The European Journal of Public Health Advance Access originally published online on July 19, 2005
The European Journal of Public Health 2006 16(1):96-100; doi:10.1093/eurpub/cki144
Miscellaneous |
Travel and health status: a survey follow-up study
Susanna Fleck1, Helmut Jäger1 and Hajo Zeeb2
1 Bernhard-Nocht Institute for Tropical Medicine, Center for Travel Medicine, Hamburg, Germany
2 School of Public Health, University of Bielefeld, Germany
Correspondence: Hajo Zeeb, MD, MSc, School of Public Health, Department of Epidemiology and Medical Statistics, University of Bielefeld, PO Box 100131, D-33501 Bielefeld, Germany, e-mail: hajo.zeeb{at}uni-bielefeld.de
Received August 19, 2003, accepted January 19, 2004
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Abstract |
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Background: To date there is little sound knowledge on the relationship between travel and health status as perceived by the traveller. Our aim was to investigate the frequency and risk factors of travel-associated illnesses and injuries and identify potential protective factors. Methods: All adults enrolled in a health insurance scheme who planned to travel in 2002 were eligible for participation in a baseline survey. Pre-travel written questionnaires and post-travel telephone interviews were conducted with responders. We analysed travel-associated health problems using descriptive methods and multivariate logistic regression. Results: From 8316 persons who returned a pre-travel questionnaire, a sample of 2384 were chosen, of whom 1471 completed post-travel interviews. 10.1% of all travellers reported travel-associated illnesses, and 1.8% suffered from injuries during travel. Among travellers to European destinations, 6.0% reported an illness as opposed to 16.2% of travellers to overseas destinations. Predictors for travel-associated illness were age <30 years (OR 1.48), duration of travel >4 weeks (OR 3.35) and travel destination. Perceived health status as scored by the travellers improved after travel. The frequency of medical consultations and personal health-related expenses decreased significantly shortly after travel. Conclusions: In this study, travel had a positive effect on the perceived health status of the traveller. The positive effects of travel seemed to outweigh the impact of health problems. Travel did not lead to increased health-related costs, neither in individual health expenses nor indirectly through increased medical consultation rates.
Keywords: travel, epidemiology, follow-up, survey
The aim of travel medicine is to reduce travel-associated risks. The risk approach perspective is supported by a great variety of studies focusing on illness and health hazards.1,2 Nevertheless little is known of the potential positive effects of travel on the health of travellers who seek well-being during their holiday abroad. There are (to our knowledge) no prospective epidemiological studies dealing with the overall health effects, the economic aspects of travel, and health impairments during travel. Population-based cohort studies of illness and injuries among travellers are rare.3,4 Most studies are based on ‘convenience samples’ of clients of travel clinics or airport visitors.
The aim of this study was to examine the relationship between travel and health status as perceived by the traveller and to identify protective factors that contribute to an improved health status after return.
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Methods |
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Design
The study followed a prospective design using a written questionnaire for the initial survey of baseline and pre-travel data. A post-travel telephone interview was used as follow-up. This design of a survey follow-up study was chosen to ensure reliable data collection and to maintain a prospective approach even with limited resources.
Participants
In April 2002 a German health insurance company invited all members (n = 120 000) to fill in a pre-travel questionnaire. Information was obtained on demographics and health-related data, including frequency of medical consultations and hospitalization, perceived health status and private health-related expenses during the previous month. Participants were asked to provide information on their travel plans and consent to a post-travel interview. All members planning to travel between May and November 2002 who returned the questionnaire were eligible to participate. Excluded from participation were relatives of members, persons who failed to give written consent or withdrew consent on telephone contact, and persons who cancelled their previous travel plans; 8316 persons met the inclusion criteria. All 1192 participants planning to travel to destinations outside Europe were included in the study. Of the remaining 7124 persons planning to travel within Europe a random sample of 1192 was drawn to obtain equally sized groups.
Data collection and analysis
The resulting group of 2384 persons was contacted for post-travel telephone interviews. A total of 1471 participants (61.7%) completed the interview and were therefore included in the analyses. Computer-assisted telephone interviews were performed from August to December 2002 obtaining information on travel details, health prevention measures, illness, medical consultations during travel and perceived health status of the travellers. The questionnaire was pre-tested in a pilot study among 141 travel clinic clients of the Bernhard-Nocht-Institute (BNI).
In the pre-travel questionnaire travellers were asked to rate their health status as currently perceived. During the post-travel interview they were asked to assess their health status directly before travelling, in the last week of the journey and directly after return. Using the same rating scale as in the German federal health survey5 we calculated and compared means for each time point.
EpiInfo 2000 was used for descriptive analysis. Descriptive analyses of means were conducted using Student's t test; for other data situations 
2, ANOVA or non-parametric tests were used as appropriate.
The number of medical consultations and health-related expenses during the 4-week period prior to the first survey (pre-travel) and the 4-week period after travel were compared.
The variables of gender, age, travel duration and organization, destination (by region), pre-existing medical conditions and travel health advice were then entered into a logistic regression model to identify risk factors for travel-associated illnesses using STATA 6.0 (STATA corporation, College Station, TX). We considered any illness to be travel-associated if it occurred during the journey and was not related to a pre-existing medical condition. A second regression analysis was performed to identify factors leading to an improvement in the perceived health status. Analysed variables were: gender, age (<30 years, 30–49 years, 50 years and over), travel destination (by region) and travel organization (self organized, package tour, occupational, family visit), travel health advice (yes, no), travel-related health expenses (up to 
10, 11–25, 26–50, over 50) and travel health insurance cover (yes, no). The study was approved by the regional ethics committee and the relevant data inspectorate.
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Results |
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Demographic and travel profile of participants
Of the 1471 participants, 885 travelled to European and 586 to overseas destinations. Details on the demographics and travel profiles of the participants are shown in table 1.
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A non-responder analysis showed non-participants to be slightly younger than participants (medium age 43.9 years, S.D. 12.2 versus 45.3 years, S.D. 11.5; two-sided ANOVA: P < 0.001). The proportion of women in the participant's group (54.6%) was higher than in the non-participants (47.4%; two-sided
2-test: P < 0.001). The participation rate amongst persons planning to travel inside Europe was higher than amongst those planning to travel overseas.
Travel-associated health problems
Out of 1471 participants, 148 (incidence proportion 10.1%) reported an illness during their travel, and 26 (1.8%) had suffered an injury. Illness occurred more frequently in travellers to overseas as compared to European destinations (16.2 versus 6.0%; crude OR 3.03; 95% CI 2.14–4.35). No significant difference was seen concerning the frequency of injuries between the two groups. Some health problems occurred more frequently among travellers to overseas as compared to European destinations: 8.7 versus 0.7% suffered from diarrhoea (OR 13.97; 95% CI 5.95–32.76), 2.4 versus 0.8% from gastrointestinal symptoms except diarrhoea (OR 3.08; 95% CI 1.24–8.16) and 3.4 versus 1.7% from respiratory diseases (OR 2.05; 95% CI 1.04–4.11).
The results of the logistic regression analysis identifying risk factors for travel-associated illness are shown in table 2. Travel time over 4 weeks and travel to the regions ‘Tunisia, Morocco, Egypt and Turkey’, ‘Central- and South America’ and ‘Middle East and Central Asia’ increased the risk for travel-associated illness. Young age and a pre-existing medical condition were also associated with an increased risk of illness.
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Perceived health status at different time points
For the overall cohort the mean score values of the perceived health status (1 = very well, 5 = unwell) were: 2.15 (S.D. 0.75) in the pre-travel questionnaire in April 2002, 2.29 (S.D. 0.97) directly before travel, 1.64 (S.D. 0.74) in the last week of the journey and 1.72 (S.D. 0.80) immediately after return. The perceived health status improved in the last week of the journey compared to directly before travelling (P < 0.0001) and also as compared to the pre-travel survey in April 2002 (P < 0.0001). It decreased again after return compared to the last week of the journey (P < 0.0001) but was still higher than before the journey (P < 0.0001). Figure 1 shows an almost identical distribution of the perceived health status of travellers to European destinations and of those to overseas destinations.
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The score value of perceived health status obtained in the pre-travel questionnaire was lower than the value directly before travel, which had been retrospectively assessed in the post-travel interview (P < 0.001).
According to the second regression analysis only health-related travel expenses were positively associated with an improvement in the perceived health status: for expenses between 11 and 25 the adjusted OR was 1.47 (95% CI 1.09–1.98), for expenses between 26 and 50 it was 2.03 (1.51–2.74) and for expenses of more than 50 the OR was 1.52 (1.03–2.25). Travelling to North America (OR 0.46; 95% CI 0.28–0.82), to Africa (OR 0.20; 95% CI 0.09–0.48) and to South East Asia (OR 0.35; 95% CI 0.18–0.67) decreased the chance for an improved health status, as well as occupational travel (OR 0.21; 95% CI 0.06–0.71).
Medical consultations
Of the 148 diseased travellers, only 35 (23.6%) received outpatient treatment while travelling, and one was treated in hospital. Of the 26 participants who reported an injury, eight (30.8%) received outpatient treatment while travelling and one was treated as an inpatient.
After return no hospitalizations occurred because of travel-associated health problems.
Individual medical consultation frequencies were lower in the post-travel period than in the pre-travel period (mean difference 0.42; S.D. 3.09; P < 0.0001). No differences were found for consultation frequencies between travellers to European and to overseas destinations (Kruskall–Wallis, P = 0.38).
Further economic aspects
The personal health expenses in the pre-travel period as evaluated in the first questionnaire ranged from 0 to 800 [median x50 = 10 (x25 = 0; x75 = 25)]. In the post-travel period expenses ranged from 0 to 700, with a rather skewed distribution [x50 = 0 (x25 = 0; x75 = 0]). Comparing both periods, individual health expenses were significantly lower after travel (mean difference 15.64; S.D. 71.14; P < 0.0001). Normal distribution of the differences was assumed.
In the overseas travellers group the mean difference of individual expenses before and after travel was 18.69 (S.D. 91.75) and this was higher than that recorded for the European travellers group (13.62; S.D. 53.20). Compared to the expenses in the pre-travel period the post-travel expenses were significantly lower in the overseas travellers' group than among travellers in Europe (Kruskall–Wallis; P < 0.001).
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Discussion |
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Strengths and weaknesses
To our knowledge this is the only study so far dealing with the perceived health status of travellers. It is also unique in focusing on economic aspects, taking individual health expenses as well as effects of hospitalization and medical consultation rates into account. Other strengths are the design as a follow-up study and a population-based approach.
Weaknesses of the study are the exclusion of children from the study population and the lack of socio-economic status data for travellers. Also, medical records could not be used for the study. The differences that were seen between participants and non-participants in the study may have slightly biased the comparisons between overseas and within-Europe travellers which therefore need to be interpreted with caution.
Travel-associated health problems
The proportion of overseas travellers falling ill was 16.2%, lower than the 30–80% reported in earlier studies; however, these mostly included travellers to selected ‘high risk’ areas.6–9 The relatively low frequency found in our study could reflect the inclusion of a wider range of destinations visited by the study population. Diarrhoea (8.7%) was the most common complaint of overseas travellers; other studies report a range from 20 to 50%.2,10–14 While respiratory symptoms frequently occur during travel, no systematic evaluations could be found on the topic.15
Similar to other studies3,16,17 young adults had an increased risk for travel-associated illness in our cohort.
Not surprisingly the risk of suffering an illness during the journey increased with the duration of travel. In other studies this association has been shown only for short to medium term travel.7,17,18 Risks for long-term travellers and particularly expatriates who stay abroad for years may differ and should therefore be dealt with separately.19,20
Strong associations between the risk of a travel-related illness and the travel region or specifically defined ‘risk-regions’ have been found before.7,19,21 In our study, Central and South America and the Middle East were regions associated with an increased health risk. The risk of illness in sub Saharan Africa was not higher, a fact that could be explained by a high proportion of travellers to South Africa and Namibia. Travel to Tunisia, Morocco, Egypt and Turkey, common destinations for German tourists, was associated with an increased risk.
For institutions offering travel health advice it may seem disappointing that travel health advice did not show any effect on disease frequencies. In the study we included travel health advice given by doctors and pharmacists, but could not assess the quality of advice.
We found an overall low uptake of travel health advice among travellers to destinations outside Europe. This is particularly surprising with respect to the recommended vaccinations for many of the overseas destinations. Possibly, travellers to these destinations obtained vaccinations exclusively, e.g. from their general practitioners without receiving concurrent travel health advice.
Medical consultation frequencies and other economic aspects
In our study population, the frequency of medical consultations during the reference period prior to travel was in a similar range to figures given in the German federal health survey.22 Nevertheless, after travel the individual consultation frequencies were lower for both travellers to European and to overseas destinations.
Similarly, the individual health expenses of our participants during the reference period were in the same range as those calculated from figures of the German health survey23 and from population data.24 The personal health-related expenses decreased in the post-travel period compared to the reference period in April 2002. The expenses of travellers to overseas destinations decreased even more compared to those of travellers to European destinations. Our results suggest that neither personal health expenses nor costs due to medical consultations increase due to travel-associated morbidity. On the contrary, a reduction in these costs was found, which may be attributed to the general recreational and relaxing effect of travel.
Perceived health status
The improvements in perceived health status of travellers in the last week of the journey might reflect the general recreational effect of the journey. While the health status decreased again after return it was still higher than before travel. Possible reasons for the decrease may lie in the strains of long travel, including time difference and jet lag, as well as in the return to everyday burdens and to the working environment. The majority of travellers still showed a lasting improvement of their subjective health status. However, the design of our study does not allow us to conclude that this positive effect is caused by travel or by leisure time in general.
Personal expenses on health-related travel preparation showed a positive effect on perceived health status. Persons who are aware of health risks and deal with health protection measures beforehand may have better chances for positive health effects. Accordingly, younger travellers who may be more prepared to take risks during their travel were less likely to experience improved health after travelling. Occupational travellers differ from tourists in their professional involvement and time constraints leading to health impacts during travel.25,26 These constraints are the most likely explanation for their decreased probability of health status improvement while travelling. This observation supports the view that the journey alone is not responsible for the improvement in the subjective health status but a combination of both journey and recreational period.
Further research
To consolidate our study results the health effects of travelling as opposed to the effects of leisure time spent at home should be evaluated. The type of travel organization and the reasons for travel (recreational, occupational, family visit) could also be associated with travel health although in our study no significant findings were obtained.
Travel health advice overall did not show an effect on disease frequencies or perceived health status in our cohort. Future studies, which should include quality measures for the advice given, could identify how travel advice could support the positive health effects of travel. Since health advice for overseas destinations is of greater relevance, travel outside Europe should be a particular focus for further research.
We did not obtain information about the time point during the travel at which an illness occurred or how the perceived health status changed within the travel period. Recent studies27,28 suggest an increased risk for disease or leisure sickness during the first days of travel. Time-related aspects of travel health should be evaluated in further, more detailed surveys because they could be important for individualized travel health advice.
Key points
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Acknowledgments |
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The study was supported by a grant from BKK health insurance, Berlin.
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References |
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