Travel, for a variety of different purposes, is becoming increasingly prevalent globally, with an almost continuously rising number of international tourists going up from 25 million in 1950 to 1 billion 235 million travellers in 2016; a number predicted to approach 1.8 billion in 2030 as stated by the World Tourism Organisation (UNWTO)1. According to the International Air Transport Aviation (IATA), air traffic currently concerns 3 billion passengers per year and will affect 7 billion passengers in 20342. With an increasingly diverse mixture of international travellers, comes an increase in potential health risks and disease brought about by the plethora of fresh physiological, psychological, microbial, and cultural exposure that individuals are likely to encounter3.  According to studies, 15 to 70% of travellers will declare a travel-related illness and 10% will consult a doctor during their stay abroad or on their return4. This underscores the importance of travel medicine, a specialty that focuses on preventive care before travel5.  Factors such as destination, duration, and purpose of travel remain highly influential determinants affecting the risk of infectious disease but are also essentially complemented by the traveller’s personal profile and many relevant traits6. An individual’s resilience and adaptability are influenced by a variety of demographic, sociocultural, medical, psychological and experiential characteristics7. While environmental factors such as sanitation, hygiene, unclean water, and inadequate medical services pose serious health risks in certain areas, these are greatly exacerbated by travellers’ lack of preparation and failure to take certain measures such as those suggested by the World Health Organisation8,9.

Travel medicine is a relatively nascent field, stemming from the increasing demand that accompanies the increasing worldwide traveller population10. Travel health experts and clinics can, based on individual assessments and risk evaluation, provide counselling regarding recommended or required precautions and offer support to travellers both before and after traveling to certain destinations.  Previous surveys in the field have aimed to unravel the knowledge, attitudes and practices (KAP) of travellers regarding a range of issues including infectious and vaccine-preventable diseases, and trauma-related injuries. In the context of these studies, “knowledge” is generally measured by the accuracy of risk-perception, “attitude” is usually classified as either risk-taking or risk-avoiding behaviour, and “practice” is measured by the rate of protection against a given travel-related health risk. Travellers have been found to often play a role in increasing existing travel health risks, whether through reluctance or refusal to follow pre-travel health guidelines, or due to the lack of public knowledge and information11,12,13. Previous studies have shown a general lack of awareness and preparation among a majority of travellers, such as failure to receive necessary immunisations and medications and failure to take advantage of available resources for travel health advice14,15,16. In addition, the lack of knowledge of some health professionals, misinformation, inaccurate medical advice, and even sometimes erroneous medical intervention have also been shown to often contribute to greater travel-related health risks17,18,19,20.

Many studies have highlighted the underutilisation of pre-travel health advice, the lack of knowledge regarding travel medicine, and the large number of travellers that are unaware of the health risks abroad28. Overall, previous research has found a trend of poor risk perception and awareness in both the Arab and Gulf region, and in developed countries21,22. In Oman for example, where a generally positive attitude towards travel health has been observed, practice remains overwhelmingly low with only 22.5% of travellers seeking pre-travel health services. Similar observations across various studies show these rates to range from as high as 86% in Johannesburg, to as low as 19% in Qatar21-24.

Lebanon is a country of around 4.2 million Lebanese, and it is served by a single international airport, the Rafic Hariri International Airport located in Beirut. The geopolitical situation in the region has caused Lebanon to have over 1.5 million Syrians and Syrian refugees coming from Syria, 174,000 Palestinian refugees and around 6,000 Iraqi refugees. The country has the highest concentration of refugees per capita in the world25. As shown by the statistics provided by the Lebanese General Security, the increasing number of passengers travelling through Rafic Hariri International Airport between January 1st, 2013 and January 1st, 2018 is equal to 36,073,561, i.e. 17,755,689 entering Lebanese territory and 18,317,872 leaving the country. Despite the instability and security issues facing the country in recent years, during the first nine months of 2017, Lebanon counted 6.5 million passengers and an increase in these figures was expected over the last three months of that same year, according to an article by the Ministry of Public Health concerning activity at Beirut International Airport26.

Travel medicine in Lebanon is underdeveloped despite the large number of Lebanese travellers. It is practiced within the framework of ambulatory care, in various structures: private practices, pharmacies, health centres, few travel clinics, and in the health control centre of the Beirut International Airport. Travel medicine services are offered by health professionals from different specialties: family physicians, infectious disease specialists and pharmacists. Moreover, the health control centre of the Ministry of Public Health at Beirut International Airport offers an average of 5,000 vaccines per year; it includes mainly the yellow fever and pilgrim meningitis vaccines offered to travellers who go to Hajj (pilgrimage) and Umrah (visit to Mekkah)26. No study concerning the practice of travel medicine has been conducted so far in Lebanon, only one study looked at the health risks of international travellers coming to Lebanon27.

This is the first study to be conducted in Lebanon focusing on Lebanese travellers’ knowledge, attitudes and practices (KAP) towards health travel, travel related risks, pre-travel medical advice and consultation, vaccinations and prevention measures of travel-related infectious diseases, aiming to determine the levels of KAP among a sample of Lebanese travellers departing from Rafic Hariri International Airport. This study aims to assess the KAP of Lebanese travellers in order to determine where travellers were going to seek travel health advice and identify the gaps in knowledge among travellers and travel health services, and to also determine Lebanese Travellers’ KAP towards travel vaccinations and travel-related risks. By achieving its goals, this study will help assessing the knowledge gap, and the essential needs of more public awareness and education as well as better developed and structured travel health services in Lebanon.

This is a cross-sectional study looking at travel health KAP of Lebanese travellers. It was conducted in Rafic Hariri International Airport in Beirut and included a sample collected within a period of 1 week from January 2nd, 2020 to January 10th, 2020. Of the 655 travellers asked to participate, 625 accepted to fill out the questionnaire (response rate of 95.42%); after exclusion of the questionnaires with many incomplete answers, the final number included in the study was 615.  A four-page, self-administered, anonymous questionnaire was used for this study in order to measure the KAP regarding travel health. This questionnaire is based on similar ones developed and used in previous studies for the same purpose29. It consists of three main sections, including questions about sociodemographic general information, preparation of travel and barriers to preparation, and finally, travel health itself. The questionnaire takes less than 10 minutes to complete and was available in Arabic, English, and French to meet participants’ preferences. Questionnaires were administered at the boarding gates by trained personnel to willing participants waiting to board an international flight at Rafic Hariri International Airport. Inclusion criteria for the participants were: being Lebanese, aged 18 years or more, and boarding an international flight.

Statistical analysis

Data analysis was carried out in Stata V10.0 and all statistical tests were conducted at the 5% level of significance. The statistical tests used in bivariate analysis were for the comparison of percentages, Pearson’s Chi-square test or Fisher's exact test in case of small numbers.

Ethical considerations

Participation was completely voluntary, and data were collected anonymously. All participants submitted written and oral informed consent prior to their participation, and no incentives were given to them. Following the survey, no further contact was made with the participants.

Prior to its launching, the study obtained approval from the ethics committee of the Saint Joseph university of Beirut (USJ), and its affiliated medical centre, Hotel Dieu de France (HDF), Beirut.

Descriptive results

The response rate in our study reached 95.42% and half of the questionnaire were filled in Arabic. Regarding the study’s population demographics and characteristics (table.1), all the 615 respondents were Lebanese (100%) and predominantly men (68%). The sample had only a few seniors with just 28 participants (4.6%) being older than 60 years old. More than two thirds were aged between 18 and 45-year-old respectively: 24.6% aged 18 to 25-year-old, 32.7% aged 26 to 35-year-old, and 21.8% aged 36 to 45-year-old. The big majority had a higher level of education with 80% stating to be university graduates. the vast majority (93%) stated that Lebanon was their country of residence, with the majority (71.5%) living in the capital Beirut and in Mount Lebanon. Regarding travel profile, almost all participants (97%) claimed to have already travelled outside Lebanon, and more than half (57%) said they travel alone.  Travel destinations were almost equally distributed between Middle East and Gulf countries (36%) and sub-Saharan Africa (35%), with only 14% going to Europe. Only 110 respondents (18.0%) were traveling to their destination for the first time. The length of stay in the travel destination was stated to be more than one month, by more than two thirds of the travellers (64%). A total of 251 (40.9%) participants were travelling to rural areas, 190 (30.9%) claimed that they were planning to visit touristic areas. The most common sleeping arrangement was in private homes (74.5%) followed by hotels and resorts (19.4%).

Multiple reasons for travel were reported; the most common was work for 418 (68%) of the respondents, followed by visiting friends and family for 117 (19%), tourism for 84 (13.7%), and education was only reported in 9.9% of cases. Religion and missionary work were the very least reported, by 3 (0.5%), and 20 (3.3%) of the participants respectively. A total of 287 (46.7%) participants began the preparation for their travel at least 1month prior to their travel date, 139 (22.6%) during the week preceding their trip, 105 (17.1%) two to four weeks prior to their trip, and finally 84 (13.7%) said they started planning one to two weeks prior to their travel. Most of the travellers (75%) reported seeking general information about their trip destination, and their primary source was family and friends (44%), followed by the internet (36.7%).

The most commonly recognised vaccine-preventable travel-associated communicable diseases that participants recall being ever vaccinated to in their lifetime were respectively, yellow fever in 281 (45.7%), hepatitis B in 260  participants (42.3%), MMR in 259  (42.1%), polio in 242 (39.4%), followed by typhoid in 209 (34%),  and rabies was the least recognised, reported by only 83 (13.5%) participants. Remarkably, almost half of all respondents (49.3%) were not vaccinated to flu. (table. 2)

Regarding participants’ knowledge, food items that can commonly cause infections while traveling were distributed as following: food from street vendors was the most frequently identified as a harmful item (60.2%), followed by tap water (56.6%), sushi/shellfish (37.2%), raw fruits and vegetables (30.7%),  while ice cubes (31.1%), milk (25.5%) and ice cream (20.3%) were the least likely to be identified correctly as potentially harmful. 

Half of all participants (50.6%) planned on participating in outdoor activities: mainly walking and hiking (41.1%), swimming (16.9%), and backpacking (13.2%). However, in relation to knowledge about preventive measures against insect bites, sleeping with windows closed or under mosquito nets was the most frequent answer, by 228 respondents (37.1%), and only 158 (25.7%) of participants and 144 (23.4%) labelled covering arms/legs while outside at night and, using bug repellent, respectively, as a preventive measure.

Positive attitude toward pre-travel medical advice was detected in one third (33%) of participants who did obtain pre-travel advice. Of those, 47.1% did it more than one month prior to their trip, while 20.4% and 15.1% did it 1 to 2 weeks prior, and 2 to 4 weeks prior to their travel, respectively, and finally 17.5% obtained pre-travel medical advice during the week of the trip.

The primary source of seeking pre-travel medical advice was physicians in 118 respondents (19.2%), followed by the ministry of health (7.3%), the pharmacies (5%) and the internet (4.4%). Only 15 travellers (2.4%) sought pre-travel health advice at a specialized travel clinic. Barriers to seeking medical advice prior to travelling were various; they were either ‘‘no medical concerns or worries” by 270 (43.9%) participants, or ‘‘no time too busy” by 98 (15.9%); only some (11.1%) claimed they “didn’t know where to get it from” and 11 participants (1.8%) claimed financial obstacles by choosing “it costs too much”. Almost the third (32%) of all respondents claimed to have received or purchased medications prior to travel specifically for this trip: OTC drugs ranging from NSAIDs, antidiarrheal, anti-histaminic, anti-vertiginous, antiemetics, paracetamol, to antibiotics, aspirin, melatonin for jet lag, and vitamins were purchased by 19.02%, flu vaccine by 7.8% and antimalarials by 12.68%.

Finally, nearly half of travellers only (49%) were certain of having health insurance at their travel destination.

Analytical results

Travellers who sought information at least one month prior to their trip (n=97) got it from physicians (n=58), followed by misinitry (33), internet (11) and only 4 subjects sought it from a travel clinic.

When it comes to determining potential independent factors related to travellers seeking pre-travel medical advice at least one month prior to travel, no significant association was found between seeking medical advice at least 1 m before and age (Chi-2 test, p-value=0.202), gender (Chi-2 test, p-value=0.171), level of education (Chi-2 test, p-value=0.154), nor having Lebanon as a country of residence (Chi-2 test, p-value=0.250). Seeking medical advice for travel at time was not significantly associated with the area of residence, whether it was Beirut/Mount Lebanon or other mohafazas (Chi-2, p-value=0.524). (table. 3)

On the other hand, those who have not travelled outside Lebanon before had a higher probability of consulting at least 1 month before travel (40% vs14.96%) Chi-2 test, p-value=0.003. Moreover, participants travelling to their destination for the first time ever, also had a higher probability of consulting at least 1 month before travel (24.6% vs 13.9%) Chi-2 test, p-value=0.005.

Travelling alone or with company was not associated with seeking medical advice at time before the trip (Chi-2 test, p-value=0.123). However, people travelling to relatively risky final destinations tend to seek medical advice before their trip significantly more than those who travel to Europe/ Middle East and Gulf/ North America countries (Chi-2 test, p-value<0.001).

An association was also found between consulting at time and length of stay at destination; the lowest being for short stay < 7 days, and the highest for those staying 8 to 14 days (Chi-2 test, p-value<0.001).

When it comes to travel purpose, no association was found between seeking medical advice at least 1 month before travel and travelling for work/business, Chi-2 test, p-value=0.334.

In contrast, those travelling for tourism or leisure sought medical advice significantly less than those not traveling for that purpose (3.57% vs 17.7%), Chi-2 test, p-value=0.001. Travellers also sought pre-travel medical advice one month before travel significantly less when they travel for education (6.56% vs 16.79%), Chi-2 test, p-value = 0.037; or for visiting friends/ family members (6.84% vs 17.87%), Chi-2 test, p-value=0.003. On the other hand, those who had a travel purpose as religion or mission significantly consulted more at least 1 month before travel (Chi-2 test, p-value<0.001).

When it comes to participants’ attitudes, those planning on visiting rural areas/countryside and participating in any outdoor activity consulted significantly more at least 1 month before travel with Chi-2 test, p-value=0.019 and 0.048, respectively.

Moreover, an association between sleeping arrangement and seeking medical advice at least 1 month before travel was only noted with dorms/youth hostels, Chi-2 test, p-value <0.001; and planning the trip at least 1 month before, and getting general information about the destination, were both significantly associated with seeking pre-travel medical advice at least 1 month prior to the trip, with Chi-2 test, p-value <0.001 and <0.001, respectively.

Finally, travellers who have travel insurance were found to significantly seek medical advice at least 1 month before travel compared to those without insurance, Chi-2 test, p-value<0.001.

The questionnaire used in this study was distributed to a sample of Lebanese travellers at the boarding gates in Rafic Hariri International Airport in Beirut with a response rate of 95.42%. This response rate is considered the highest among other studies^30,31,21.

Age and sex distribution in this study, with more than two thirds being men and aged between 18 and 45 years old, are similar to other studies conducted in the neighbouring Gulf countries.^{21, 22, 33} In contrast, respondents from Western countries tend to be nearly equally divided into men and women ^{23,33,34,35,36} and come from a slightly older group.^29,36

This difference in age and sex distribution, keeping in consideration that the study was conducted right after the end of winter season holidays, and in a delicate period of time during which the country was witnessing multiple protests and peaking a destabilizing political and economic situation, highlights the nature of a large sector of respondents in our study as the Lebanese workforce who were leaving Lebanon back to their working places and businesses abroad.

This could also explain why the most common purpose of travel reported was work (68%), followed by visiting friends and family (19.02%), while tourism was the main purpose of travel in other studies.^6,22,23 This exceptional context could also explain the fact that the vast majority were travelling to the Middle East and Gulf countries and sub-Saharan Africa, known to be primary working destinations to the young working Lebanese, and this destination profile finding is similar to other studies conducted in Gulf countries.^22,35

Although the majority of the study group were experienced travellers, got general information about their destinations, and slightly less than half of them prepared for their trip at least 1 month in advance, the overall level of knowledge about vaccine-preventable diseases, food safety, and preventive measures against insect bites was less than optimal. Rather, the practice concerning preventive health measures, especially the use of specific immunizations and anti-malarial prophylaxis, was very limited. Risk perception is very important for self-protection against many diseases associated with travel.³⁷ Less than half of our respondents had poor knowledge regarding the risk of travel-associated communicable diseases and methods of preventions. In addition, more than half (66%) of travellers with a negative attitude toward travel medicine denied their need to pre-travel medical advice and any preventive measures with many (43.9%) stating they had no medical worries, this finding implies a higher susceptibility of exposure to travel risks. Poor risk perception was also detected in studies conducted in Gulf countries^21,22 as well as in developed countries.^32,33,35

In this study, more than one third (33%) of Lebanese travellers had a positive attitude toward pre-travel health advice, but travel medicine services were underutilized, as only the minority (2.44%) of travellers sought travel health advice from specialized travel clinics, while physicians were the most reported source of pre-travel medical advice (19.9%). However, in terms of rates of utilization for pre-travel health advice reported in other studies, the 33% reported in this study is not as high as 86% reported in Johannesburg but is however better than the lowest rate being 19% reported in Qatar.^{6,21,23,24, 34,35,38}

Of those who did seek pre-travel health advice, physicians were the source most reported (19.9%), whereas it is noteworthy that specialized travel health clinics were the least consulted (2.44%). This contrasts with some studies, where general practitioners and travel health clinics were equally the most frequent source of pre-travel health advice, as found in the Swedish and South African travellers.^6,24,38

Moving on to the timing of pre-travel medical advice, only 15.8% of the study sample consulted at least 1 month prior to their trip, which is the recommended timing of consultation to ensure adequate time for necessary vaccination³⁹. In addition to this research paper being the first to study KAP among Lebanese travellers towards travel health, this study also aims to determine potential independent predicting factors associated with travellers seeking pre-travel advice adequately at least one month prior to their travel. No significant associations were found between age, gender, level of education, having Lebanon as a country of residence nor the area of residence whether it is Beirut/Mount Lebanon or other mohafazas, and the fact of seeking pre-travel medical advice at least 1 month prior to travel, as opposed to the Omani study⁴⁰ where gender was correlated to higher knowledge with males scoring more than females, and among travellers who reported pre-travel consultation, participants aged between 18 years and 35 years were the most likely to seek travel health advice prior to the trip, and the Egyptian traveller’s KAP study⁴¹ as well which showed that the total travel health knowledge, practice, general attitude toward vaccination, and the malarial prophylaxis were significantly correlated with older age and high educational level.

Having health insurance at destination was also analysed and found to be significantly associated with seeking pre-travel medical advice at time, most probably because of the pre-travel consultation’s relatively high cost perceived by travellers. Similarly to the previous Saudi and Omani studies, the importance of legislation to improve adherence to pre-travel consultation is evident^22,40. This was highlighted by the fact that those travelling for missionary or religious purposes were found to seek medical advice at least one month prior to travel more than the others.  Saudi Arabia’s annual guidelines for Hajj travellers are an example of what is behind this finding. However, with growing numbers of travellers to the Hajj and to certain African destinations, legislations and formal implementations could be useful to optimize pre-travel consultations.

Another remarkable result is the correlation between prompt pre-travel health advice and travellers planning on visiting rural areas or engaging in outdoor activities, which could reflect travellers’ relatively good risk perception and willingness to apply prevention measures. A correlation was also found between early trip preparation (earlier than 1 month before travel date) and getting general information about travel destination with pre-travel medical advice seeking at least one month prior to travel date. A timeframe of 4-6 weeks before travel is ideal for seeking medical advice. This is why last-minute trip planning (less than 2 weeks before departure) has shown to be an important factor in inadequate pre-travel medical advice seeking^6.33. This trend should make last-minute travellers a high priority target for travel medicine. Increased support from health professionals and institutions, especially family physicians and GPs, is needed, as well as more increased training in the field of travel medicine. This need is brought out by the finding that the majority of travellers who sought medical advice prior to departure (59.8%) claimed to have consulted their physicians.

At last, it is worth mentioning that this study was conducted in Lebanon in the first week of January 2020, just before the Covid-19 pandemic reached the country and first cases were confirmed.

It would be interesting to conduct this study in Lebanon in the post-Covid19 period and evaluate the effects of this pandemic on the KAP of travellers regarding Travel Health.

Limitations

Our study has some limitations : it was conducted despite some extremely unusual circumstances coinciding with the end of holidays, a low season, and the beginning of an economic and political downfall of the country. In addition, travellers of only one week in January may not reflect all travellers, and participants were asked to remember their past immunizations without relying on their vaccination’s records, which potentially constitutes a recall bias as well.

The need to establish specialized travel medicine services at a national level is demonstrated by this study, as well as the necessity to develop programs and materials that educate travellers on the importance of seeking pre-travel health advice and raise the awareness about it. Further research including a larger number of travellers and over a longer period of time would be of greater use.

To sum up, this study proves an inadequate level of traveler knowledge towards travel health and has shown poor utilization of specialized travel medicine resources. It also emphasizes on the necessity to provide educational programs promoting pre-travel health counselling and the unmet needs of specialized travel medicine services. Overall, this study recommends the establishment of a well-structured travel medicine service in Lebanon, with strong strategic material of education and awareness to the public at a national level. Moreover, a study over a longer period, with larger numbers of travellers and covering more destinations is recommended and would be of great benefits.

Declarations

• Ethics approval and consent to participate

The study was not considered a medical experiment. It was approved by the Ethics and Scientific Research Committee of the Saint Joseph University of Beirut. The questionnaire was only filled after an informed written consent form was read, approved and signed by participants before proceeding. The form detailed the study’s purpose, the voluntary nature of participation, and a guarantee of confidentiality and secure data storage. The questionnaire was anonymous.

• Consent for publication
• Not applicable.
• Availability of data and materials
• The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
• Competing interests
• The authors declare that they have no competing interests.
• Funding

This research received no specific grant or funding.

Authors’ contributions

All authors contributed to the design of the study. MH collected the data and drafted the manuscript. SH conducted statistical analysis. RD reviewed the manuscript. All authors approved the final manuscript.

Acknowledgments

The authors gratefully acknowledge Sary Sader, Christelle Haddad, and Reine Azzi for their support in data collection.

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