14 (9)|
|Thought no risk area||12 (8)|
|Sources of travel health advice*||Internet||26 (58)|
|Travel guidebooks||19 (42)|
|Travel agency||5 (11)|
|The physician of the Chinese||1 (2)|
|Specialist in travel medicine||0 (0)|
Factors related to pretravel health information–seeking behavior
Female travelers were more likely to look for pretravel health information than men (OR = 2.69, 95% CI 1.17–6.15, p= 0.019). Other factors that were significantly related to health information–seeking behavior are listed in Table 4. Those who traveled for more than 2 weeks, individual travelers, those who planned to visit rural areas, and those who recognized the risk of malaria tended to seek pretravel health information.
Factors that were not related to health information–seeking behavior were age, education level, travel preparation period, first or subsequent travel, and having regular checkups for chronic disease.
All the factors were independent of each other.
Knowledge, attitude, and practice regarding malaria infection
Among the 188 travelers, only 44 (23%) looked for information on malaria before they traveled. Among them, 89 (47%) did not know about the risk of malaria in India and 92 (49%) responded that “there is a little bit of risk” or “high risk” of malaria. Table 6 shows the details of these responses.
Table 6. Factors associated with seeking travel health advice on univariate analysis
| Older than 50||1||0.85–10.335||0.088|
| Younger than 50||2.97|
| Less than college||1||0.46–2.18||0.997|
| More than college||1.00|
|Length of stay (d)|
|Plan to backpack|
|When plans made for traveling|
| Within 14 d before departure date||1|| || |
| More than 2 wk before departure date||0.71||0.31–1.62||0.41|
|Plan to travel outside city|
|First visit to India|
|Seeing the doctor regularly|
|Perceived risk of malaria|
| Do not know/no risk||1||2.42–11.50||<0.001*|
| Low/high risk||5.28|
Among all participants, 84 (45%) did not have any malaria prevention. The most common method used was long-sleeved shirts and long pants (32%), followed by mosquito repellent lotion (26%) and mosquito coils (19%). Only 13 (7%) of the study participants had malaria prophylaxis (multiple selections permitted; Table 7).
Table 7. Knowledge, attitudes, and practice regarding malaria and malaria prevention
|Get information on malaria before travel|
| Yes||44 (23)|
| No||144 (77)|
|Perception of risk for malaria in India|
| No risk||7 (3.7)|
| Low risk||82 (44)|
| High risk||10 (5.3)|
| Do not know||29 (15)|
|The route of infection|
| Mosquito bite||139 (74)|
| Polluted water||11 (6)|
| Insect bite||7 (4)|
| Infected blood||2 (1)|
| Do not know||29 (15)|
|Chief complaint with malaria|
| Fever||148 (79)|
| Itching||3 (1)|
| Fatigue||2 (1)|
| Do not know||35 (19)|
|Personal protective measures*|
| Long sleeves shirts and long pants||61 (32)|
| Mosquito repellent||48 (26)|
| Mosquito coil||36 (19)|
| Malaria chemoprophylaxis||13 (7)|
| Mosquito net||5 (3)|
| Nothing||84 (45)|
|Reasons for not preparing malaria chemoprophylaxis|
| No risk area||88 (47)|
| Knowing necessities but not prepared||26 (14)|
| Too short staying||19 (10)|
| Denial to medicines (side effect, efficacy)||18 (10)|
| Not enough risk to get medicines||8 (4)|
| Too long period of travel||6 (3)|
| Too expensive||5 (3)|
| Never thought about chemoprophylaxis||2 (1)|
| Others||14 (7)|
The most common reason for not having any malaria prevention was an incorrect perception that India was not a malaria-risk region (47%).
This study involved questionnaires distributed to study subjects in the departure lounge of Incheon International Airport, replicating studies conducted in other airports.6–9 However, there were some limitations in the study. Travelers who arrived at the departure lounge just before departure could not be questioned; the purpose of many of the travelers was business as the study was conducted during the off-season; there were a small number of subjects (n= 201); and there were no statistically significant factors related to malaria prophylaxis as only 13 participants carried it.
India has recently become a popular travel destination for Koreans, and there is a high possibility that travelers to the country might be exposed to various infectious diseases. However, according to the results, only 23.9% of the sample of travelers had obtained pretravel health information. This is a lower proportion than for western travelers who visit Asia (63%)6 and is much lower than the proportion of western travelers who obtain pretravel health information before visiting Africa (91%).11 It appears that there are several factors that influence the proportion of Korean travelers who look for pretravel health information.
Travelers who plan long trips, personal travelers, those who plan to travel to rural areas, and female travelers are those who recognize the high risk of malaria and tend to look for pretravel health information a bit more often. The level of education and having regular checkups for chronic disease were not associated with the behavior. This study has demonstrated that there is lack of general recognition of travel medicine in Korean society, as even people with a higher level of education and those who attend their doctor regularly did not look for pretravel health information.
Although some travelers did look for pretravel health information, very few of them (5%) asked for advice from doctors. Instead, they looked at the Internet (24%) and consulted travel guidebooks and travel agencies for such information. As other studies have clarified, these sources can provide insufficient and misleading information.12–14 Although 23.9% of the travelers had obtained pretravel health information, many had an incorrect perception that India is not a malaria-risk region, and only 7% had obtained preventive medicine. Of particular note is the fact that not one person had asked for medical advice from a travel medical clinic or specialist. The most probable reason for this is low demand due to the low recognition of the importance of pretravel health information. However, there is also a lack of supply and promotion of medical practitioners who provide pretravel health information.
In conclusion, the results of this study show a very low level of social recognition of travel medicine in Korea. Proper preparation for preventable infectious diseases such as malaria is required, and this can be carried out most effectively by raising travelers’ knowledge of disease risk. Media interest, education of primary physicians, and partnerships between travel agencies and medical clinics are potential means of improving public perception of travel medicine. Family physicians should have a full understanding of travel medicine, and they require related education and training.
Declaration of interests
The authors state that they have no conflicts of interest.