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Knowledge, Attitudes, and Practices Toward Malaria Risk and Prevention Among Frequent Business Travelers of a Major Oil and Gas Company Johannes Berg, MD, FACP,∗ Daan Breederveld, MD,† Anna H. Roukens, MD, PhD,‡ Yvonne Hennink, MD,§ Marjolijn Schouten, MD, Judy K. Wendt, MPH,¶ and Leo G. Visser, MD, PhD‡ ∗ Shell
Health - Shell International B.V., The Hague, The Netherlands; † Harderwijk & Breederveld Occupational Health Consultancy, Amsterdam, The Netherlands; ‡ Department of Infectious Diseases, Leiden University Medical Center (LUMC), Leiden, The Netherlands; § Arbo Unie Occupational Health Services, Zaandam, The Netherlands; Achmea Vitale Occupational Health Services, Zaandam, The Netherlands; ¶ Shell Health - Shell Oil Company—Americas, Houston, TX, USA DOI: 10.1111/j.1708-8305.2011.00555.x
Background. Despite significant morbidity and mortality among business travelers due to malaria, very little has been published on knowledge, attitudes, and practices (KAP) toward malaria risk. The aim of this study was to assess KAP among frequent international business travelers (FBT) and to identify recommendations for improving malaria prevention that could be applied to the wider FBT community in occupational health. Methods. A retrospective web-based survey was conducted in 2005 among self-registered FBT of an oil and gas company based in the Netherlands. Results. The survey was completed by 328 of the 608 self-registered FBT (54%). Fifty-four percent of respondents had visited a high-risk area for malaria. Most respondents (96%) were experienced travelers; the majority (71%) sought health advice before their trip and made use of a company health resource. Fever was recognized as a malaria symptom by all FBT; travel to high-risk malaria areas was correctly identified by 96%, and 99% of these travelers adhered to use of adequate personal protective measures. The proportion of travelers carrying appropriate anti-malaria drug regimen was positively associated with receiving company advice among FBT traveling to high-risk destinations (RR = 2.10, 95% CI: 1.21–3.67), but not for those traveling to low- or no-risk destinations. Only 8% (14) of those going to a high-risk area were not carrying malaria prophylaxis. One in five of FBT traveling to no-risk areas were unnecessarily carrying malaria prophylaxis. Conclusions. The majority of KAP results were excellent. We postulate that a company culture with a strong focus on health, safety, security, and environment can positively contribute to high KAP scores. Notwithstanding the excellent findings, this study also provides a cautionary tale for company health functions against overprescribing of malaria prophylaxis. It demonstrates the need for constant review and audit of adherence to quality criteria.
I
n major oil and gas companies, many frequent business travelers (FBT) travel to the malarious areas of the world and are thus exposed to the risk of acquiring malaria.1 For 1% of all non-immune travelers globally, who acquire Plasmodium falciparum infection, it is a fatal disease.2 In the United States, 19.2% of fatal malaria cases were business travelers.3 In the UK, between 1987 and 2006, 10.5% of all cases of imported malaria occurred among business/professional travelers Corresponding Author: Leo G. Visser, MD, PhD, Department of Infectious Diseases, Leiden University Medical Centre, C5P-41, Albinusdreef 2, 2333 ZA Leiden, The Netherlands. E-mail:
[email protected]
and mortality due to imported malaria in this group was 19%.4 Despite these high mortality rates, very little has been published on knowledge, attitudes, and practices (KAP) toward malaria risk among business travelers.5 In a more recent study conducted by the European Travel Health Advisory Board (ETHAB), only 9.5% of participants were business travelers but besides a comparison with tourists regarding seeking of travel health advice, little other information about this subpopulation was provided.6 ETHAB concluded that an important need remained for improving knowledge on travel-related infectious diseases and malaria in all groups of travelers to risk destinations, including business travelers. © 2011 International Society of Travel Medicine, 1195-1982 Journal of Travel Medicine 2011; Volume 18 (Issue 6): 395–401
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Berg et al.
We performed a retrospective cohort study among FBT using the malaria questionnaire (Q-Mal) developed by ETHAB for their European Airport Survey.6 Our objective was to assess KAP toward malaria risk and prevention among international FBT of an oil and gas company based in the Netherlands who frequently travel to high-risk malaria areas to identify specific recommendations for improving malaria prevention that could be applied to the wider FBT community in occupational health settings.
from ETHAB, the original survey was adapted for electronic use for this retrospective study covering the most recent travel in the preceding 2 years. A question on the incubation period of malaria was added. All 608 self-registered FBT were invited to take part in this study by a personal e-mail containing a link to the web-based questionnaire and a unique password, which ensured that each individual could enter only once. With intervals of a few weeks, non-responding employees received 2 to 3 reminders.
Methods
Statistical Analysis Where appropriate, chi-square test or Fisher’s exact test was used. Continuous data were compared with t-test or Wilcoxon’s test for non-parametrical distributed numerical data. Statistical analysis was performed using a computer-assisted software package (SPSS version 12.0, SPSS Inc., Chicago, IL, USA). Results were considered statistically significant at p < 0.05.
Study Subjects and Methods This study was conducted between July and October 2005 among FBT of Shell International and Exploration (SIEP) based in Rijswijk, The Netherlands. These FBT had registered themselves previously as part of the Fitness to Work (FtW) program for business travelers. An e-mail containing an introduction to the FtW program and the definition of a FBT had been sent to all employees (∼2,500). Using travel booking data we confirmed that this self-registration had successfully registered 97% of all FBT. A FBT was defined as an employee who met at least one of the following company-developed criteria: • Travel within a region (eg, Europe) on flights of more than 4 hours, three or more times per month; or • Long distance (intercontinental) trips three or more times annually; or • Less frequent trips but to high-risk destinations (areas with significant local health risks and often limited availability and/or difficult accessibility of local health facilities; this applied to most of Africa, Asia, and Latin America). The use of adequate personal protective measures (PPM) was defined by us as the combination of two or more measures such as covering arms and legs, using mosquito repellents, keeping windows and doors closed, using air-conditioning, mosquito nets, or insecticide spray. Appropriate anti-malarial drug regimens were defined to conform to Shell travel advice standards [based on World Health Organization (WHO),7 U.S. Centers for Disease Control and Prevention, and LCR8 (Dutch national coordination centre for traveler’s health) advice]. The actual risk of contracting malaria was based on destination (countries and regions) and length of stay, and was scored as high, low, or no risk using the WHO map and details in the accompanying country list.7 Malaria risk was ‘‘indeterminate’’ if travelers had not indicated exact routing through countries where areas with different risks exist. The web-based questionnaire was developed with the use of Apian Survey Pro 3.0. With approval J Travel Med 2011; 18: 395–401
Results Study Population (Table 1) The survey was returned by 383 of the 608 self-registered FBT (63%). Twenty-eight respondents revealed they had not traveled to a malaria endemic country in the preceding 2 years; another 27 respondents did not fully complete the questionnaire. We analyzed only the 328 completed questionnaires.
Table 1
Demographic characteristics of study population N (%)
Gender Male Female Age category (y) 18–25 26–35 36–45 46–60 >60 Nationality Dutch British Europe other American Other Country of residence Netherlands Other Malaria risk of country visited Nil Low High Indefinite
311 (95) 17 (5) 1 (0) 22 (7) 98 (30) 205 (63) 2 (1) 146 (45) 96 (29) 31 (9) 25 (8) 30 (9) 317 (97) 11 (3) 102 (31) 43 (13) 176 (54) 7 (2)
KAP of Frequent Business Travelers Toward Malaria Risk/Prevention
Overall, the vast majority of respondents were male (95%) and the age category most predominantly represented was between 46 and 60 years of age (63%). With regard to nationality, the vast majority came from Europe (83%). In addition, most respondents were residents of The Netherlands from where they started their trip (97%). Most respondents were experienced travelers; only 4% (13) were first-time travelers to a developing country. For the vast majority (86%), the business trip lasted between 3 and 28 days, and sub-Saharan Africa was the most common destination (57%), followed by Asia (39%), and Latin America (4%). Fifty-four percent of respondents had visited an area considered high-risk7 for malaria. Travel Health Preparations The majority of FBT (71%) sought health advice before their trip. The most common source for travel health advice was the company travel health service, either the travel clinic of the internal occupational health department (62%) or the company Intranet (21%) (Figure 1). All first-time travelers sought health advice. Although this group of first-time travelers was very small, they appear to be more likely to seek health advice
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than experienced travelers [Relative Risk (RR) = 1.4, 95% CI: 0.3–2.6]. Thirty-four percent of FBT sought travel advice 2 weeks prior to departure. The longer the duration of stay, the more likely health advice was sought (p = 0.01, data not shown). Twenty-nine percent did not seek travel health advice and 39% of these travelers visited a high-risk area. Reasons for not seeking health advice were: 49% answered that they knew what to do, 8% were not aware that they should, 8% stated that there was no risk to their health, and the remaining 35% listed various reasons for not soliciting health advice from ‘‘a dislike of drugs’’ to ‘‘deliberate risk taking.’’ KAP on Malaria In the questionnaire, respondents were asked to indicate the correct maximum incubation period of falciparum malaria using a multiple choice question format with time intervals ranging from 1 week to more than 1 year. Knowledge of the correct maximum incubation period of malaria was poor, regardless of risk at destination (Table 2). Only 19% (n = 64) of all FBT estimated the incubation period correctly. Fifty-five percent wrongly estimated this period shorter than it actually was (data not shown). Fever, the most important symptom of malaria, was correctly identified by all FBT. Several
Figure 1 Sources of health travel advice consulted by respondents. Note that multiple sources could be cited per respondent. SHS = Shell Health Service, GP = General Practitioner. J Travel Med 2011; 18: 395–401
398 Table 2
Berg et al. Relation between receiving company travel advice and selected KAP indicators, by actual risk level of destination Source of advice
KAP indicator (N /total) Travelers to high-risk destinations Correctly identified maximum incubation period (3 mo) (n = 31/176) Correct assessment of malaria risk (n = 169/176) Carrying malaria prophylaxis (n = 162/176) Adequate malaria prophylaxis (n = 119/176) Travelers to low-risk destinations Correctly identified maximum incubation period (3 mo) (n = 7/43) Correct assessment of malaria risk (n = 25/42) Carrying malaria prophylaxis (n = 16/43) Adequate malaria prophylaxis (n = 11/43) Travelers to no-risk destinations Correctly identified maximum incubation period (3 mo) (n = 26/102) Correct assessment of malaria risk (n = 15/98) Carrying malaria prophylaxis (n = 21/102) Adequate malaria prophylaxis (n = 81/102) ∗ Reference
‘‘None’’ or ‘‘Other’’∗ N /total (%)
‘‘Company’’ or ‘‘company + other’’ N /total (%)
RR (95% CI)
4/39 (10.3) 36/39 (92.3) 5/12 (41.7) 4/12 (33.3)
27/137 (19.7) 133/137 (97.1) 157/164 (95.7) 115/164 (70.1)
1.92 (0.72–5.16) 1.05 (0.96–1.16) 2.30 (1.18–4.49) 2.10 (1.21–3.67)
2/18 (11.1) 12/17 (70.6) 3/18 (16.7) 3/18 (16.7)
5/25 (20.0) 13/25 (52.0) 13/25 (52.0) 6/25 (24.0)
1.80 (0.39–8.26) 0.74 (0.45–1.20) 3.12 (1.04–9.37) 1.44 (0.42–4.98)
15/51 (29.4) 9/49 (18.4) 3/40 (7.5) 37/40 (92.5)
11/51 (21.6) 6/49 (12.2) 18/62 (29.0) 44/62 (71.0)
0.73 (0.37–1.44) 0.67 (0.26–1.73) 3.87 (1.22–12.30) 0.77 (0.63–0.92)
category (RR = 1.0).
other frequent symptoms (eg, chills, sweating, fatigue, and headaches) were correctly identified by most FBT (Figure 2). Gastrointestinal complaints (nausea and/or vomiting) were less consistently associated with the possibility of malaria. When comparing the perceived risk to the actual risk of malaria, 96% of FBT going to a high-risk area correctly identified their risk as high; no one was considered to be at no risk (Table 3). Among travelers going to a no-risk malaria destination, 18.6% perceived
the risk as high and 3.9% gave the risk as unknown. Pre-travel health advice was sought by 82% (n = 169) of those with a perceived high malaria risk at destination, by 54% (n = 54) of those with a perceived low risk, and by 41% (n = 7) of those with a perceived absent malaria risk (p = 0.001, data not shown). As shown in Table 4, the proportion of travelers carrying prophylaxis differed depending on the actual risk of malaria at destination (p < 0.001). A company source of advice was positively associated with carrying
Figure 2 Percentage of respondents correctly identifying clinical symptoms of malaria. Rash and swelling were ‘‘negative controls’’ to check validity of responses. J Travel Med 2011; 18: 395–401
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KAP of Frequent Business Travelers Toward Malaria Risk/Prevention Table 3
Knowledge of malaria risk, comparing the perceived risk for malaria with the actual risk for malaria Perceived risk for malaria
Actual risk for malaria High Low Nil Total
High
Low
Nil
Don’t know
Total
169 (96%) 16 (38%) 19 (18.6%) 204 (63.5%)
7 (3.9%) 25 (59.5%) 64 (62.7%) 96 (29.9%)
0 (0%) 1 (2.3%) 15 (14.7%) 16 (4.9%)
0 (0%) 1 (2.3%) 4 (3.9%) 5 (1.5%)
176 43 102 321
malaria prophylaxis to high-risk (RR = 2.30, 95% CI: 1.18–4.49) and low-risk (RR = 3.12, 95% CI: 1.04–9.37) destinations (Table 2). However, FBT who received company advice were also more likely to carry malaria prophylaxis when it was not necessary to do so (ie, when traveling to no-risk destinations; RR = 3.87, 95% CI: 1.22–12.30): one in five of these travelers were unnecessarily carrying malaria prophylaxis (Table 2). The proportion of travelers carrying an appropriate anti-malaria drug regimen was positively associated with receiving company advice among those traveling to high-risk destinations (RR = 2.10, 95% CI: 1.21–3.67), but not for those traveling to low- or no-risk destinations. Sixty-eight percent (n = 119) of travelers to a high-risk area were carrying an appropriate anti-malaria drug regimen; for travelers to low-risk areas this was only 21% (n = 9). Advice as to which tablets to use was provided in 68.4% by the company (occupational health physician or nurse). The company Intranet was used as a sole source by 6.6% and an additional 9.2% used multiple sources, but this always included an occupational health source of information. The remainder (9.2%) used miscellaneous sources and 6.6% did not specify the source. Most anti-malarials were taken for prevention (75.3%), 2.5% for standby treatment, and 22% for both reasons. During the time this study was conducted, the occupational health department did not advise standby emergency treatment. Atovaquone/proguanil was by far the most commonly reported drug (44.6%), followed by mefloquine (14.3%), chloroquine (21.5%), Table 4 Percent of FBT carrying chemoprophylaxis when traveling, in relation to type of destination
Discussion
Number (%) of FBT carrying chemoprophylaxis Destination
Yes
Actual malaria risk Nil 21 (21%) Low 16 (37%) High 162 (92%) Type of region City or beach 115 (58%) Rural 84 (65%) ∗p
No
and proguanil (14.8). Quinine (3.5%) and halofantrine (1%) were much less common. No one reported the use of doxycycline or artemether/lumefantrine. The reasons why FBT traveling to a malarious area did not carry malaria prophylaxis varied widely. There was no significant difference in carrying prophylaxis between FBT traveling to rural, urban, or beach destinations (Table 4). The majority stated that they were advised not to take tablets (39.5%). The second largest group (22.5%) judged that it was not necessary; 14% said they did not know why; for 13% the answers were very miscellaneous, and 7% had a dislike for all tablets in general. All other categories such as ‘‘I took the risk,’’ ‘‘prophylaxis not being deemed effective,’’ ‘‘forgetfulness,’’ and ‘‘allergy’’ contributed less than 6%. With regard to behavior outdoors, participants could choose between one or more of six adequate PPM. Of all FBT traveling to a high-risk area, 99% (175/176) adhered to the use of adequate PPM. Travelers to high-risk destinations were more inclined to cover arms and legs (p = 0.02) and to use mosquito repellents (p = 0.04) than FBT visiting low-risk areas. Of those traveling to a low-risk area, 98% (42/43) complied with the use of two or more measures. These FBT especially covered arms and legs, used air-conditioning at night, and kept windows and doors closed. In terms of attitude, adequate preparation as demonstrated by the packing of PPM was reported by 97% of FBT traveling to a high-risk country and by 81% traveling to a lowrisk destination. Sixty-five and 33% of all FBT traveling to a high- and low-risk destination, respectively, who visited the company’s occupational health department, took the ‘‘Shell travel kit,’’9 which contained insect skin repellent.
p value∗
