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“Travel-related risk can be defined as the threat of an adverse event affecting a person's health whilst traveling, which interferes with the trip or necessitates the use of health services.”[1]

International travel can expose travelers to various risks to health, which depend on many factors including the destination and the person. What is certain is that there is no shortage of people traveling. The United Nations World Tourism Organization estimates that there was a 4% increase in international tourist arrivals in 2011 to 982 million and that the 1 billion estimated international tourist arrivals was expected to be exceeded in 2012.[2] Travel for leisure, recreation, and holidays makes up 51% of inbound tourism with 27% traveling for visiting friends and relatives, health, religion, and related purposes and 15% traveling for business and professional reasons.[2] Just over half of travelers travel by air (51%) with the remainder traveling by road (41%), rail (6%), and sea (2%).[2] Up to 75% of travelers to the tropics and sub-tropics report some kind of health impairment or use of medication, even if minor.[3] Mortality among travelers depends on the destination, but is uncommon. Among Swiss travelers, the mortality rate of travelers going to developing countries is about 0.8 to 1.5 per 100,000 per month.[3]

A risk assessment is undertaken as part of the pre-travel health consultation for those who seek medical advice prior to departure. It involves evaluating both the risks of the destination and of the individual traveling to this destination.[4] When making a pre-travel risk assessment, travel health advisers generally focus on the probability of harm and the severity of possible consequences of travel and balance these with the probability and the severity of possible consequences of any interventions.[5] The purpose of the risk assessment is to help identify travelers at special risk, eg, those with medical conditions, pregnant travelers, children or older travelers, and/or those travelers who may be undertaking travel which has special risks, such as long-term travelers, adventure travelers, or those undertaking a pilgrimage or going to a high-risk destination.[6] Risks may be categorized as preventable, avoidable, manageable, or unexpected.[7]

Risk assessment usually involves an examination of the epidemiological evidence, relevant policies, clinical considerations, and even travelers' responses and preferences. Judgments generally pervade any assessment of risk, including the definition of outcomes that matter, the breadth of the effects to be considered, and measures of consequences. For example, epidemiological evidence is generally too broad to apply to every location that a traveler is going to and it changes over time or may even be out of date. Judgments therefore need to be made in the risk assessment. Recently published data by Rossi and colleagues reinforce the degree of uncertainty that exists in the pre-travel risk assessment, which must also be managed.[8] This is also compounded by travelers who may only know the general location where they are planning to visit, with the general notion of finding their own way once they arrive or travelers who like the freedom to try new things not knowing what they may be before departure.

Travelers' responses to pre-travel advice are influenced by their perceptions of risk, familiarity and concerns about treatments, and the preferred risk management strategies.[1] In risk perception, travelers may confound the likelihood and severity of outcomes, and also tend to be influenced by attributes of the hazard apart from its actual consequences. Familiarity, visibility, and controllability of a hazard all influence the perception of risk.[5] Understanding of the perceptions as well as the reality of risk in travel can help travel health advisers to better prepare travelers for safer and healthier travel.

The presence of preexisting knowledge and beliefs about diseases and treatments, and their socio-cultural contexts, will already be shaping travelers' perceptions of risk and how they might engage with pre-travel health advice.[1] Noble and colleagues describe various conceptual frameworks, which can be helpful in defining travelers' responses to risks.[1] One concerns people's perception of risk and their own ability to respond to it. Research into health beliefs has shown that people's likelihood of taking action in response to a perceived threat to their health is determined by their perceptions of:[1]

  • ‘The severity of the threat’
  • Their susceptibility to the threat
  • The risks, costs, and benefits of taking action
  • ‘Their own ability to successfully undertake the required action.’

Furthermore, travelers are more likely to act to avoid a health threat if they intend to take action following their consideration of the threat, and if there are cues to prompt the behavior closer to the time.[1] Noble and colleagues suggest that there is evidence that travelers' adherence to the recommendations may be related to their health beliefs and intentions, but also that these can be influenced by pre-travel advice.[1]

In this issue, Zimmermann and colleagues explore travelers' perception of risk pre- and post travel and compare this to experts.[9] What is interesting is that on the whole most people did not change their perception of risk from pre- to post travel, except in the area of sustaining an injury. Also depending on age, sex, destination, and region-related travel experience people perceived the risk differently. Particularly interesting was the observation that men perceived mosquitoes, malaria, and rabies as higher risks than women.[9] Often it is men who usually perceive things to be less risky than women.

One of the real challenges about undertaking a study around risk is understanding what the actual risk is and how that might vary for an individual. The risk or probability of an event occurring changes based on the behavior of the individual, the locations visited, the amount of time spent at any location, the activities carried out, as well as the individual's knowledge and skills.

In the area of injury and perceived risk, for example, it is not surprising but is disappointing that people did not perceive it to be more risky. The possibility of sustaining an injury comprises a wide range of potential events that can lead to an incident from drowning to road traffic accidents to burns and scalds to violence to falls. Most people do not associate the activity they are going to or undertaking as potentially harmful; this is probably partially due to the fact if one worries about being injured every time one did something then one would probably not do anything. The big question is what pre-travel health advice can be given at the time of visiting the clinic and whether there are other opportunities for reinforcing these messages or providing messages about other issues at times when they are not in the clinic. Some challenges include the development of skills to ensure their own safety, such as swimming skills or being able to drive on the opposite side of the road. Others may include, eg, ensuring that travelers take their own medication. What is even more challenging is understanding the influence of those around the traveler and how their risk-taking behavior affects them. The consumption of alcohol also has an effect on decision making.[10] George and colleagues acknowledge that it is also true that travelers in a new city, with their inhibitions reduced by the consumption of alcohol and the excitement of what is going on around them, do things that at home they would otherwise not do; they are for that moment a different person.

The study of risk, risk perception, and risk mitigation in travelers needs greater attention so that the clinician can provide advice that is both meaningful as well as impactful in ensuring safe travels.

Declaration of Interests

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  3. References

The authors state they have no conflicts of interest to declare.

References

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  2. Declaration of Interests
  3. References