It is not clearly known how frequently the recommendations given to travelers are followed, and what factors could encourage compliance with these recommended measures.
It is not clearly known how frequently the recommendations given to travelers are followed, and what factors could encourage compliance with these recommended measures.
Adults consulting at a Medical Department for International Travelers (International Travelers' Medical Services, ITMS) in October and November 2010 were asked to answer a questionnaire before their journey. They were also contacted for a post-travel telephone interview to determine whether they had followed the recommendations regarding vaccinations and malaria prevention, and the reasons for poor or noncompliance with these recommendations.
A total of 353 travelers were included, with post-travel data available for 321 of them. Complete compliance with all the recommendations (vaccinations and malaria chemoprophylaxis) was observed in 186/321 (57.9%) of the travelers. Only 55.6% (233/419) of the prescribed vaccinations were given, with huge variability according to the type of vaccine. Only 57.3% (184/321) of the patients used a mosquito net. Among the 287 prescriptions for antimalarial drugs, 219 (76.3%) were taken correctly, 37 (12.9%) were taken incorrectly (noncompliance with the duration and/or dosage), and 31 (10.8%) were not taken at all. Traveling to areas of mass tourism (Kenya/Senegal), consulting their general practitioner (GP), and being retired were significantly and independently associated with better overall compliance in univariate and multivariate analyses.
Compliance could be improved by focusing on factors associated with poor compliance to improve the advice given to less compliant travelers, by providing clear information tailored to each traveler, with a focus on key messages, and by improving coordination between ITMS and GPs.
In 2010, 935 million people traveled outside the borders of their country according to the World Tourism Organization (World Tourism Barometer, http://mkt.untwo.org/en/barometer). In France, about one in five adults make at least one trip abroad per year; one fifth of these trips are to a “high-risk” area (which corresponds to 2.7 million trips per year). Several studies have pointed out and quantified the risk of diseases for travelers, leading to recommendations of preventive measures for these travelers. The cornerstones of these preventive measures are particularly vaccinations and malaria prophylaxis. In France, International Travelers' Medical Services (ITMS) are allowed to vaccinate travelers against yellow fever and also can provide counseling and prescribe other vaccinations, malaria prophylaxis, and other measures. However, it is not clearly known how frequently these recommendations are followed, and what factors could encourage compliance or lead to noncompliance with these measures.
We thus conducted a study to identify factors associated with compliance or noncompliance with the recommendations given during an ITMS consultation, to further improve the effectiveness of counseling and limit the risk of travel-related disease.
All adults bound for a destination where malaria is endemic and yellow fever vaccine is mandatory and who consulted at the ITMS of Dijon, France, between October 1 and November 30, 2010, were asked to participate in this study. All the travelers were first examined by the ITMS nurse who provided them with the general heath recommendations for the area to which they planned to travel. They were then consulted by a physician specialized in travel medicine and a medical student for more focused information like vaccination against yellow fever, prescription of recommended malaria prophylaxis, and other vaccines. The duration of the medical consultation ranged from 10 to 15 minutes. The recommendations given for malarial prophylaxis and vaccinations were recorded by the physician during the consultation for each traveler. These recommendations were in accordance with the French national and international guidelines.
Travelers who volunteered to participate in the study then answered a questionnaire which collected the following data: age, town, occupation, destination, planned travel dates, purpose of travel, person (if any) who advised them to consult the ITMS, previous or planned consultations with their general practitioner (GP) in preparation for the trip. Travelers whose return trip was after April 1, 2011 were not included.
All the volunteers were then contacted by phone within 3 weeks after their return, to determine whether they had followed the recommendations regarding vaccinations and antimalarial medications and had respected the physical protection measures against insect bites. Compliance with medical recommendations was considered good when the prescribed vaccination had been given before the trip, and/or when at least 90% of the planned doses of antimalarial chemoprophylaxis had been taken for at least 90% of the planned duration, and/or when the other means of malaria prevention were applied at least 90% of the time. The questionnaire also sought the reasons for noncompliance for each of these items as well as the occurrence of intercurrent illnesses, drugs taken during the trip, and consultations with physicians upon return.
The qualitative variables are presented as frequencies or percentages. Quantitative variables are presented as means ± SD or medians with extreme values. Categorical variables were compared using the chi-square test, and quantitative variables by Student's t-test or analysis of variance if normally distributed, or by a nonparametric test or Mann–Whitney test in other cases. Logistic regression analyses were used to identify the variables associated with compliance. Variables with p < 0.2 in the univariate analysis were included in a multivariate model, and the selection of independent variables was based on a backward elimination procedure, retaining those with p ≤ 0.05.The statistical analysis was performed using Statview 5.0. For all tests, the significance level was set at 0.05.
Of the 475 people consulted at the ITMS during the study period, 353 (74.3%) agreed to participate in this study. Of these, 336 were successfully contacted by phone after their return (95.2%). The main characteristics of these persons are described in Table 1. The majority of trips were for leisure, with a duration of less than 14 days. The travel destinations are detailed in Table 2. Kenya and Senegal accounted for 60% of travelers' destinations.
|Mean age (years old)||46.7 ± 13.7|
|18–40 years old||110 (32.7%)|
|>40 years old||226 (67.3%)|
|Sex (female)||178 (53.0%)|
|Rural, semi-rural||128 (50.0%)|
|Reason for travel|
|≤14 days||264 (78.6%)|
|>14 days||72 (21.4%)|
|Travel destination||Number of travelers (%)|
|South America||42 (12.5)|
|French Guyana||23 (6.8)|
Most of the travelers were referred to the ITMS by their GPs (43.5%). Travel agencies were responsible for 14.6% of consultations at the ITMS, and 21.7% of the travelers came on their own initiative. The ITMS consultation occurred at least 1 month before the theoretical day of departure for 160 travelers (47.6%), between 15 days and 1 month for 103 travelers (30.7%), between 7 and 14 days for 66 travelers (19.7%), and less than 7 days before the departure for 7 travelers (2%).
Fifteen trips had to be canceled. The rest of our study only concerned the 321 travelers who actually made their trip. More than one quarter of these (25.9%, n = 83) used antidiarrheal drugs during their stay. Mosquito bites were reported by 161 travelers (50.2%). During their trip, 93 (29.0%) of the travelers had to take medications (antidiarrheal pills for 83 of them). In addition, 11 travelers (3.4%) consulted a physician during their trip: four of them for fever (none related to malaria), three wounds, one edema, one otitis, one for back pain, and one for abdominal pain. Nearly half of the travelers (161) reported being bitten by mosquitoes during their trip. Twenty-one other travelers (6.5%) consulted shortly after their return; in nine cases this was as a consequence of their trip: for diarrhea (n = 7) or fever (n = 2).
Complete compliance with all of the recommendations (vaccinations and malaria chemoprophylaxis) was observed in 186 of 321 (57.9%) of the travelers. Retirees tended to be more compliant than nonretirees (42/62: 70% vs 144/259: 55.6%, respectively, p = 0.08), as were people who also consulted their GP (124/199: 62.3% vs 62/121: 51.2%, p = 0.05), and people traveling to “mass tourism destinations” (Kenya/Senegal; 124/196: 63.3% vs 62/125: 49.6%, p = 0.02). Other factors (gender, rural, or urban residence; travel mode: alone, couple, families, or friends; length of time between the ITMS consultation and the departure, or having read the documentation provided by the ITMS) were not significantly associated with compliance with recommendations. In the multivariate analysis, being retired (OR = 1.87, 95% CI: 1.01–3.48, p = 0.049), traveling to Kenya or Senegal (OR = 3.59, 95% CI: 2.03–6.33, p < 0.0001), and having consulted a GP for this trip prior to the ITMS consultation (OR = 2.03, 95% CI: 1.18–3.49, p = 0.01) were significantly associated with good overall compliance with the medical recommendations.
Of the 419 vaccinations recommended during the ITMS consultation, only 233 (55.6%) were performed, with huge variability according to the type of vaccination recommended. Indeed, vaccination against diphtheria, tetanus, and poliomyelitis was very often performed (51 done/61 recommended, 83.6%), which contrasts sharply with vaccinations for either hepatitis A (84/169, 49.7%) or typhoid (90/177, 50.8%). Vaccination against hepatitis B was rarely recommended and was performed in 66.7% of these cases (6/9). The main reason for not performing hepatitis A and/or typhoid vaccinations were “unwillingness to be vaccinated against these diseases” in 64.7% and 73.6% of cases, a conflicting medical opinion in 10.6% and 9.2%, not enough time in 8.2% and 6.9%, and the cost of vaccine in 4.7% and 3.4%, respectively.
With regard to compliance with recommendations for vaccination alone, the destination (such as Senegal and Kenya) was no longer associated with compliance, whereas having consulted a GP was (compliance 149/199: 74.9% for those who consulted their GP vs 75/121: 62.0% for those who did not, p = 0.015). Retirees were also more compliant than nonretirees (52/62: 83.8% vs 173/259: 66.8%, respectively, p = 0.008). In the multivariate analysis, retirees (OR = 2.42, 95% CI: 1.17–5.02, p = 0.02) who have consulted a GP for this trip prior to the ITMS consultation (OR = 1.71, 95% CI: 1.05–2.80, p = 0.03) remained significantly associated with good overall compliance with the vaccine recommendations.
Of the travelers, 293 (91.3%) complied with recommendations for the use of skin repellents, whereas only 184 (57.3%) used a mosquito net.
Among the 287 prescriptions for antimalarial drugs, 219 (76.3%) were taken correctly, 37 (12.9%) were taken incorrectly (<90% of the duration and/or dosage), and 31 (10.8%) were not taken at all. The reasons for noncompliance are reported in Table 3. Poor compliance due to side effects was reported in 20.6% of cases, and the absence of mosquitoes during the stay was the reason put forward in 13.3% of cases. The antimalarial chemoprophylaxis was thought too expensive and thus given as the reason for noncompliance for 2.9% of the travelers.
|Side effects||14 (20.6)|
|Too many pills (because of other treatments)||12 (17.6)|
|No mosquitoes seen||9 (13.3)|
|Do not like taking medicine||7 (10.3)|
|Price/too expensive||2 (2.9)|
|Lack of pills||1 (1.5)|
The travel destination remained significantly associated with compliance with antimalarial chemoprophylaxis: travelers to Kenya or Senegal reported a compliance of 86.2% versus 73.6% for those who traveled to other countries (p = 0.005). This difference disappeared when those who traveled anywhere in Africa (including non-touristic areas) were compared with those who traveled to South America (81.1% vs 89.2%, p = 0.78). Compliance with chemoprophylaxis did not appear to be associated with a prior consultation with the GP. On the other hand, a trip shorter than 15 days also appeared to correlate with better compliance with antimalarial prophylaxis (215/253: 85.0% for trips shorter than 15 days vs 46/68: 67.6% for those of longer duration, p = 0.001). In the multivariate analysis, only the duration of the trip remained significantly associated with good compliance with antimalarial chemoprophylaxis (OR for a trip longer than 14 days = 0.37, 95% CI: 0.20–0.68, p = 0.001).
The main result of the present study is that the recommendations are fully observed by 57.9% of the travelers attending a representative French ITMS. This underlines the need for better knowledge of the determinants of compliance with the recommendations, to increase the proportion of patients who follow the recommendations.
Compliance with recommendations for vaccination was particularly low, since only 55.1% of the vaccinations prescribed were in fact performed. A survey in one French ITMS in 2006 found a compliance rate of 37%, with the same variations depending on the type of vaccine (good compliance for DTaP-IPV, poor compliance for hepatitis A and typhoid fever vaccines). There are no clear reasons to explain these results. It may nevertheless be suggested that typhoid fever and hepatitis A are largely unknown and not perceived to be a potential infectious threat in the general population despite the recommendations of the ITMS. It is possible that the controversy in France about the supposed toxicity of the hepatitis B vaccine could have frightened some travelers into refusing vaccinations they had not heard about before. The cost of the vaccination does not seem to significantly discourage travelers from being vaccinated, as this reason was only put forward by only 2.9% of the noncompliant persons of our study, at least because this cost seems far lower than that of the trip itself. This is in line with the results of another study in 155 American travelers, which showed that compliance was only 77% when all care (consultations, vaccinations, and treatments) was free. The cost did not appear to limit the use of chemoprophylaxis either, with 76.3% of compliant travelers, which is close to the compliance of 72% observed in a telephone survey of 4,112 French travelers.
Nevertheless, total compliance with recommendations seems to be clearly associated with particular factors. Indeed, patients traveling to areas of mass tourism (Kenya/Senegal) are probably less familiar with traveling and more fearful about the health risks associated with travel, which could explain why they are more compliant. By contrast, being a working adult, traveling to destinations other than mass-tourism areas, and traveling longer than 14 days, led travelers to be less compliant. In these cases, it may be suggested that a longer consultation with tailored advice would be beneficial, even though increasing the amount of information for this population is not a guarantee of improved compliance with recommendations.
Another point is whether the ITMS is the best place to provide such tailored information. From a technical point of view, it certainly is. Physicians and nurses are specialized in travel medicine and are particularly aware of the importance of prevention, which leads to a high proportion of prescriptions of chemoprophylaxis and vaccines. However, physicians who give consultations at ITMS do not know the people who consult, their living conditions, or their financial situation as well as the GP often does. This lack of knowledge could thus lower the likelihood that their recommendations and prescriptions will be followed. It is of interest that in our study, travelers who consulted their GP were significantly more likely to comply with the vaccination recommendations. The GP has, by his status as the family physician, an important role in promoting compliance with guidelines for prevention. It has to be noted that the GP was consulted by 62.5% of travelers in our study and was responsible for 43.5% of visits to ITMS. Increasing the duration of ITMS consultations, in some situations, and close coordination between ITMS and the GP could improve compliance with medical recommendations. Another way to specifically improve the recommended vaccination rate would be for travelers to get their vaccinations for other diseases as well as yellow fever at the ITMS, when feasible.
Nonetheless, compliance with recommendations is also closely related to the awareness and perception of the health risks associated with travel. This also underlines the need for regular reassessment of these risks, in order to provide more relevant advice and thus improve travelers' compliance with recommendations. It has to be noted that 3.1% of the patients stopped malaria prophylaxis because they did not see any mosquitoes in the area they stayed in. By contrast, 25.9% of the travelers developed and had to be treated for diarrhea during their trip, which is similar to rates observed in other larger studies (22.2% of cases of diarrhea among 17,353 travelers in the study of Freedman and colleagues and 19.1% of cases of diarrhea among 622 French travelers). The risk scale for the different diseases as well as their potential severity has to be detailed and explained in order to improve compliance with preventive measures.
This study suffers from several limitations. First of all, it included only three quarters of all the patients who attended the ITMS during the study period. It is possible that compliance with recommendations in the missing quarter, and in travelers who did not attend an ITMS consultation could be different, since it cannot be established if their profile or the characteristics of their trips differed from those in travelers who agreed to participate. Moreover, since nearly all of the travelers included came to the ITMS to be vaccinated against yellow fever (which could be either mandatory or simply recommended depending on the travel destination), and even though they did not necessarily seek advice for other recommendations, the patients who participated were at least minimally aware of the interest of prevention. It can thus be speculated that compliance in the travelers of this study was no worse than that in the whole population of travelers to at-risk destinations. The same remark may also be relevant regarding the assessment of compliance. Indeed, compliance was self-reported and it cannot be ascertained that it corresponded to reality. It could be suggested, in such cases, that compliance would tend to be overestimated, which would thus reinforce the main message of the study, ie, the strikingly low rate of compliance. More specifically, some travelers may not have used mosquito nets because there were screens in front of the windows in the hotels or houses where they stayed during their trip. Nevertheless, this could not explain the low rate of compliance with malaria chemoprophylaxis and vaccine recommendations.
In conclusion, clear information tailored to each traveler, with a focus on key messages that take into account the main determinants of compliance may contribute to improving it. The purpose is to motivate travelers to adopt an active care process, not by worrying them with threats and aggressive measures, but instead by encouraging them to prepare a pleasant trip. Closer cooperation with GPs may be helpful to reach this goal.
The authors state that they have no conflicts of interest.