key: cord-0741275-upl3ny5a
authors: Sridhar, Shruti; Régner, Isabelle; Brouqui, Philippe; Gautret, Philippe
title: Methodologies for measuring travelers' risk perception of infectious diseases: A systematic review
date: 2016-05-27
journal: Travel Med Infect Dis
DOI: 10.1016/j.tmaid.2016.05.012
sha: ec4deb95095d0a80cf7f0568e77c6f7ea545a32b
doc_id: 741275
cord_uid: upl3ny5a

Numerous studies in the past have stressed the importance of travelers' psychology and perception in the implementation of preventive measures. The aim of this systematic review was to identify the methodologies used in studies reporting on travelers' risk perception of infectious diseases. A systematic search for relevant literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. There were 39 studies identified. In 35 of 39 studies, the methodology used was that of a knowledge, attitude and practice (KAP) survey based on questionnaires. One study used a combination of questionnaires and a visual psychometric measuring instrument called the ‘pictorial representation of illness and self-measurement” or PRISM. One study used a self-representation model (SRM) method. Two studies measured psychosocial factors. Valuable information was obtained from KAP surveys showing an overall lack of knowledge among travelers about the most frequent travel-associated infections and associated preventive measures. This methodological approach however, is mainly descriptive, addressing knowledge, attitudes, and practices separately and lacking an examination of the interrelationships between these three components. Another limitation of the KAP method is underestimating psychosocial variables that have proved influential in health related behaviors, including perceived benefits and costs of preventive measures, perceived social pressure, perceived personal control, unrealistic optimism and risk propensity. Future risk perception studies in travel medicine should consider psychosocial variables with inferential and multivariate statistical analyses. The use of implicit measurements of attitudes could also provide new insights in the field of travelers’ risk perception of travel-associated infectious diseases.

Summary Numerous studies in the past have stressed the importance of travelers' psychology and perception in the implementation of preventive measures. The aim of this systematic review was to identify the methodologies used in studies reporting on travelers' risk perception of infectious diseases. A systematic search for relevant literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. There were 39 studies identified. In 35 of 39 studies, the methodology used was that of a knowledge, attitude and practice (KAP) survey based on questionnaires. One study used a combination of questionnaires and a visual psychometric measuring instrument called the 'pictorial representation of illness and self-measurement" or PRISM. One study used a self-representation model (SRM) method. Two studies measured psychosocial factors. Valuable information was obtained from KAP surveys showing an overall lack of knowledge among travelers about the most frequent travel-associated infections and associated preventive measures. This methodological approach however, is mainly descriptive, addressing knowledge, attitudes, and practices separately and lacking an examination of the interrelationships between these three components. Another limitation of the KAP method is underestimating psychosocial variables that have proved influential in health related behaviors, including perceived benefits and costs of preventive measures, perceived social pressure, perceived personal control, unrealistic optimism and risk propensity. Future risk perception studies in travel medicine should consider psychosocial variables with inferential and multivariate statistical analyses. The use of implicit

Travel medicine is based on the concept of risk reduction. Travelers' risk perception about travel-related infectious diseases is considered a major component of their response to pre-travel advice [1, 2] . Travelers' acceptance of vaccination and observance of malaria prophylaxis measures are partly dependent on their perception of the frequency of the threat and its severity and of their own susceptibility to the threat. Consequently, studies specifically addressing risk perception in travelers have been conducted so that the clinician can provide advice that is both meaningful as well as effective in ensuring safe travel [3] . However, the perception of risk by travelers as well as by travel medicine experts is highly subjective, and although this subjectivity suffuses the field of travel medicine, it has rarely been discussed [4] and there has been little formal study on the subject of risk (i.e., risk research) in the context of travel medicine [5] .

In this paper, we review the available literature about risk perception for infectious diseases in travelers with the aim to identify the methodologies used in this context and discuss a number of existing methods used in risk perception measurement that could possibly be used in the field of travel medicine. We do not address non-communicable travel-associated disease risk perception.

The systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (http://www.prismastatement.org). The PubMed database (http://www.ncbi. nlm.nih.gov/pubmed) was searched, attempting to identify all relevant studies published from January 2000 to March 2016. The most recent search was conducted on March 18, 2016. The topic search terms used for searching the databases were as follows: #1: "travel" OR "traveler" OR "traveller". #2: "risk perception"; #3: #1 AND #2. Only articles published in English or French were included, based on common languages shared by the authors.

For inclusion, the article needed to fulfill the following criteria: (1) it needed to be related to international travel, (2) report on risk perception by travelers and (3) to report on travel-associated infectious disease risk perception and (4) to provide quantitative data. The reference lists of papers were screened to identify studies possibly missed by the search. Papers addressing only practices of preventive measures for travel-associated infectious diseases were not included. Studies involving less than 100 participants were not included.

Two researchers (S.S. and P.G.) independently performed the screening of the abstracts. Any discordant result was discussed in consensus meetings. After screening the abstracts, the full text of the articles was assessed for eligibility by the same two researchers and selected or rejected for inclusion in the systematic review.

The following data (if available) were extracted from each article: year, methodology, profile of travelers, number of individuals, focus of the study and key findings.

As a result of the nature of the studies and the heterogeneity in patient populations, a formal meta-analysis was not possible. Therefore, the study results were summarized to describe the main outcomes of interest (i.e., methodologies used for the assessment of risk perception of infectious diseases in travelers).

A total of 134 articles were found after elimination of duplicates, and 20 additional references were found through manual search. After screening of titles and summaries, 44 articles were finally retained for full text-assessment. There were 40 articles corresponding to 39 studies included in the qualitative synthesis of the systematic review ( Fig. 1 ). other studies were conducted among specific populations of travelers, including Hajj pilgrims (n Z 6) [6, 7, 9, 11, 14, 24] , business travelers (n Z 3) [13, 21, 40] , students (n Z 2) [19, 27] , missionary personnel and their families (n Z 1) [45] , ethnic Africans visiting their country of origin (n Z 1) [34] , backpackers (n Z 1) [26] , airline crews (n Z 1) [18] and public health professionals (n Z 1) [10] .

There were 15 studies conducted in travelers recruited at airports [8,15e17,20,22,31e33,35e39,43,44] and one onboard flight [41] , in Europe [8,15e17,32,37,39] , Asia [20, 33, 36] , Australia [36] , US [22, 38] and Canada [41] before flying abroad or at airports in Africa [31, 35, 43, 44] and Asia [31] before flying back home. Thirteen studies included travelers recruited at travel clinics when seeking travel advice [7,9e12,14,23,24,28,29,34,40,42] in Europe [7, 11, 12, 14, 23, 24, 28, 34, 40] , Australia [9] , US [10] , Canada [42] and Asia [29] . Travelers were also recruited through travel agencies (n Z 5) [7, 25, 29, 30, 34] in Europe [7, 25, 34] and Asia [29, 30] , business corporations in Europe (n Z 2) [13, 21] , universities (n Z 2) in Australia [19] and the US [27] , a commercial airline in the US (n Z 1) [18] , a Japanese embassy in Africa (n Z 1) [29] , post-Hajj seminars or social gatherings or randomized trials in Australia (n Z 1) [6] ; one study was conducted among foreign backpackers recruited in the Khao San Road area, Bangkok, Thailand [26] and another among missionary personnel and their families stationed abroad (n Z 1) [45] . Some studies combined several sources of recruitment [7, 29, 34] . A total of 14 studies focused on a group of selected infectious diseases, including notably malaria, hepatitis A and B and HIV infection [12,13,19,25,27,30,32,35e39,41,42] ; 13 focused on malaria only [10, 15, 16, 18, 20, 21, 26, 29, 31, 33, 34, 40, 43, 44] , 2 on respiratory tract infections [9, 24] , 2 on influenza [22, 23] , 2 on rabies [28, 45] , and 1 each on Ebola [6] , pneumococcal disease [7] , hepatitis A [17] , hepatitis B [8] , infections transmitted through camel milk consumption [11] and Middle East respiratory syndrome [14] . Key findings are reported in Table 1 and show an overall underestimation of risks.

In 35 of 39 studies, the methodology used was that of the knowledge, attitude and practice (KAP) survey [6e11,13e24,26,28e41,43e45]. Of the 35 KAP surveys, 34 used a cross-sectional design with self-administered questionnaires (n Z 26) [6,8e10,13,15e23,26,29e31,33,35e37, 39e41,43e45], four of which were web-based [13, 18, 19, 21] , or face-to-face questionnaires (n Z 7) [7, 11, 14, 24, 28, 32, 38] . One KAP survey was a prospective cohort survey using face-to-face and telephone questionnaires [34] . Only four studies used a methodology distinct from KAP surveys. One cross-sectional study used a combination of questionnaires and a visual psychometric measuring instrument called the 'pictorial representation of illness and self-measure' or PRISM [12] . One cross- Participants ranked malaria, rabies and epidemic outbreaks as the most frequent risks. Sexually transmitted infections were ranked last. Men perceived malaria and rabies as higher risks than women and compared to younger participants, travelers aged >40 years considered STIs as [12] (continued on next page) [41] (continued on next page) sectional study used a self-representation model (SRM) method [27] . Two cross-sectional studies measured psychosocial factors [25, 42] .

In this review paper about the methodology used in studies addressing the risk perception of travelers about infectious diseases, we show that almost all have been conducted using the KAP method. In 2002e2003, the European Travel Health Advisory Board (ETHAB) conducted a multicenter, cross-sectional study to determine the KAP for travel health matters in passengers traveling to developing countries [35e39]. The questionnaire included demographic and travel data, source of travel advice, perceived risk of specific infectious diseases, perception and status of vaccinations, perception and practice of malaria prophylaxis. This questionnaire (or adapted versions) has been used in many studies in different populations of travelers to date. With this method, the studies were able to quantitatively define three components: travelers' actual knowledge of a given disease (symptoms, transmission, preventive measures, etc.), their attitudes (negative, positive, or neutral) toward preventive measures or in terms of intended risk taking/ avoidance behavior, and their practices (protection rate).

As is typically the case for the KAP method [46] , measurements were obtained using either self-report questionnaires or structured interviews. A large amount of descriptive data can be collected from a single survey, revealing quantitative as well as qualitative information [47] . Valuable information was obtained from the above KAP surveys showing an overall lack of knowledge among travelers about the most frequent travel-associated infections and associated preventive measures. These findings have led researchers to outline the need for efficient communication strategies in order to improve travelers' 19,20,23e37,45] . Although the KAP method has been widely advocated, it is not without limitations. One shortcoming is that this methodological approach is mainly descriptive. Estimates in percentages are typically provided for knowledge, attitudes, and practices separately, but the interrelationships between these three components are hardly examined. However, knowing whether and how safety behaviors can be predicted by risk knowledge and attitudes is important information. Descriptive statistics alone can be misleading. This is the case in the KAP studies reviewed here, where high percentages of knowledge have been found to coexist with either high [6] or low [18, 22, 38, 40] percentages of protective behavior, while other studies reported low percentages in both knowledge and protective behavior [17,19,20,23e37,45] . The use of multivariate statistical analyses is thus necessary to assess the respective and real contribution of each key variable. In addition, repeated descriptions of how poor the risk knowledge of travelers is do not inform about efficient measures likely to promote healthy behavior. Travel medicine would benefit at present from experimental studies designed to test different interventions for improving adherence to safety behaviors [48] .

Another limitation of the KAP method is that it overlooks psychosocial variables that have proven to be influential in health related behaviors. For example, the health belief model [49, 50] states that the adoption of safety behaviors will not only depend on individuals' perceptions of the likelihood and seriousness of the disease (often measured with the KAP method), but also on their perceived balance between benefits and costs of preventive measures. In line with this, a meta-analysis of 18 studies [51] showed that low perceived barriers and high perceived benefits were consistently the strongest predictors of various healthy behaviors such as tuberculosis screening, quitting smoking, taking medication, dental care, condom use, or attending programs. The theory of planned behavior [52, 53] also proposes that subjective norms (perceived social pressure from important others like friends, family, general and specialized practitioners) and perceived personal control over the behavior are direct predictors of intentions to engage in healthy behavior, which in turn predict behavior. Findings provided support for this model across various health-related behavior categories such as addictive behaviors, automobile-related behavior, clinical and screening behavior, eating behavior, and safe sex behaviors [54e56]. At least one other psychosocial factor is worth mentioning that can help understand why low adherence to safety behaviors can be observed despite high risk knowledge: positive illusions. Social and cognitive psychology has demonstrated that individuals tend to exhibit unrealistically positive self-evaluations [57] , which can make them overconfident in their decisions and unrealistically optimistic. Of particular interest here, unrealistic optimism (the tendency to think that bad events are more likely to happen to others than to oneself) [58, 59] has been documented in over a thousand studies and for various undesirable events such as diseases and natural disasters [60] . Findings show that unrealistic optimism leads to overestimating the ability to quit smoking [61] , neglecting risk information [62] , and hindering precautionary behaviors [63] to the point that unrealistic optimism has been found to be positively associated with higher levels of subclinical atherosclerosis [64] . In sum, the perceived costs and benefits of safety behaviors, social pressure, personal behavioral control, and unrealistic optimism are key variables that should receive attention in travel medicine, in order to provide a fairer picture of travelers' risk perception about infectious diseases and their likelihood to adopt safety behaviors (See Table 2 ).

Finally, the KAP method is also vulnerable to the limitations of self-reporting, with participants being either unwilling or unable to report their true feelings, intentions, and behaviors [65] . Some individuals may indeed report their intention to use chemoprophylaxis for social desirability purposes. Others may honestly report their intention to adopt healthy behaviors while finally failing to adopt them for reasons beyond their awareness. Implicit measurements of attitudes such as the Implicit Association Test (IAT) [66] have been proposed to complement the information provided by self-reports. The IAT is a 10-min computer-based task that assesses the degree to which people associate some target categories (e.g., "smoking, " "not smoking") with specific attributes (e.g., "positive, " "negative"). The relative strength of these associations (as indexed by reaction times) reflects individuals' automatic or implicit attitudes. For instance, an IAT designed to assess individual risk propensity uses the categories "me" and "not me" and attributes "risky" and "secure" [67] . Individuals with high risk propensity are typically quicker to associate "me" with "risky" than "me" with "secure, " and these implicit attitudes predict higher risk-taking behavior. Several IATs have been developed in the health domain to measure implicit attitudes towards addiction (e.g., alcohol, smoking, drug abuse), diet (tendency to a eat high fat diet), or suicidal ideation/attempt, and these implicit attitudes have proved significant predictors of risky behaviors above and beyond the effects of explicit attitudes [68e70]. Travel medicine could benefit from such implicit measurements. New IATs adapted to travelers and infectious disease need to be developed and evaluated. They might help identify travelers likely to engage in risky behaviors, and thus provide a more appropriate pre-travel consultation.

Shruti Sridhar was funded as a doctoral fellow by the foundation Méditerranée Infection.

None.

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