ORIGINAL RESEARCH * NOUVEAUTES EN RECHERCHE
Knowledge and beliefs of international travellers about the transmission and prevention of HIV infection Robert Allard, MD, MSc, FRCPC; Gilles Lambert, MD Objectives: To measure the perceived risk of acquired immunodeficiency syndrome (AIDS) among international travellers, to measure their knowledge of the transmission and prevention of HIV infection abroad and to identify some of the determinants of this knowledge. Design: Survey. Setting: Travellers' immunization clinic providing mostly primary preventive care to international travellers. Participants: All clients aged 18 to 50 years seen at the clinic between Oct. 2 and Dec. 21, 1989, before their departure. Main outcome measures: Sixteen statements measured knowledge of transmission and prevention of HIV infection. Standardized scales measured health beliefs. Results: The response rate was 81% (331/409). Compared with other diseases AIDS was perceived to be associated with a low risk except by those travelling to countries with a high prevalence of AIDS. Most of the clients were found to have a good knowledge of HIV transmission to travellers, although some myths remained popular and some real routes of transmission, especially blood, remained underrated. In all, 70% of the subjects believed in the efficacy of condoms when used with local people, as compared with 79% when used with other tourists; this difference was greatest among travellers who perceived AIDS as being particularly severe but difficult to prevent. The determinants of the knowledge of HIV transmission and prevention were a high level of education, a mother tongue other than French, unmarried status, a high prevalence of AIDS at the destination, the duration of the trip and a high perceived risk of HIV infection. Conclusions: Counselling should teach travellers (a) not to underestimate their risk of HIV infection during their trip, (b) to decrease the risk of requiring health care in developing countries and (c) to rely on their own prudent sexual behaviour rather than on their assessment of the level of risk posed by the environment. Objectifs: Mesurer la perception du risque de contracter le syndrome d'immunodeficience acquise (SIDA) chez les voyageurs internationaux afin d'evaluer leurs connaissances sur la transmission et la prevention de l'infection a virus d'immunodeficience humaine (VIH) a l'etranger et d'identifier certains determinants de ces connaissances. Conception: Sondage. From the Department of Community Health, Maisonneuve-Rosemont Hospital, and the Department of Social and Preventive Medicine,
University of Montreal, Montreal, Que.
Correspondence to: Dr. Robert Allard, Department of Community Health, Saint-Luc Hospital, 1001 St. Denis St., Montreal, PQ H2X 3H9 FEBRUARY 1, 1992
CAN MED ASSOC J 1992; 146 (3)
353
Contexte: Une clinique de vaccination des voyageurs qui fournit principalement des soins de prevention primaire aux voyageurs internationaux. Participants: Tous les clients ages de 18 a 50 ans examines a la clinique entre le 2 oct. et le 21 dec. 1989, avant leur depart. Mesures des resultats: Seize enonces mesuraient les connaissances sur la transmission et la prevention de l'infection a VIH. Des echelles standardisees mesuraient les convictions relatives a la sante. Resultats: Le taux de reponse etait de 81 % (331/409). Par comparaison avec d'autres maladies, on percevait le SIDA comme etant relie a un faible risque, sauf chez ceux qui se rendaient dans des pays a prevalence elevee du SIDA. La plupart des clients avaient de bonnes connaissances sur la transmission du VIH aux voyageurs, bien que certains mythes demeurent populaires et que certaines voies de transmission reelles, en particulier le sang, demeurent meconnues. En tout, 70 % des sujets croyaient a l'efficacitd des condoms lors de contacts avec la population locale par comparaison avec 79 % lorsqu'ils sont utilises avec d'autres touristes; cette difference etait la plus importante chez les voyageurs qui percevaient le SIDA comme particulierement grave mais difficile a prevenir. Les determinants des connaissances sur la transmission et la prevention du VIH etaient determinees par un niveau de scolarite eleve, une langue maternelle autre que le francais, le celibat, la prevalence dlevee du SIDA a destination, la duree du voyage et la perception d'un risque eleve d'infection a VIH. Conclusions: Les services de counselling devraient enseigner aux voyageurs (a) a ne pas sous-estimer leur risque d'infection a VIH au cours du voyage, (b) a reduire le risque de recevoir des soins de sante dans les pays en voie de developpement et (c) a se fier a la prudence de leur propre comportement sexuel plut6t qu'a leur evaluation du degre de risque attribuable a l'environnement.
A lthough most human immunodeficiency virus (HIV) transmission in developed countries is indigenous, the possibility of being infected while travelling to pattern II countries' is real. In Quebec as of May 15, 1991, 47 of 1614 reported cases of acquired immunodeficiency syndrome (AIDS) in adults were in people whose only risk factor was sexual contact with a person from a pattern II country; in 21 of the 44 cases in which the location of the contact was known it was the pattern II country itself (Dr. Robert Remis: personal communication, 1991). These 21 cases represent 1.3% of all reported cases of AIDS in adults and 48% of cases acquired heterosexually from a person from a pattern II country. This route of transmission is relatively more important in Quebec than in the United States, where sexual contact (in or outside the United States) with a person born in a pattern II country accounted for only 82 (0.07%) of 115 786 cases in adults as of December 1989.2 In Britain as of the end of August 1990, 179 (77%) of the 231 heterosexually transmitted cases of HIV infection had been acquired abroad.3 4 The potential for HIV transmission to travellers has been described previously.5- 18 In one study about 4% of Swiss tourists were found to have had unprotected sexual intercourse with local people during short stays abroad.5 The rate of admission of Swiss travellers to hospital has been estimated to be 400 per 100 000 tourist-months and the rate for all accidents 500 per 100 000 tourist-months.6 The use of alcohol and other drugs is thought to promote various kinds of risk-taking behaviour.7 The risk of 354
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HIV infection through sexual contact and blood transfusion during international travel is also indicated by the fact that 1 traveller in 2500 acquires hepatitis B.5 An increased rate of HIV infection in international travellers has actually been observed among drug addicts,8 homosexual men9 and prostitutes.'°0" HIV transmission to international travellers otherwise at low risk has been documented anecdotally. 12.13 As for documenting the need for preventive education the clients of a travel clinic in England were found usually to underestimate the risk of HIV infection associated with travel to certain areas.4 The authors concluded that (a) many travellers with deficient knowledge about AIDS do not request information, (b) travellers who are members of ethnic minorities should be targetted for AIDS education and (c) condoms need to be made far more available to travellers.'9 We know of no other published study on this topic. Our goal was to document objectively the counselling needs of international travellers for the prevention of HIV infection. The study was specifically designed to (a) measure the perceived risk of HIV infection among international travellers consulting an immunization clinic before their departure, (b) measure these travellers' knowledge of the transmission and prevention of HIV infection abroad and (c) identify some of the determinants of this knowledge among the sociodemographic characteristics of the clients and among their beliefs about AIDS. LE ler F£VRIER 1992
Methods Questionnaire A self-administered questionnaire was used to obtain the following information: sociodemographic data, a description of the planned journey (destinations and lengths of stay), perceived risk of various infectious diseases during the trip, knowledge about the transmission and prevention of HIV infection while travelling, beliefs about AIDS (as defined by the Health Belief Model20-23), locus of control and presence of standard high-risk behaviour patterns for HIV infection. The statements used to measure the subjects' knowledge about HIV infection while travelling are listed in Appendix 1. Four statements (2, 3, 6 and 8) describe behaviours that would increase the risk of HIV infection, six (9, 11 and 13 through 16) describe behaviours that would decrease it, and six (1, 4, 5, 7, 10 and 12) describe behaviours that would have no effect on it. The respondent had to indicate whether performing each behaviour during the planned trip would increase, decrease or not affect his or her risk of HIV infection, regardless of the actual intention to carry it out. Some components of the Health Belief Model were measured with the use of published Likert-type scales of good reliability and validity20-22 that had been used in the general population of the same city.23 Briefly, the components measured were perceived severity of AIDS, perceived susceptibility to AIDS, perceived efficacy of measures to prevent AIDS and general health motivation. These components concern AIDS in general and do not refer to travel. We did not study components of the Health Belief Model relating to the perceived efficacy of, and barriers to, specific preventive actions, as there were too many possible actions. Locus of control (internal or external) was measured with the use of one of the two published versions of the Health Locus of Control scale.24 The high-risk behaviours, regardless of the respondents' travel plans, were determined by closed questions on (a) the sharing of unsterilized injection equipment, (b) sexual intercourse with people who share such equipment, (c) whether the respondents or their parents were born in a pattern II country, (d) sexual intercourse with people who were born in such a country, (e) sexual intercourse with a homosexual or bisexual man and (f) sexual intercourse with a person who possibly or certainly has HIV
infection. The French version of the questionnaire was pretested in a sample of 27 patients under the same conditions as those for the main study; several questions were then reworded and others added. FEBRUARY 1, 1992
Those parts that were not originally in English were then translated into it.
Data collection The study was carried out at a large travellers' immunization clinic operating in eastern Montreal. The questionnaire was handed out by the receptionist at the time of registration to all clients aged 18 to 50 years who visited the clinic from Oct. 2 to Dec. 21, 1989. A covering letter asked them to fill it out in the waiting room before being seen by the physician or nurse and to drop it in a closed box as soon as completed; it stressed that participation was optional and anonymous and that it would have no influence on care.
Results Of the 409 questionnaires distributed during the study period 331 (81%) were returned with sufficient information to be usable. The average age of the respondents was 37 years; 46% were men. The mother tongue was French for 89%, English for 5% and another language for 6%; 45% were married, 41% were single, and 14% were separated, divorced or widowed. The respondents were relatively well off: most had attended university (53%) or junior college (27%); 45% lived in households with a total annual income above $40 000 and 23% in households with an income from $30 000 to $40 000. Risk factors for HIV infection were present: 0.3% of the respondents had shared unsterilized injection equipment, 0.9% had had intercourse with a person who possibly or certainly had HIV infection, 1.2% originated from a pattern II country, 4.2% had had intercourse with people who had the previous two risk factors, and 7.3% (11.8% of the men and 3.4% of the women) had had intercourse with homosexual or bisexual men. In all, 11.8% (16.4% of the men and 7.8% of the women) had one or more risk factors. For 22% of the respondents the planned trip was the first one outside of Canada, the United States or Europe. The expected duration of the trip was less than 7 days for 10%, 7 to 13 days for 37%, 14 to 20 days for 18%, 21 to 27 days for 15% and 28 or more days for 20%. The main destination was Mexico, Central America or South America for 40%, Asia for 27%, the Caribbean for 13%, northern Africa for 1 1% and central or South Africa for 9%.
Perceived risk of disease The following proportions of respondents considered the risk of disease, if no preventive action were taken, to be higher during the planned trip than CAN MED ASSOC J 1992; 146 (3)
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~ ~ .tl _
if they stayed home for the same period: malaria 90%, diarrhea 88%, yellow fever 83%, typhoid fever 80%, hepatitis (type unspecified) 80%, cholera 72%, meningitis 46%, rabies 43%, AIDS 26% and gonorrhea 22%. A similar question specifically about HIV infection (but without mention of whether precautions would or would not be taken) resulted in 10% of the respondents stating that the risk would be much higher, 1 1% higher, 71% equal, 2% lower and 5% much lower. On the basis of reported prevalence rates of AIDS central Africa, South Africa and the Caribbean can be considered, all else being equal, to be highrisk regions for travellers;' 32% of the 68 respondents going to these regions considered themselves at higher risk of HIV infection, as compared with 17% of the 246 going elsewhere (X2 = 7.18, p < 0.007). HIV infection was the only disease that showed such a pattern: the perceived risk of all the other diseases was the same regardless of the destination. A multivariate logistic regression analysis showed that a perceived higher risk of HIV infection was associated mostly with the respondent's mother tongue being a language other than French, travelling to a highly endemic destination and a high perception of susceptibility to the disease (Table 1). Only 79 (24%) of the respondents stated that they had thought about taking precautions
356
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against HIV infection during the trip. These precautions were mostly the use of condoms (18% of the respondents), abstinence or monogamy (7%) and various steps to prevent blood transmission (4%). The consideration of precautions was associated with unmarried status, a perception that the risk of HIV infection would be higher on the trip than at home, a higher level of education and a long journey (Table 1). Locus of control seemed irrelevant.
Knowledge about HIV transmission
The proportion of the respondents who gave the "correct" answer follows each statement in Appendix 1. For most of the statements the majority of respondents gave the correct answer. Answers to some specific statements were of special interest. First, 14% of the respondents felt that avoiding all sexual contact would not decrease their risk of HIV infection. Second, about half stated that avoiding mosquito, dog and monkey bites would help to prevent HIV infection. Finally, asking to be transferred to a hospital in a developed country and (even more so) driving carefully were steps seldom considered to be relevant in preventing AIDS. This absence of concern about nosocomial infection makes it unlikely that the concern about animal bites was
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ihcntmntdeupet(n about treatment with contaminated equipment (instead of the bite itself).
abu
ramn
Perceived efficacy of safer sex
bites) and least accurate when it referred to foreign situations seldom mentioned in the media (avoiding injections or unscreened blood transfusions). Unlike the perceived risk of typical tropical diseases, that of AIDS and gonorrhea was not considered to be higher abroad than at home by
Of the respondents 97% felt that unprotected intercourse with locals would increase their risk of most of the respondents; only 21% of the responAIDS and 86% that avoiding penetration would dents thought that the risk of AIDS would be decrease the risk. Condoms were felt to be effective increased by the planned journey. This may have by 79% if used with fellow travellers but by only 70% been due to underrecognized modes of transmission if used with locals. In fact, 46 (14%) of the respon- of HIV, especially blood borne; however, false dents stated that condoms would be effective with sources were identified as true about as frequently, tourists but not with locals, whereas only 16 (5%) felt and in any case the respondents' knowledge was the reverse would be true. This association was good in general. Perhaps the travellers were unable highly significant (X2 = 86.7, p < 0.00001). Through or unwilling to apply their knowledge about HIV multiple logistic regression analysis (using the same transmission to themselves. potential determinants as in the second column of The perceived risk of HIV infection during the Table 1) we found that the characteristics that planned trip was influenced by characteristics of the differentiated these 46 from the others were (a) a respondents (mother tongue and perceived susceptilow perceived efficacy of measures to prevent AIDS bility to AIDS in general) and of the trip (prevalence (p = 0.021), (b) a high perceived severity of AIDS of AIDS in the region to be visited). The consider(p = 0.046) and (c) a mother tongue other than ation of precautions against AIDS when planning the French (p = 0.042). journey was also influenced by characteristics of the respondents (level of education and marital status) and of the trip (duration and perceived risk of HIV Discussion infection). We propose the hypothesis that travellers tend The high response rate and the general similarity between the socioeconomic profile of the sample to look for the source of their risk of HIV infection and the known characteristics of clinic-using travel- in the local population and living conditions as well lers from Montreal25 support the representativeness as in their own behaviour. This is suggested by three of the study sample as people who consult an observations: first, the perceived risk of HIV infecimmunization clinic before leaving on a trip. How tion on the planned trip was related to the prevathe AIDS-related knowledge, beliefs and practices lence of the disease in the country of main destinadiffer from those of travellers who do not consult tion, whereas the perceived risk of other diseases was such a clinic is unknown. The data collection was not. Second, the main destination was a stronger carried out in fall and early winter; since it did not predictor of the perceived risk than were beliefs span a whole year a seasonal effect on destination about AIDS unrelated to travel. Third, condoms was likely; however, there remained a fair variety of were thought to be less effective with locals than destinations, and the effect of destination on the with fellow travel- lers; this was especially true of dependent variables of interest was taken into ac- travellers who considered AIDS as being particularly severe but difficult to prevent. Our interpretation is count in the multivariate analyses. Since there was no published study of this kind that for some travellers, especially those who already when we planned ours, we had to create some parts feel particularly threatened by AIDS, the presence of of the questionnaire, especially the items in Appen- "other people," the locals, not only increases the dix 1. We refrained from interpreting differences in perceived threat of AIDS but also provides them the responses that could have been due to discrepan- with an object on which to project the risk. This cies in the formulation of some of the statements. may be one manifestation of a more general pattern: Also, differences between the French and English there is evidence that people from Montreal who versions of the questionnaire could not explain the feel particularly threatened by AIDS tend to higher perceived risk of AIDS reported by nonfran- favour coercive measures against specific groups cophones, since most of these used the French at home.23 We believe that the following suggestions can be version. We have no explanation for this difference drawn from this study. in perceived risk. Knowledge was most accurate when it referred * Travellers should be taught not to underestito familiar behaviours (sexual transmission and precautions), less accurate when it referred to foreign mate the risk of sexually transmitted diseases associsituations having received media coverage (animal ated with travelling. FEBRUARY 1, 1992
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* Some actions that create a risk of HIV transmission but are not considered to do so by most travellers (the use of unsterilized injection equipment, the receipt of unscreened blood transfusions and dangerous driving) should be brought to their attention. * Some myths about HIV transmission (through mosquito and animal bites) need to be dispelled.
* It should be emphasized that the risk of HIV infection depends far more on the traveller's behaviour than on the living conditions or the local
population. * The applicability of some familiar precautions (abstinence and the use of condoms) to unfamiliar situations should be reinforced. * The possibility of age, educational and cultural differences in the perception of risk and of the effectiveness of precautions should be borne in mind. We thank the clinic staff and Dr. Julio Soto for helping with the data collection and the interpretation of the results.
References
8. Bisset C, Jones G, Davidson J et al: Mobility of injection drug users and transmission of HIV [C]. Lancet 1989; 2: 44 9. Merino N, Sanchez RL, Munoz A et al: HIV-1, sexual practices, and contact with foreigners in homosexual men in Colombia, South America. J Acquir Immune Defic Syndr 1990; 3: 330-334
10. Koenig ER: International prostitutes and transmission of HIV. Lancet 1989; 1: 782-783 11. Dan M, Rock M, Bar-Shany S: Prevalence of antibodies to human immunodeficiency virus among intravenous drug users in Israel - association with travel abroad. Int J Epidemiol 1989; 18: 239-241
12. Vittecoq D, May T, Roue RT et al: Acquired immunodeficiency syndrome after travelling in Africa: an epidemiological study in seventeen Caucasian patients. Lancet 1987; 1: 612614 13. Hill DR: HIV infection following motor vehicle trauma in Central Africa. JAMA 1989; 261: 3282-3283 14. Lange WR, Dax EM: HIV infection and international travel. Am Fam Physician 1987; 36: 197-204 15. Gras C, Jeandel P, Cuisinier-Raynal JC et al: Le risque du SIDA pour le voyageur occasionnel en Afrique. Med Trop (Mars) 1987; 47: 293-295 16. Lepage P, Van de Perre P: Nosocomial transmission of HIV in Africa: What tribute is paid to contaminated blood transfusions and medical injections? Infect Control Hosp Epidemiol 1988; 9: 200-203
17. Gilmore N, Orkin AJ, Duckett M et al: International travel and AIDS. AIDS 1989; 3 (suppl 1): S225-S230 18. Von Reyn CF, Mann JM, Chin J: International travel and HIV infection. Bull WHO 1990; 68: 251-259 19. Porter JDH, Phillips-Howard PA, Behrens RH: AIDS awareness among travellers. Travel Med Int 1991; 9: 28-32
1. Mann JM, Chin J, Piot P et al: The international epidemiology of AIDS. Sci Am 1988; 259 (4) 82-89
2. HI V/AIDS Surveillance (year-end ed), Division of HIV/AIDS, Centers for Disease Control, US Dept of Health and Human Services, Atlanta, 1990 3. Ellis EJ: HIV infection and foreign travel [C]. BMJ 1990; 301:
984-985
20. Jette AM, Cummings KM, Brock BM et al: The structure and reliability of health belief indices. Health Serv Res 1981; 16: 81-98
21. Maiman LA, Becker MH, Kirscht JP et al: Scales for measuring health belief dimensions: a test of predictive value, internal consistency, and relationships among beliefs. Health Educ Monogr 1977; 5: 215-231
4. Behrens RH, Porter JDH: HIV infection and foreign travel [C]. Ibid: 1217
22. Champion VL: Instrument development for health belief model constructs. Adv Nurs Sci 1984; 6: 73-85
5. Steffen R: Risks of hepatitis B for travellers. Vaccine 1990; 3 (suppl): S3 1-S32
23. Allard R: Beliefs about AIDS as determinants of preventive practices and of support for coercive measures. Am J Public Health 1989; 79: 448-452
6. Steffen R: Health risks for short-term travelers. In Steffen R, Lobel HO, Haworth J et al (eds): Travel Medicine, Springer, Zurich, 1989: 27-36
24. Strudler-Waliston B, Wallston KA, Kaplan GD et al: Development and validation of the Health Locus of Control (HLC) scale. J Consult Clin Psychol 1976; 44: 580-585
7. Lange WR, McCune BA: Substance abuse and international travel. Adv Alcohol Subst Abuse 1989; 8 (2): 37-51
25. Allard R: Problems in adequately immunizing international travellers. Can MedAssoc J 1983; 128: 40-41
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Conferences continuedfrom page 337 Singapore Scientific Meeting and Medical Education Seminar / Une Reunion scientifique et un Seminaire de formation medicale a Singapour Oct. 30-Nov. 6, 1992 / du 30 oct. au 6 nov. 1992 Cosponsored by the Singapore Medical Association and the CMA / coparrainees par l'Association medicale singapourienne et l'AMC. Singapore Pat Herr, Conference Planners International, 7711 Bonhomme Ave., St. Louis, MO 63105-1961; 1-800-234-6900, ext. 382, fax (314) 727-9354
Mar. 23, 1992: Advanced Skills of Group Work: an Interactional Approach Royal Ottawa Hospital Education Services, Royal Ottawa Hospital, 1145 Carling Ave., Ottawa, ON KlZ 7K4; (613) 724-6521 or 724-6525 Mar. 23-24,1992: Kellogg Nutrition Symposium Metro Toronto Convention Centre Liz Routliffe, 6700 Finch Ave. W, Etobicoke, ON M9W 5P2; (416) 675-5236 May 12-15, 1992: Catholic Health Association of Canada Annual Convention Holiday Inn, Winnipeg Freda Fraser, director of communications, Catholic Health Association of Canada, 1247 Kilborn Pl., Ottawa, ON KIH 6K9; (613) 731-7148, fax (613) 731-7797
Other Conferences * Conferences diverses Mar. 13-14, 1992: Gender Identity and Development in Childhood and Adolescence Two-Day International Conference St. George's Hospital, London Philippa Weitz, Conference Unit, Department of Mental Health Sciences, St. George's Hospital Medical School, Cranmer Terrace, London SW 17 ORE, England; telephone 011-44-1-081-672-9944, ext. 55534, fax 011-44-1-081-767-4696 FEBRUARY 1, 1992
Oct. 18-21, 1992: ITCH '92 - Building Partnerships in Community Health Through Applied Technology (sponsored by the British Columbia Ministry of Health, the University of Victoria and the Canadian Public Health Association) Victoria Conference Centre Larry Scott, chairperson, ITCH '92, School of Health Information Science, University of Victoria, PO Box 1700, Victoria, BC V8W 2Y2; (604) 721-8575, fax (604) 721-1457 CAN MED ASSOC J 1992; 146 (3)
359
Knowledge and beliefs of international travellers about the transmission and prevention of HIV infection Robert Allard, MD, MSc, FRCPC; Gilles Lambert, MD Objectives: To measure the perceived risk of acquired immunodeficiency syndrome (AIDS) among international travellers, to measure their knowledge of the transmission and prevention of HIV infection abroad and to identify some of the determinants of this knowledge. Design: Survey. Setting: Travellers' immunization clinic providing mostly primary preventive care to international travellers. Participants: All clients aged 18 to 50 years seen at the clinic between Oct. 2 and Dec. 21, 1989, before their departure. Main outcome measures: Sixteen statements measured knowledge of transmission and prevention of HIV infection. Standardized scales measured health beliefs. Results: The response rate was 81% (331/409). Compared with other diseases AIDS was perceived to be associated with a low risk except by those travelling to countries with a high prevalence of AIDS. Most of the clients were found to have a good knowledge of HIV transmission to travellers, although some myths remained popular and some real routes of transmission, especially blood, remained underrated. In all, 70% of the subjects believed in the efficacy of condoms when used with local people, as compared with 79% when used with other tourists; this difference was greatest among travellers who perceived AIDS as being particularly severe but difficult to prevent. The determinants of the knowledge of HIV transmission and prevention were a high level of education, a mother tongue other than French, unmarried status, a high prevalence of AIDS at the destination, the duration of the trip and a high perceived risk of HIV infection. Conclusions: Counselling should teach travellers (a) not to underestimate their risk of HIV infection during their trip, (b) to decrease the risk of requiring health care in developing countries and (c) to rely on their own prudent sexual behaviour rather than on their assessment of the level of risk posed by the environment. Objectifs: Mesurer la perception du risque de contracter le syndrome d'immunodeficience acquise (SIDA) chez les voyageurs internationaux afin d'evaluer leurs connaissances sur la transmission et la prevention de l'infection a virus d'immunodeficience humaine (VIH) a l'etranger et d'identifier certains determinants de ces connaissances. Conception: Sondage. From the Department of Community Health, Maisonneuve-Rosemont Hospital, and the Department of Social and Preventive Medicine,
University of Montreal, Montreal, Que.
Correspondence to: Dr. Robert Allard, Department of Community Health, Saint-Luc Hospital, 1001 St. Denis St., Montreal, PQ H2X 3H9 FEBRUARY 1, 1992
CAN MED ASSOC J 1992; 146 (3)
353
Contexte: Une clinique de vaccination des voyageurs qui fournit principalement des soins de prevention primaire aux voyageurs internationaux. Participants: Tous les clients ages de 18 a 50 ans examines a la clinique entre le 2 oct. et le 21 dec. 1989, avant leur depart. Mesures des resultats: Seize enonces mesuraient les connaissances sur la transmission et la prevention de l'infection a VIH. Des echelles standardisees mesuraient les convictions relatives a la sante. Resultats: Le taux de reponse etait de 81 % (331/409). Par comparaison avec d'autres maladies, on percevait le SIDA comme etant relie a un faible risque, sauf chez ceux qui se rendaient dans des pays a prevalence elevee du SIDA. La plupart des clients avaient de bonnes connaissances sur la transmission du VIH aux voyageurs, bien que certains mythes demeurent populaires et que certaines voies de transmission reelles, en particulier le sang, demeurent meconnues. En tout, 70 % des sujets croyaient a l'efficacitd des condoms lors de contacts avec la population locale par comparaison avec 79 % lorsqu'ils sont utilises avec d'autres touristes; cette difference etait la plus importante chez les voyageurs qui percevaient le SIDA comme particulierement grave mais difficile a prevenir. Les determinants des connaissances sur la transmission et la prevention du VIH etaient determinees par un niveau de scolarite eleve, une langue maternelle autre que le francais, le celibat, la prevalence dlevee du SIDA a destination, la duree du voyage et la perception d'un risque eleve d'infection a VIH. Conclusions: Les services de counselling devraient enseigner aux voyageurs (a) a ne pas sous-estimer leur risque d'infection a VIH au cours du voyage, (b) a reduire le risque de recevoir des soins de sante dans les pays en voie de developpement et (c) a se fier a la prudence de leur propre comportement sexuel plut6t qu'a leur evaluation du degre de risque attribuable a l'environnement.
A lthough most human immunodeficiency virus (HIV) transmission in developed countries is indigenous, the possibility of being infected while travelling to pattern II countries' is real. In Quebec as of May 15, 1991, 47 of 1614 reported cases of acquired immunodeficiency syndrome (AIDS) in adults were in people whose only risk factor was sexual contact with a person from a pattern II country; in 21 of the 44 cases in which the location of the contact was known it was the pattern II country itself (Dr. Robert Remis: personal communication, 1991). These 21 cases represent 1.3% of all reported cases of AIDS in adults and 48% of cases acquired heterosexually from a person from a pattern II country. This route of transmission is relatively more important in Quebec than in the United States, where sexual contact (in or outside the United States) with a person born in a pattern II country accounted for only 82 (0.07%) of 115 786 cases in adults as of December 1989.2 In Britain as of the end of August 1990, 179 (77%) of the 231 heterosexually transmitted cases of HIV infection had been acquired abroad.3 4 The potential for HIV transmission to travellers has been described previously.5- 18 In one study about 4% of Swiss tourists were found to have had unprotected sexual intercourse with local people during short stays abroad.5 The rate of admission of Swiss travellers to hospital has been estimated to be 400 per 100 000 tourist-months and the rate for all accidents 500 per 100 000 tourist-months.6 The use of alcohol and other drugs is thought to promote various kinds of risk-taking behaviour.7 The risk of 354
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HIV infection through sexual contact and blood transfusion during international travel is also indicated by the fact that 1 traveller in 2500 acquires hepatitis B.5 An increased rate of HIV infection in international travellers has actually been observed among drug addicts,8 homosexual men9 and prostitutes.'°0" HIV transmission to international travellers otherwise at low risk has been documented anecdotally. 12.13 As for documenting the need for preventive education the clients of a travel clinic in England were found usually to underestimate the risk of HIV infection associated with travel to certain areas.4 The authors concluded that (a) many travellers with deficient knowledge about AIDS do not request information, (b) travellers who are members of ethnic minorities should be targetted for AIDS education and (c) condoms need to be made far more available to travellers.'9 We know of no other published study on this topic. Our goal was to document objectively the counselling needs of international travellers for the prevention of HIV infection. The study was specifically designed to (a) measure the perceived risk of HIV infection among international travellers consulting an immunization clinic before their departure, (b) measure these travellers' knowledge of the transmission and prevention of HIV infection abroad and (c) identify some of the determinants of this knowledge among the sociodemographic characteristics of the clients and among their beliefs about AIDS. LE ler F£VRIER 1992
Methods Questionnaire A self-administered questionnaire was used to obtain the following information: sociodemographic data, a description of the planned journey (destinations and lengths of stay), perceived risk of various infectious diseases during the trip, knowledge about the transmission and prevention of HIV infection while travelling, beliefs about AIDS (as defined by the Health Belief Model20-23), locus of control and presence of standard high-risk behaviour patterns for HIV infection. The statements used to measure the subjects' knowledge about HIV infection while travelling are listed in Appendix 1. Four statements (2, 3, 6 and 8) describe behaviours that would increase the risk of HIV infection, six (9, 11 and 13 through 16) describe behaviours that would decrease it, and six (1, 4, 5, 7, 10 and 12) describe behaviours that would have no effect on it. The respondent had to indicate whether performing each behaviour during the planned trip would increase, decrease or not affect his or her risk of HIV infection, regardless of the actual intention to carry it out. Some components of the Health Belief Model were measured with the use of published Likert-type scales of good reliability and validity20-22 that had been used in the general population of the same city.23 Briefly, the components measured were perceived severity of AIDS, perceived susceptibility to AIDS, perceived efficacy of measures to prevent AIDS and general health motivation. These components concern AIDS in general and do not refer to travel. We did not study components of the Health Belief Model relating to the perceived efficacy of, and barriers to, specific preventive actions, as there were too many possible actions. Locus of control (internal or external) was measured with the use of one of the two published versions of the Health Locus of Control scale.24 The high-risk behaviours, regardless of the respondents' travel plans, were determined by closed questions on (a) the sharing of unsterilized injection equipment, (b) sexual intercourse with people who share such equipment, (c) whether the respondents or their parents were born in a pattern II country, (d) sexual intercourse with people who were born in such a country, (e) sexual intercourse with a homosexual or bisexual man and (f) sexual intercourse with a person who possibly or certainly has HIV
infection. The French version of the questionnaire was pretested in a sample of 27 patients under the same conditions as those for the main study; several questions were then reworded and others added. FEBRUARY 1, 1992
Those parts that were not originally in English were then translated into it.
Data collection The study was carried out at a large travellers' immunization clinic operating in eastern Montreal. The questionnaire was handed out by the receptionist at the time of registration to all clients aged 18 to 50 years who visited the clinic from Oct. 2 to Dec. 21, 1989. A covering letter asked them to fill it out in the waiting room before being seen by the physician or nurse and to drop it in a closed box as soon as completed; it stressed that participation was optional and anonymous and that it would have no influence on care.
Results Of the 409 questionnaires distributed during the study period 331 (81%) were returned with sufficient information to be usable. The average age of the respondents was 37 years; 46% were men. The mother tongue was French for 89%, English for 5% and another language for 6%; 45% were married, 41% were single, and 14% were separated, divorced or widowed. The respondents were relatively well off: most had attended university (53%) or junior college (27%); 45% lived in households with a total annual income above $40 000 and 23% in households with an income from $30 000 to $40 000. Risk factors for HIV infection were present: 0.3% of the respondents had shared unsterilized injection equipment, 0.9% had had intercourse with a person who possibly or certainly had HIV infection, 1.2% originated from a pattern II country, 4.2% had had intercourse with people who had the previous two risk factors, and 7.3% (11.8% of the men and 3.4% of the women) had had intercourse with homosexual or bisexual men. In all, 11.8% (16.4% of the men and 7.8% of the women) had one or more risk factors. For 22% of the respondents the planned trip was the first one outside of Canada, the United States or Europe. The expected duration of the trip was less than 7 days for 10%, 7 to 13 days for 37%, 14 to 20 days for 18%, 21 to 27 days for 15% and 28 or more days for 20%. The main destination was Mexico, Central America or South America for 40%, Asia for 27%, the Caribbean for 13%, northern Africa for 1 1% and central or South Africa for 9%.
Perceived risk of disease The following proportions of respondents considered the risk of disease, if no preventive action were taken, to be higher during the planned trip than CAN MED ASSOC J 1992; 146 (3)
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if they stayed home for the same period: malaria 90%, diarrhea 88%, yellow fever 83%, typhoid fever 80%, hepatitis (type unspecified) 80%, cholera 72%, meningitis 46%, rabies 43%, AIDS 26% and gonorrhea 22%. A similar question specifically about HIV infection (but without mention of whether precautions would or would not be taken) resulted in 10% of the respondents stating that the risk would be much higher, 1 1% higher, 71% equal, 2% lower and 5% much lower. On the basis of reported prevalence rates of AIDS central Africa, South Africa and the Caribbean can be considered, all else being equal, to be highrisk regions for travellers;' 32% of the 68 respondents going to these regions considered themselves at higher risk of HIV infection, as compared with 17% of the 246 going elsewhere (X2 = 7.18, p < 0.007). HIV infection was the only disease that showed such a pattern: the perceived risk of all the other diseases was the same regardless of the destination. A multivariate logistic regression analysis showed that a perceived higher risk of HIV infection was associated mostly with the respondent's mother tongue being a language other than French, travelling to a highly endemic destination and a high perception of susceptibility to the disease (Table 1). Only 79 (24%) of the respondents stated that they had thought about taking precautions
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against HIV infection during the trip. These precautions were mostly the use of condoms (18% of the respondents), abstinence or monogamy (7%) and various steps to prevent blood transmission (4%). The consideration of precautions was associated with unmarried status, a perception that the risk of HIV infection would be higher on the trip than at home, a higher level of education and a long journey (Table 1). Locus of control seemed irrelevant.
Knowledge about HIV transmission
The proportion of the respondents who gave the "correct" answer follows each statement in Appendix 1. For most of the statements the majority of respondents gave the correct answer. Answers to some specific statements were of special interest. First, 14% of the respondents felt that avoiding all sexual contact would not decrease their risk of HIV infection. Second, about half stated that avoiding mosquito, dog and monkey bites would help to prevent HIV infection. Finally, asking to be transferred to a hospital in a developed country and (even more so) driving carefully were steps seldom considered to be relevant in preventing AIDS. This absence of concern about nosocomial infection makes it unlikely that the concern about animal bites was
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ihcntmntdeupet(n about treatment with contaminated equipment (instead of the bite itself).
abu
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Perceived efficacy of safer sex
bites) and least accurate when it referred to foreign situations seldom mentioned in the media (avoiding injections or unscreened blood transfusions). Unlike the perceived risk of typical tropical diseases, that of AIDS and gonorrhea was not considered to be higher abroad than at home by
Of the respondents 97% felt that unprotected intercourse with locals would increase their risk of most of the respondents; only 21% of the responAIDS and 86% that avoiding penetration would dents thought that the risk of AIDS would be decrease the risk. Condoms were felt to be effective increased by the planned journey. This may have by 79% if used with fellow travellers but by only 70% been due to underrecognized modes of transmission if used with locals. In fact, 46 (14%) of the respon- of HIV, especially blood borne; however, false dents stated that condoms would be effective with sources were identified as true about as frequently, tourists but not with locals, whereas only 16 (5%) felt and in any case the respondents' knowledge was the reverse would be true. This association was good in general. Perhaps the travellers were unable highly significant (X2 = 86.7, p < 0.00001). Through or unwilling to apply their knowledge about HIV multiple logistic regression analysis (using the same transmission to themselves. potential determinants as in the second column of The perceived risk of HIV infection during the Table 1) we found that the characteristics that planned trip was influenced by characteristics of the differentiated these 46 from the others were (a) a respondents (mother tongue and perceived susceptilow perceived efficacy of measures to prevent AIDS bility to AIDS in general) and of the trip (prevalence (p = 0.021), (b) a high perceived severity of AIDS of AIDS in the region to be visited). The consider(p = 0.046) and (c) a mother tongue other than ation of precautions against AIDS when planning the French (p = 0.042). journey was also influenced by characteristics of the respondents (level of education and marital status) and of the trip (duration and perceived risk of HIV Discussion infection). We propose the hypothesis that travellers tend The high response rate and the general similarity between the socioeconomic profile of the sample to look for the source of their risk of HIV infection and the known characteristics of clinic-using travel- in the local population and living conditions as well lers from Montreal25 support the representativeness as in their own behaviour. This is suggested by three of the study sample as people who consult an observations: first, the perceived risk of HIV infecimmunization clinic before leaving on a trip. How tion on the planned trip was related to the prevathe AIDS-related knowledge, beliefs and practices lence of the disease in the country of main destinadiffer from those of travellers who do not consult tion, whereas the perceived risk of other diseases was such a clinic is unknown. The data collection was not. Second, the main destination was a stronger carried out in fall and early winter; since it did not predictor of the perceived risk than were beliefs span a whole year a seasonal effect on destination about AIDS unrelated to travel. Third, condoms was likely; however, there remained a fair variety of were thought to be less effective with locals than destinations, and the effect of destination on the with fellow travel- lers; this was especially true of dependent variables of interest was taken into ac- travellers who considered AIDS as being particularly severe but difficult to prevent. Our interpretation is count in the multivariate analyses. Since there was no published study of this kind that for some travellers, especially those who already when we planned ours, we had to create some parts feel particularly threatened by AIDS, the presence of of the questionnaire, especially the items in Appen- "other people," the locals, not only increases the dix 1. We refrained from interpreting differences in perceived threat of AIDS but also provides them the responses that could have been due to discrepan- with an object on which to project the risk. This cies in the formulation of some of the statements. may be one manifestation of a more general pattern: Also, differences between the French and English there is evidence that people from Montreal who versions of the questionnaire could not explain the feel particularly threatened by AIDS tend to higher perceived risk of AIDS reported by nonfran- favour coercive measures against specific groups cophones, since most of these used the French at home.23 We believe that the following suggestions can be version. We have no explanation for this difference drawn from this study. in perceived risk. Knowledge was most accurate when it referred * Travellers should be taught not to underestito familiar behaviours (sexual transmission and precautions), less accurate when it referred to foreign mate the risk of sexually transmitted diseases associsituations having received media coverage (animal ated with travelling. FEBRUARY 1, 1992
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* Some actions that create a risk of HIV transmission but are not considered to do so by most travellers (the use of unsterilized injection equipment, the receipt of unscreened blood transfusions and dangerous driving) should be brought to their attention. * Some myths about HIV transmission (through mosquito and animal bites) need to be dispelled.
* It should be emphasized that the risk of HIV infection depends far more on the traveller's behaviour than on the living conditions or the local
population. * The applicability of some familiar precautions (abstinence and the use of condoms) to unfamiliar situations should be reinforced. * The possibility of age, educational and cultural differences in the perception of risk and of the effectiveness of precautions should be borne in mind. We thank the clinic staff and Dr. Julio Soto for helping with the data collection and the interpretation of the results.
References
8. Bisset C, Jones G, Davidson J et al: Mobility of injection drug users and transmission of HIV [C]. Lancet 1989; 2: 44 9. Merino N, Sanchez RL, Munoz A et al: HIV-1, sexual practices, and contact with foreigners in homosexual men in Colombia, South America. J Acquir Immune Defic Syndr 1990; 3: 330-334
10. Koenig ER: International prostitutes and transmission of HIV. Lancet 1989; 1: 782-783 11. Dan M, Rock M, Bar-Shany S: Prevalence of antibodies to human immunodeficiency virus among intravenous drug users in Israel - association with travel abroad. Int J Epidemiol 1989; 18: 239-241
12. Vittecoq D, May T, Roue RT et al: Acquired immunodeficiency syndrome after travelling in Africa: an epidemiological study in seventeen Caucasian patients. Lancet 1987; 1: 612614 13. Hill DR: HIV infection following motor vehicle trauma in Central Africa. JAMA 1989; 261: 3282-3283 14. Lange WR, Dax EM: HIV infection and international travel. Am Fam Physician 1987; 36: 197-204 15. Gras C, Jeandel P, Cuisinier-Raynal JC et al: Le risque du SIDA pour le voyageur occasionnel en Afrique. Med Trop (Mars) 1987; 47: 293-295 16. Lepage P, Van de Perre P: Nosocomial transmission of HIV in Africa: What tribute is paid to contaminated blood transfusions and medical injections? Infect Control Hosp Epidemiol 1988; 9: 200-203
17. Gilmore N, Orkin AJ, Duckett M et al: International travel and AIDS. AIDS 1989; 3 (suppl 1): S225-S230 18. Von Reyn CF, Mann JM, Chin J: International travel and HIV infection. Bull WHO 1990; 68: 251-259 19. Porter JDH, Phillips-Howard PA, Behrens RH: AIDS awareness among travellers. Travel Med Int 1991; 9: 28-32
1. Mann JM, Chin J, Piot P et al: The international epidemiology of AIDS. Sci Am 1988; 259 (4) 82-89
2. HI V/AIDS Surveillance (year-end ed), Division of HIV/AIDS, Centers for Disease Control, US Dept of Health and Human Services, Atlanta, 1990 3. Ellis EJ: HIV infection and foreign travel [C]. BMJ 1990; 301:
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20. Jette AM, Cummings KM, Brock BM et al: The structure and reliability of health belief indices. Health Serv Res 1981; 16: 81-98
21. Maiman LA, Becker MH, Kirscht JP et al: Scales for measuring health belief dimensions: a test of predictive value, internal consistency, and relationships among beliefs. Health Educ Monogr 1977; 5: 215-231
4. Behrens RH, Porter JDH: HIV infection and foreign travel [C]. Ibid: 1217
22. Champion VL: Instrument development for health belief model constructs. Adv Nurs Sci 1984; 6: 73-85
5. Steffen R: Risks of hepatitis B for travellers. Vaccine 1990; 3 (suppl): S3 1-S32
23. Allard R: Beliefs about AIDS as determinants of preventive practices and of support for coercive measures. Am J Public Health 1989; 79: 448-452
6. Steffen R: Health risks for short-term travelers. In Steffen R, Lobel HO, Haworth J et al (eds): Travel Medicine, Springer, Zurich, 1989: 27-36
24. Strudler-Waliston B, Wallston KA, Kaplan GD et al: Development and validation of the Health Locus of Control (HLC) scale. J Consult Clin Psychol 1976; 44: 580-585
7. Lange WR, McCune BA: Substance abuse and international travel. Adv Alcohol Subst Abuse 1989; 8 (2): 37-51
25. Allard R: Problems in adequately immunizing international travellers. Can MedAssoc J 1983; 128: 40-41
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Conferences continuedfrom page 337 Singapore Scientific Meeting and Medical Education Seminar / Une Reunion scientifique et un Seminaire de formation medicale a Singapour Oct. 30-Nov. 6, 1992 / du 30 oct. au 6 nov. 1992 Cosponsored by the Singapore Medical Association and the CMA / coparrainees par l'Association medicale singapourienne et l'AMC. Singapore Pat Herr, Conference Planners International, 7711 Bonhomme Ave., St. Louis, MO 63105-1961; 1-800-234-6900, ext. 382, fax (314) 727-9354
Mar. 23, 1992: Advanced Skills of Group Work: an Interactional Approach Royal Ottawa Hospital Education Services, Royal Ottawa Hospital, 1145 Carling Ave., Ottawa, ON KlZ 7K4; (613) 724-6521 or 724-6525 Mar. 23-24,1992: Kellogg Nutrition Symposium Metro Toronto Convention Centre Liz Routliffe, 6700 Finch Ave. W, Etobicoke, ON M9W 5P2; (416) 675-5236 May 12-15, 1992: Catholic Health Association of Canada Annual Convention Holiday Inn, Winnipeg Freda Fraser, director of communications, Catholic Health Association of Canada, 1247 Kilborn Pl., Ottawa, ON KIH 6K9; (613) 731-7148, fax (613) 731-7797
Other Conferences * Conferences diverses Mar. 13-14, 1992: Gender Identity and Development in Childhood and Adolescence Two-Day International Conference St. George's Hospital, London Philippa Weitz, Conference Unit, Department of Mental Health Sciences, St. George's Hospital Medical School, Cranmer Terrace, London SW 17 ORE, England; telephone 011-44-1-081-672-9944, ext. 55534, fax 011-44-1-081-767-4696 FEBRUARY 1, 1992
Oct. 18-21, 1992: ITCH '92 - Building Partnerships in Community Health Through Applied Technology (sponsored by the British Columbia Ministry of Health, the University of Victoria and the Canadian Public Health Association) Victoria Conference Centre Larry Scott, chairperson, ITCH '92, School of Health Information Science, University of Victoria, PO Box 1700, Victoria, BC V8W 2Y2; (604) 721-8575, fax (604) 721-1457 CAN MED ASSOC J 1992; 146 (3)
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