This study was undertaken as a project for the Diploma in Travel Medicine of the Royal College of Physicians and Surgeons (Glasgow) and, in part, was presented as a poster at Asia Pacific International Conference on Travel Medicine, Melbourne, Australia, February 24 to 27, 2008.
Watcharapong Piyaphanee, MD, Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, PhayaThai, Bangkok 10400, Thailand. E-mail: email@example.com
Background Malaria is still prevalent in Southeast Asia where large numbers of backpackers visit each year. This study aimed to assess the knowledge, attitude, and practices among foreign backpackers toward malaria risk in Southeast Asia.
Methods Questionnaires were administered to foreign backpackers in Bangkok, Thailand. They were asked about their general background, their attitude to malaria risk, and their preventive measures against malaria. Their knowledge about malaria was assessed by 10 true–false questions in the questionnaires.
Results In total, 434 questionnaires were evaluated. Fifty-five percent of travelers were male and the median age was 28 years. The main reason for travel was tourism (91%). Almost all travelers (94%) were aware of the risk of malaria. Twenty-two percent of them would take antimalarial prophylaxis and 33% would use measures against mosquito bite, but nearly 40% had “no prevention” at all. Mean knowledge score was only 5.52 of 10. Most backpackers (92%) knew that malaria is a serious disease and sometime fatal and 74% knew that some travelers could develop malaria after they return. However, up to 35% believed that eating contaminated food could lead to malaria infection. And 49% believed that malaria could be 100% prevented by chemoprophylaxis. In backpackers, who had traveled in the forest (n = 65), only 54% used insect repellent regularly. Among those who had taken antimalarial prophylaxis, nearly 30% had stopped the medication prematurely.
Conclusions Although most backpackers perceive the risk of malaria in Southeast Asia, they have some misunderstandings about malaria and tend to comply poorly with mosquito bite prevention and chemoprophylactic strategies.
Malaria is one of the most dangerous diseases, which is a risk to the travelers to the tropics. It is prevalent in Asia, Africa, Oceania, and Central and South America, and Southeast Asia is also a risk area and among the most popular tropical destinations in the world.1 In 2005, Southeast Asia had 49.3 million tourist arrivals, which increased to 53.9 million in 2006.1 Although the risk of contracting malaria in Southeast Asia is quite low compared with Africa,2,3 the risk still exists. A recent report in 2006 found that 13% of febrile diseases among travelers who returned from Southeast Asia were attributable to malaria.4 In the same year, at least one fatal malaria case was reported.5 He had had fever after returning from Southeast Asia and tried to treat himself at home without seeking proper medical care; unfortunately, after that he died. The autopsy report showed that he died from Plasmodium falciparum infection.5
This report underlines the importance of pretravel preparation. Ideally, all travelers to a malaria-risk area should be well informed and well prepared. Unfortunately, data from many knowledge, attitudes, and practice (KAP) studies have shown the opposite.6–9 Although travelers to Asia had been included in some KAP studies, to our knowledge, there has been no KAP study among travelers in Southeast Asia before. Moreover, little is known of their actual malaria preventive measures.
Therefore, this questionnaire-based study was conducted among foreign backpackers in Southeast Asia, aiming to determine their KAP related to malaria risk and prevention in the region.
Materials and Methods
This was a cross-sectional, questionnaire-based study. Data were collected from foreign backpackers in the Khao San Road area, which is a famous backpacker center in Bangkok, Thailand. The questionnaire was designed and tested before actual data collection. Final version of the questionnaire consisted of 30 questions in four parts: general information of travelers, perception of malaria in Southeast Asia, information of malaria, and practice in malaria-risk area. We calculated the sample size by using the data from the Tourism Authorities of Thailand10 and the standard Yamane sample size table.11 To achieve 95% confidence level, we required at least 397 persons.
Accidental sampling method was used in data collection. Backpackers who agreed to join the study filled out a questionnaire by themselves. The investigating team was available to help participants when needed. The study protocol and questionnaire were reviewed and approved by the Ethics Committee of the Faculty of Tropical Medicine, Mahidol University.
All statistical analyses were performed using SPSS for Windows version 10.0.7 (SPSS Inc., Chicago, IL, USA) software.
Continuous data were presented as mean with SD (for normally distributed data) or median with range (for nonnormally distributed data). Categorical data were presented as numbers and percentage. The Student’s t-test was used to compare means of two groups, while the chi-square test was used for categorical data, as appropriate; a p value of <0.05 was regarded as statistically significant.
Data were collected in the Khao San Road area for 2 weeks in October 2007, yielding a total of 434 completed questionnaires. Fifty-five percent of travelers were male and the median age was 28 years. The main reason for travel was tourism (91%). The majority of travelers (62.9%) were visiting Southeast Asia for the first time. The demographic profile of the study participants is shown in Table 1.
Table 1. Demographic and travel characteristics (N = 434)
Age (y) (median 28 y, range 15–65 y)
Continents of origin
Reason for travel
Work or business
Visiting friends and relatives
Education and research
Times been in Southeast Asia (including this trip)
This is the first trip
Two to three times
More than three times
Duration of travel
Within 1 mo
More than 3 mo
Plan to trek in the forest
Number of Southeast Asia countries planned to visit in this trip
1 (Thailand only)
2 or more countries
The majority of travelers sampled (74.4%) had sought some travel health information before travel in Southeast Asia and most of them had used more than one source. The most common sources of information were travel clinic/general practitioners (GP), followed by the Internet, friends and relatives, guidebooks, and pharmacists. The details are shown in Table 2.
Table 2. Pretravel preparation and source of information
Most travelers had sought more than one source of information.
Had sought any travel health information before leaving
Backpackers’ Knowledge and Relation to Pretravel Health Advice
Ten true–false questions have been used as a tool to assess the individuals’ knowledge. The results revealed wide score variation (range 0–10, mean 5.52) (Figure 1). Detailed results for each question were shown in Table 3.
Malaria is a serious and sometimes fatal disease (True)
Mosquitoes that bring malaria usually bite in the day time (False)
Garlic and vitamin B1 provide some prevention against mosquito (False)
Electronic buzzers can repel mosquito effectively (False)
Flies and some insects can also transmit malaria (False)
Taking dirty/uncooked food can lead to malaria infection (False)
Malaria risk in Southeast Asia is in the forested/rural area only (True)
Fever is the main symptom of malaria (True)
Some tourists develop malaria symptoms after they return (True)
Malaria can be 100% prevented by antimalarial medication (False)
Of the 434 backpackers studied, 281 (64%) had received pretravel health advice from a travel clinic and/or GP. The mean knowledge score for this travel clinic/GP group was 5.71; this was significantly higher than the score of the control group (ie, those who had not received pretravel health advice from a travel clinic/GP) at 5.71 versus 5.15, p < 0.001.
When the detail of each knowledge item was analyzed, it was found that the backpackers in the travel clinic/GP group possessed some more specific knowledge items than the control group. For example, up to 79% of this group knew that some tourists could develop symptoms of malaria after they returned home, while only 66% of the control group knew. The details are shown in Table 4.
Table 4. Relation of pretravel health advice on particular knowledge of backpackers
Important knowledge about malaria risk and prevention
GP = general practitioners.
Statistically different between travel clinic/GP group and control group (p < 0.05).
Some tourists develop malaria symptoms after they return*
Malaria cannot be 100% prevented by antimalarial medication*
Perceptions and Attitude of Backpackers
Almost all backpackers (94%) were aware of the risk of malaria in Southeast Asia; 45.8% felt that they had “very low risk” (<1/1,000 per month), while 5.8% felt that they had “high risk” (>5% per month).
When asked about their plans to prevent malaria, 22% of backpackers would take antimalarial prophylaxis and 33% would take measures against mosquito bite; however, nearly 40% stated that they employed “no protection” at all (Table 5).
Table 5. Attitude of backpackers toward malaria risk
Risk of acquiring malaria infection in Southeast Asia (n = 428)
No risk of malaria
Very low risk (less than 1/1,000 per month)
Low risk (less than 1% per month)
Intermediate risk (1%–5% per month)
High risk (more than 5% per month)
I do not know
Plan to prevent malaria
Take antimalarial prophylaxis
Carry standby emergency treatment
Antimalarial prophylaxis plus standby emergency treatment
Mosquito bite prevention only
The perceived risk of contracting malaria in major tourist destinations in Southeast Asia was also investigated. Nearly half (48.8%) of backpackers still believed that there was malaria risk in Bangkok, while in fact, there is no risk at all. The complete results are shown in Table 6.
Table 6. Risk perception of malaria in tourist destination in Southeast Asia
According to the Centers for Disease Control and Prevention guideline: Health Information for International Travel (Yellow Book 2008)12.
Koh Chang (Yes)
Koh Samui (No)
Luangprabang, Lao PDR (Yes)
Vientiane, Lao PDR (No)
AnkorWat, Cambodia (Yes)
Danang, Vietnam (No)
Bali, Indonesia (No)
Papua New Guinea (Yes)
Practices of Backpackers in Risk Area
Among the 434 backpackers studied, 65 (14.9 %) had visited a forested area. Table 7 illustrates their practices while traveling in malaria risk areas.
Table 7. Practices in backpackers who had traveled in forested area (n = 65)
The use of insect repellent
Yes, most of the time (>70% of outdoor activity)
Yes, sometimes (50%–70% of outdoor activity)
Yes, not so often (10%–50% of outdoor activity)
Yes, but rarely (<10% of outdoor activity)
Type of insect repellent used
DEET and botanic repellent
Never use insect repellent
Slept under bed net or stay in a well screen accommodation
No, sometimes sleep in a tent/shelter without screening
No, always sleep in a tent/shelter without screening
Took antimalarial prophylaxis in the forest
Type of antimalarial prophylaxis (n = 38)
Mefloquine and doxycycline
Missed any dose of antimalarial drug (n = 37)
Stopped antimalarial drug before leaving the forested area? (n = 36)
Yes, because of side effect
Yes, I often forget to take it
Yes, I thought I may not need it
No, I took it throughout my stay in the forest
Only 54% stated that they used insect repellent most of the time, while 21.5% used it sometimes, 4.6% “not so often,” and 3.1% rarely; 17% said that they “never used” insect repellent while traveling in the forest.
N,N-diethyl-m-toluamide (DEET) was the most commonly used insect repellent, while a small percentage used a botanic repellent.
Among those who had traveled in forest areas, 57.6% had taken antimalarial prophylaxis; doxycycline was the most commonly used medication, followed by malarone, mefloquine, and chloroquine.
Compliance with antimalarial prophylaxis was not good. Among those who had taken antimalarial prophylaxis, nearly half (47.4%) said that they had missed a dose and 30% had stopped taking the medication prematurely. Side effects of the antimalarial medication were the most common causes of their discontinuation (Table 7).
To our knowledge, this was the first study focusing on foreign backpackers in Southeast Asia. Their demographic data were similar to what was expected; most of them were young, came from Western countries, and on average planned to visit three countries in the region.
Although 74.4% had sought health information before traveling, their knowledge regarding malaria risk and prevention was limited. Up to 35% of our participants believed that malaria could be transmitted via dirty food and beverages. This misunderstanding has also been found in other studies, with varying percentages (5%–43%).9,12–14 A very serious and dangerous misunderstanding among nearly half (49%) of the travelers was the belief that malaria could be completely prevented by antimalarial medication. In fact, no one can rely completely on chemoprophylaxis, as chemoprophylactic failure has been reported frequently, even with good compliance.15–17 This is particularly the case in this region, where multidrug-resistant P falciparum malaria exists.18,19 Moreover, in our study, at least 30% of backpackers who had taken chemoprophylaxis had stopped the medication prematurely. This behavior can lead to greatly increased risk if they still believe that they are fully protected against malaria.
As suggested by previous studies,12,20 travel clinics/GP might be good sources of information for travelers. Our analysis showed that the group of travelers who had visited a travel clinic and/or GP had higher mean knowledge scores than those who had not.
On additional analysis, it was found that the backpackers in the travel clinic/GP group had significantly better knowledge of some specific details, such as the seriousness of malaria, the symptoms of malaria, the possibility of developing malaria after return, and the efficacy of antimalarial medication. Our results suggested that this information was probably given to the travelers in pretravel advice. However, many misunderstandings about malaria risk and prevention were found in both groups. They should be explored and corrected in pretravel counseling.
In our study, the awareness of malaria among backpackers was very good. Up to 94% of backpackers were aware of the risk of malaria in Southeast Asia; 45.8% of backpackers perceived the risk as “very low” (less than 1/10,000 per month), while 27.1% perceived the risk as “low” (less than 1% per month).
When asked about their plans to prevent malaria, 33% stated that they would use bite preventive measures without medication, 22% take antimalarial prophylaxis, and 3% carry standby medication. Unfortunately, 40% answered “no prevention” at all. This may be due to their perception that the risk was “very low.” It should be stressed that “very low risk” is not “no risk.” Bite preventive measures should be emphasized for all travelers because they can prevent not only malaria but also Japanese encephalitis and dengue infection, which are highly endemic in Southeast Asia.
The risk of malaria in Southeast Asia is not uniform throughout the region but is mainly confined to forested or mountainous areas.21,22 There is no risk in cities or urban areas. This may not been known by backpackers. We found that 50% and 43% of our participants still believed that there was risk of malaria in Bangkok and Singapore, respectively. Moreover, when they were asked to assess malaria risk in popular tourist destinations in Southeast Asia, most of them assessed falsely when compared to the current Centers for Disease Control and Prevention recommendation (Yellow Book 2008). Our finding is similar to a study of Swiss business travelers where 68.8% of participants falsely perceived malaria-free areas as risk areas.23 This may be due to travelers, or even health care professionals, possibly considering the whole of Southeast Asia as a risk area. Ideally, the travel medicine specialist should pay special attention to the detailed itinerary of the traveler and malaria epidemiological data for that area.
Regarding antimalaria-risk practices among the backpackers, we analyzed only 65 backpackers who had traveled in forest areas during the current trip, that is, had a real risk of exposure to malaria. Other backpackers were excluded because the aim was to analyze practices in actual risk areas. The results showed that their mosquito bite preventive measures were inadequate. Only 54% regularly used insect repellent and 30% had slept without a proper mosquito screen/net. Our results confirmed the findings of other studies, that is, travelers tend to have low compliance with the use of antimosquito measures.23
As found in many studies,9,24,25 the backpackers in our study who had taken chemoprophylaxis adhered poorly to medication; more than half had missed a dose. Nearly 30% had stopped chemoprophylaxis while they were traveling in the forest. The majority of them had stopped because of side effects of the medication. The proper use of chemoprophylaxis should be advised and emphasized to the backpackers. However, it should be noted that chemoprophylaxis strategy mainly aims to prevent P falciparum malaria only. But a large proportion of malaria in Southeast Asia is due to Plasmodium vivax, which will not be prevented by routine chemoprophylaxis.
There were some limitations to this study. First, data were collected only from foreign backpackers in Bangkok and thus may not represent the whole backpacker group in Southeast Asia. However, geographically, Bangkok is in the center of Southeast Asia and it is the main transport hub for the region. So, most backpackers use Bangkok as their base, before exploring Southeast Asia.26 Although not perfect, data from Bangkok may thus potentially represent backpackers in this region.
Because this study was cross-sectional, with no subsequent follow-up of any type, it can provide only a “snapshot” of backpacker characteristics in Southeast Asia. A future longitudinal study will provide more information. Although it was a snapshot, it was really “the first shot” focusing on backpackers in Southeast Asia. We believe that this study will be a good start for us to understand them better.
We would like to thank Dr Apaporn Chitchina, Ms Thitiya Ponam, Ms Phatcharee Danwiwatdecha, and Mr Trakul Tangtrakul for their help during data collection period.
Declaration of Interests
The authors state that they have no conflicts of interest.