Seeking health-related information prior to travel may prepare travelers for health risks at their destination and studies have shown an association between receiving advice and accurate risk perception and undertaking preventative behaviors [4
]. Considerable variation exists in the published literature on the proportion of surveyed travelers seeking pre-travel health advice, ranging from as low as 32% of departing travelers from Australasian airports [10
] to 85-94% of those traveling to sub-Saharan Africa and Central and South America [7
]. In our study, less than half of all respondents (49%) reported seeking health information from any source prior to travel, similar to a number of published studies [6
]. We found travel to tropical regions, such as countries in South East Asia associated with higher rates of health seeking compared to travel to more temperate regions such as countries in North East Asia. The risk of infectious disease is not limited to low resource countries and travelers to Australia may still be at risk of infectious diseases, particularly in the tropical regions [21
]. Visitors to Australia should be aware of the risks of travel at any destination.
While numerous health resources are available to travelers, it is recommended that travelers seek advice from a health professional prior to international travel [3
]. In our survey, approximately two thirds of respondents traveled without professional medical advice. General practice was the main source of professional pre-travel health advice, reflecting results from other airport surveys of travelers [5
] and providing further weight to the importance of general practice in preventative travel medicine. Despite differences in health systems, the majority of travelers internationally seek advice from their general practitioner [8
]. This is particularly so in Australia, where general practitioners play a central role in the delivery of primary and preventative health care [23
]. While some studies report increased knowledge and accurate risk perception in travelers who consult travel medicine specialists [4
], only 4.2% of travelers in our study (ranging from 2.2% to 8.5% depending on region of residence) attended a travel clinic prior to travel. The role of the general practitioner is under-valued in travel medicine research and few studies of travelers who consult general practice are available. With this key role in the health of travelers, general practice is challenged with the provision of accurate and tailored advice during consultations that are limited by time and resources.
Pre-travel health seeking is influenced by many factors including traveler demographic characteristics, reasons for travel and previous travel experience. Few studies investigate differences in health-seeking norms by nationality. Our study showed that uptake of pre-travel health advice from a health professional differed considerably by region of residence. Health seeking is likely to differ by nationality due to differences in health seeking practices, country-specific healthcare systems including national vaccination programs and travel health facilities as well as promotional activities undertaken by health departments and private travel medicine groups. While it is likely that pre-travel health practices and vaccine uptake differs by destination and prior travel experience, pre-travel health advice may still be warranted and provides the opportunity to vaccinate if required. In Australia, a number of recent cases of measles have been imported from developed countries, and high risk Australian travelers to Europe and North America during the northern hemisphere winter are advised to receive the influenza vaccine [25
]. Furthermore, many travelers travel to multiple destinations and may not be aware of the individual risks. Alongside other studies, our study confirms the low uptake of pre-travel health advice and vaccination among Asian travelers. Another airport survey conducted in the region found only 26% of Asian travelers reported seeking pre-travel health advice compared to 63% of Western travelers [10
], while a separate study reported 23.9% of South Korean travelers to India [26
], a high risk destination for many infectious diseases [27
], sought pre-travel health advice. Expansion of the Asian travel market has been forecast due to increasing wealth within the region and growth in intra-regional tourist arrivals [28
]. As more people within the Asia-Pacific region can afford to travel, it is important to increase the uptake of pre-travel advice, particularly from medical sources. The limited number of specialist travel clinics in low resource countries may be a current barrier to uptake of pre-travel health advice and differences in health seeking behaviors and associated factors by region of residence may limit the generalisability of traveler studies, highlighting the growing need to better understand travelers from emerging travel markets.
Travel to visit friends and relatives (VFR) is an established risk factor for acquiring infectious diseases during travel [29
] and for poor uptake of pre-travel health advice [8
]. We did not identify a significant association between VFR travel and uptake of professional pre-travel health advice. However, we found migrant Australian travelers to be half as likely to seek pre-travel advice from a health professional and more likely to be traveling to visit friends and relatives than Australian-born travelers. Recent evidence also suggests that ethnicity, in addition to travel to visit friends and relatives, is an important indicator of infectious disease risk during travel [30
]. Australian migrants who travel may be at a greater risk of infectious diseases than Australian-born travelers due to their lower uptake of pre-travel health advice, regardless of reason for travel.
We acknowledge some limitations to our study. A brief self-administered questionnaire design, although appropriate to maximize the response rate in high volume airport surveys, limits the amount of detail obtainable and is also subject to recall bias. Additional factors which have been found to be associated with uptake of pre-travel health advice, such as previous travel experience and economic barriers were not obtained. Due to strict security measures at Sydney Airport, we were not able to gain access beyond customs and conducted our interviews in the departures check-in area. This resulted in a lower response rate than those reported by other airport surveys conducted in the departure lounges [26
] in which a response rates have been reported. However, our method allowed for the recruitment of passengers from a variety of carriers and flight times including weekends and evenings during the study period, providing a representative cross-section of departing passengers. We utilized a number of techniques to ensure a representative sample of travelers including a multistage sampling method of flight selection and random participant recruitment in which all passengers joining selected check-in queues had an equal probability of selection excluding those few who exceeded the recommended check-in time before departure. The use of simplified English and the provision of additional language versions of the questionnaire by bi-lingual interviewers aimed to reduce language barriers and subsequent selection biases of visitors to Australia from Asia.
A low proportion of participants in this study reported receipt of pre-travel vaccines (12%) with lower rates of pre-travel vaccination reported by Asian travelers compared to Western travelers. Wilder-Smith et al. also reported low uptake of pre-travel vaccines among Asian travelers, with 5% of Asian resident respondents reporting any pre-travel vaccination and low rates of self-reported prior vaccination against common vaccine-preventable diseases [10
]. The findings of this airport study were similar to other traveler surveys in that the most commonly reported vaccines received prior to travel were hepatitis A, hepatitis B, tetanus and typhoid [2
]. Influenza vaccine was reported by <3% of participants, a vaccine not often reported in other traveler surveys. It is likely that awareness of influenza as a travel-associated disease has increased for both providers and travelers with a post-pandemic survey of travel clinic attendees reported 13% uptake of seasonal influenza vaccine [34
]. The proportion reporting a pre-travel vaccine after pre-travel attendance at a specialist travel medicine clinic was almost three times that reported at a general practice visit. Sample size limitations precluded a detailed analysis of factors associated with individual vaccine choices. However, the demographic and travel characteristics significantly associated with travel vaccination differed by residency group. A limitation to this study is that we did not collect data on prior vaccine uptake and are unable to determine the proportion of travelers who did not receive vaccines prior to this trip due to prior disease or vaccine-induced immunity. This airport study, like much research assessing vaccine uptake, relies on the self-reported history of previous vaccination and is subject to recall bias. As the time since vaccination is likely to influence recall, pre-travel vaccines may not be as vulnerable to recall bias as those vaccines received routinely, particularly childhood vaccines. Errors introduced by self-reported history include the misclassification of the vaccine received, particularly hepatitis A and B vaccine [35
] and underestimation of the number of vaccines received. Other surveys have found that respondents report vaccines for non-vaccine preventable diseases such as hepatitis C and malaria, indicating a poor knowledge of their vaccination history [36
] and other studies have shown wide differences between perceived vaccination status and vaccination certificates or blood antibody levels in travelers and other population groups [7
]. Without serological testing it is difficult to ascertain if those who visited a medical professional prior to travel were up-to-date with their vaccinations, if they were vaccinated but could not recall the vaccines received or if their visits were a missed opportunity to vaccinate. Difficulties in assessing vaccination history for travel vaccines would be alleviated by the carriage of a vaccination record card for all vaccines received by travelers along with their passport and other travel documents, such as the requirement for entry and exit from yellow fever endemic regions.
Lack of time has been reported as a reason for not seeking pre-travel advice and vaccinations in other studies [6
]. Other studies have reported that approximately one third of travelers seek advice for their trip within 2
weeks of departure [8
]. Almost half of travelers departing from airports in Australasia reported planning their trip less than two weeks prior to departure [10
]. This results in lower rates of pre-travel health seeking, particularly from a health professional as well as the reduced uptake of vaccines, incomplete vaccination schedules for vaccines requiring more than one dose and lack of adequate protection at the time of departure. Although the length of time between health seeking and departure was not assessed in this airport survey, 63% of respondents had visited a health professional at least once in the past year, providing an opportunity for health professionals to inquire about possible overseas trips during their consultation and improve the provision of pre-travel health advice, particularly for migrants and those traveling to visit friends and relatives.