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Journal of Immigrant Health, Vol. 3, No. 1, 2001
Adherence to Travel Health Guidelines: The Experience of Nigerian Immigrants in Houston, Texas Lori Leonard1,3 and Mark VanLandingham 2
The objective of this study was to learn about the travel health practices of Nigerians in Houston, Texas, and to describe factors affecting adherence to recommendations for the prevention of malaria, typhoid, and hepatitis A set forth by the Centers for Disease Control and Prevention (CDC). Data were collected through focus group discussions and one-onone interviews with travelers and health care providers. Data collection and analysis relied on a process-based framework that included questions about health and health-maintenance strategies before, during, and after travel. The cost of travel health services and the availability of vaccines and medications were important structural barriers to adherence. Perceptions of individual susceptibility and disease severity varied across the infections of interest. Travelers perceive themselves to be at risk for malaria, but are generally not concerned about its consequences. A notable exception is the fear of becoming symptomatic post-travel in the United States. Typhoid was less salient than malaria, and few had heard of or worried about acquiring hepatitis A. Stigma associated with the acquisition of travel-related conditions and the perceived incompetence of physicians to treat illnesses related to overseas travel, and malaria in particular, also affect preventive decisions and strategies. The results of the study have broad relevance for the traveling public and for programs and services that seek to improve travel health and travel health care. KEY WORDS: travel health; Nigeria; malaria; typhoid; hepatitis A.
NATHAN
were spent getting a GED and a college diploma and working two jobs to afford out-of-state tuition. During those early years he rarely went home to Nigeria; for the past three he has been able to travel regularly, and estimates that he has made a total of 10 trips home since coming to this country. Health concerns are not foremost on Nathan’s mind when he travels. His health-related worries are limited to two problems: malaria and the quality of the drinking water. “The only thing you suffer in Nigeria is malaria. That’s all. Another one is carelessness. It makes you catch typhoid. If you just go drink anything you see, it can cause typhoid.” Nathan got malaria during two of his approximately ten visits home, and as a result of those experiences, he now “work[s] hard to protect [him]self” and doesn’t think he’ll get it again. On Sundays, for two to three weeks before he travels, he takes what he calls “Sunday-Sunday” medicine— “if[he] remember[s].” He continues taking the tablets,
Nathan talked to us over the front seat of his taxi cab as he waited in a long queue of drivers at one of Houston’s airports. He is a frequent traveler to Nigeria, going to see his mother and to remit funds for the education of his nieces and nephews every four months or so. In fact, when we spoke he was preparing his next visit. But it hasn’t always been that way. Nathan has lived in Houston for 24 years, 16 of which 1 Department
of International Health, Johns Hopkins University, School of Public Health, Baltimore, Maryland. 2 Department of International Health and Development, Tulane University, School of Public Health, New Orleans, Louisiana. 3 Author to whom correspondence should be addressed at Johns Hopkins University, School of Public Health, Department of International Health, 615 N. Wolfe Street, Room 7142, Baltimore, Maryland 21205. Telephone: (410) 502-7396. Fax: (410) 502-6733; e-mail:
[email protected].
31 C 2001 Plenum Publishing Corporation 1096-4045/01/0100-0031$19.50/0 °
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32 that he got from a pharmacist in Nigeria, for three weeks after he comes back to Houston. On the advice of a friend, he also buys a packet of Halfan each time he goes to Nigeria and brings it back with him in case the “Sunday–Sunday” medicine doesn’t work. Nathan’s regimen has developed over time and is a product of personal experience. The first time he came down with malaria, on his very first return trip, he was in Nigeria, and tried traditional medicine that he had used as a child. When that didn’t work— “because I have Americanized myself”—he went to a doctor who gave him a shot of chloroquine. The chloroquine caused such severe itching that Nathan went back to the doctor saying, “I’m not taking it again. I’d rather die with the malaria.” His second bout of malaria, following a subsequent trip, occurred in Houston, and worried friends brought him Halfan and urged him to take it. He liked the Halfan because it didn’t cause him to itch, and since then, he has carried a supply with him; a packet, that he has now had for two years (“I haven’t caught malaria and so it stays”), is in his “luggage” on the front seat of the cab. He is a bit unsure as to how it should be taken, though he thinks the pills are taken every 4 hrs—“one or two, somehow.” Although Nathan has not had typhoid or suffered from diarrhea or stomach problems, he is careful about the water he drinks, buying bottled water in both Nigeria and Houston. He has never heard of hepatitis. When asked what else he does to stay healthy, Nathan responded, “Just get on KLM and fly. You’ll be excited to get home, OK?”
THERESA Theresa is a 34-year-old, college-educated mother of three who traveled to Nigeria to see her family and friends seven months before she attended one of our focus group discussions. As part of her pre-travel preparations, she called the city health department to get information about immunizations for her 11-month old daughter. A worker at the health department told her about the CDC’s hotline and suggested that she call to get the latest recommendations for international travelers. From the hotline, Theresa requested information on a number of topics, including malaria and yellow fever. She said, “I wanted to know about the facts, the real things. I’m not the kind that restricts myself to anything . . . I wanted to know about plenty of things.”
Leonard and VanLandingham Toward the end of the group discussion, Theresa acknowledged that, despite receiving useful information from the hotline, she didn’t follow it. Cost was a major barrier. “Well, [I didn’t follow the advice] from here, because the pills were too expensive. I think $90 for five. So I decided to go back to Nigeria and just get Fansidar. It’s cheaper.” Theresa judged that her daughter would not be at risk for infection with typhoid since she was still breastfeeding, and decided to forgo immunization for yellow fever. While it was required for entry into neighboring Togo, which Theresa also intended to visit, yellow fever vaccination was not required by the Nigerian government, and she planned to enter Togo by an overland route— not through the airport—where she felt the scrutiny would be less intense. While Nathan and Theresa differ in terms of their backgrounds and their approaches to health maintenance while traveling abroad, they face a similar array of concerns and constraints. This paper presents the findings from an assessment of the travelrelated health practices of Nigerian immigrants living in Houston, Texas. The objectives of the study were twofold. We wanted to learn what Nigerian travelers, like Nathan and Theresa, do to prevent malaria, typhoid, and hepatitis A when they return home, and we wanted to identify barriers to following the recommendations (see Appendix A) published by the Centers for Disease Control and Prevention (CDC) for preventing these three travel-related infections. The decision to focus on the practices and experiences of Nigerians was determined partly by the size and mobility of the Nigerian population in Houston, where the data were collected. There is no official count of the Nigerian population in the city, but our informants provided estimates that ranged from 20,000 to 50,000. Most of those 18 years of age and older are first-generation immigrants, and many retain strong ties with Nigeria and travel home frequently. The focus on men and women of Nigerian origin was also based on the prevalence of malaria, typhoid, and hepatitis A in sub-Saharan Africa. Globally, malaria is becoming increasingly salient due to more frequent international travel and the development and spread of drug-resistance. In the United States, reported cases of malaria increased 15% between 1994 and 1995, with 44.8% of the 1,167 reported cases acquired in Africa (1). This is the largest number of malaria cases reported in the United States since 1980, and the largest number of civilian cases ever reported. However, the impact of malaria remains greatest in sub-Saharan Africa; in 1998, 87.1% of all
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Adherence to Travel Health Guidelines incident cases and 86.5% of the estimated three million deaths attributable to malaria occurred in this region of the world (1–2). The risk of acquiring malaria is estimated to range from 1 in 50 to 1 in 100 among travelers to the region (3). Hepatitis A is endemic in most parts of the developing world, including Africa, and is the most common vaccine-preventable infection acquired by international travelers. The risk of infection varies with length of stay, living conditions, and local incidence rates; however, it is estimated at three to six cases per 1,000 unprotected travelers who stay in a developing region for a one-month period (3–4). Typhoid fever is less common, affecting approximately 16 million people worldwide (4), including 2.6 per 1 million travelers to affected areas (4–5). Slightly more than 70% of the 450 cases of typhoid fever diagnosed in the United States each year are acquired through international travel (5). Though the stories of Nathan and Theresa do not represent the experiences of all Nigerians who travel home, they illustrate a number of themes relevant to the prevention of infectious diseases among travelers. The findings from this study, while drawn from interviews with Nigerian travelers and their health care providers, have broad relevance to the traveling public. They can be used to develop and improve travel health programs with the aim of preventing infectious disease.
The Experience of the Traveler: An Organizing Framework Why are travelers like Nathan and Theresa not adequately protected against malaria, typhoid, hepatitis A, and other travel-related health threats? What would enhance the chances that they are optimally protected in the future? We took an empirical approach in answering these questions, and organized our interviews around travelers’ experiences before, during, and after travel. These include: (1) pre-travel health concerns; (2) factors influencing the decision to access preventive care and services; (3) quality of pretravel health care and services; (4) in-country precautions taken to prevent infections; and (5) post-travel treatment and care of illnesses. The process-based framework used in this study highlights different levels and types of barriers to the attainment of health. The organizing framework clearly acknowledges the role individual travelers play in preventing health problems. To prevent cases
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33 of malaria, typhoid, and hepatitis A, travelers need to be aware of the risks to their health, judge them to be important, and have accurate knowledge about how to prevent infection. Travelers also have to make the decision to seek medical care prior to travel in order to obtain vaccinations and prescriptions. Yet knowledgeable and motivated individuals may still be at risk for travel-related health problems if the services they need are unavailable or inaccessible. Access is dependent upon the availability of travel health clinics or physicians specializing in travel health in the area and the recommended medications or vaccines, adequate insurance coverage, and affordable services. These and other structural impediments to obtaining optimal, or even adequate, care are real and relevant. The third domain included in the framework relates to patient-provider interactions and the quality of pre-travel advice and care provided. Of interest here is whether physicians, in particular, are aware of the latest travel health recommendations and provide accurate and up-to-date advice and information to their patients. From our interviews we elicited information about the comprehensiveness of the travel health advice provided to patients, the range of therapies or prevention strategies presented to travelers as potential protective options, and the use of referrals for appropriate care and services, including information about where to obtain vaccinations and prescription medications. The steps travelers take while in-country to avoid malaria, typhoid, and hepatitis A make up the fourth domain of experience that we examined. In some instances these actions may supplement pre-travel precautions taken prior to leaving the United States, while in others they may serve as the sole means of preventing disease. Included in this category are hygienic measures (e.g., hand washing), dietary precautions, the use of medications, and behavioral accommodations such as using bed nets or mosquito repellant. Finally, we examined the experiences of travelers who fall sick, both in Nigeria and, post-travel, in the United States. We asked about travelers’ perceptions of the quality of care they received, including its appropriateness and timeliness. Another critical element of experience relates to the reception of patients with travel-related conditions at health care facilities, and patients’ perceptions of the attitudes of health care personnel toward them. While these domains of experience are often encountered sequentially in the context of a specific
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34 trip, travelers’ past experiences obviously color current and future practice. Over time the system functions as a feedback loop, and experiences in one domain influence practice in the others. Therefore, the organizing framework we present does not describe a linear pathway to the prevention of infection, and no single domain serves as the fulcrum for prevention. The implications for public health programs are clear: prevention will be most effective if attention is devoted to each of the five domains of experience included in the organizing framework. Methods of Data Collection and Analysis Focus group discussions, one-on-one semistructured interviews with travelers, and semistructured key informant interviews with health personnel (physicians and pharmacists) serving the Nigerian community were conducted between June and December of 1999. Travelers included men and women who had visited Nigeria within the last year, those who were planning to travel to Nigeria in the coming year, and those who had fallen sick during a previous trip. The researchers’ personal contacts and local organizations and agencies serving the Nigerian community recruited most of the study participants through their networks. Chain or snowball sampling was also used, as those who participated in the focus groups and interviews provided us with contact information for other potential informants. We also posted flyers advertising the study in local businesses, including African markets, travel agencies, and beauty supply stores; however, the posted flyers yielded no telephone inquiries or informants. We audio-taped and transcribed three focus group discussions that ranged in size from four to ten participants, two one-on-one interviews with travelers, and seven key informant interviews with physicians and pharmacists. We also conducted 4 additional focus group discussions and numerous less formal conversations with members of the Nigerian community that were not audio-taped or transcribed, but for which we took hand-written notes. Most travelers were interviewed as part of a focus group discussion; however, in cases where focus groups were logistically complicated (e.g., in interviewing taxi cab drivers in queue at the local airports) informants were interviewed individually. Data were collected in a variety of settings, including private homes, restaurants, informants’ offices, local airports, and conference rooms of hotels or universities reserved for this purpose.
Leonard and VanLandingham Separate but closely related protocols were used to guide the focus group discussions, one-on-one interviews with travelers, and key informant interviews. Within the process-based framework, travelers were queried about their travel history and objectives, awareness of travel-related threats to their health, beliefs about travel and health, information networks, precautionary measures taken, and treatment received, and were asked to provide detailed information on some of these themes as they relate to their first and last trips to Nigeria. Health care providers were asked to describe the nature of their practice, and to comment on the travel-related health advice they provide to their clients and the questions and requests they hear. All respondents were asked about sources of information for news and for health news and information more specifically, and were asked to provide suggestions for interventions. The authors independently coded each transcript using NUDIST (6) and The Ethnograph (7), both qualitative software analysis packages, and derived a common set of codes for classification of the data. A draft version of this paper was sent to interested informants for comments and clarifications as a form of member checking (8), and the feedback provided was added to the database. RESULTS Findings from the study are organized according to the process-based framework that guided this inquiry. Pre-Travel Health Concerns Perceived Threats to Health When asked what they worry about when they travel to Nigeria, travelers expressed a number of concerns, ranging from physical security to air pollution. However, threats to health arose early and frequently. (Informants knew that the study was related to health, which may have stimulated some of the responses. However, the fact that informants discussed a wide variety of worries makes us confident that they were considering the question quite broadly.) Concerns about malaria and water were the most prominent. The focus on malaria vis-a-vis other diseases was pronounced. Our interview guides first address travelrelated health generally, and then give equal weight to concerns and strategies regarding malaria, typhoid, and hepatitis A. In spite of this, travelers focused on
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Adherence to Travel Health Guidelines malaria, sometimes despite our efforts to change the subject to the other two diseases. Within the traveler transcripts, there were 2171 lines of text devoted to malaria, 777 to typhoid, and 79 to hepatitis A. Our medical key informants were aware of the preoccupation with malaria. One physician reported the travelhealth concerns of her patients as “Malaria, malaria, malaria, and malaria. And diarrhea.” The relative salience of malaria for study participants was due to several factors. One is a heightened sense of perceived risk to malaria in comparison to the other diseases discussed. Helen:
I wouldn’t want to take the typhoid vaccine. Moderator: Because? Helen: I don’t feel I’ll ever be in—How do I put it. That doesn’t really seem like a danger to me, because I think I know exactly what to do and I’m not scared about it. But if there is anything like a malaria vaccine. . . .
Another factor, related to the first, is the relative lack of information about and experience with typhoid and hepatitis A: Moderator: Right. We’ll talk about prevention in just a second. One thing that nobody mentioned was hepatitis A. James: I don’t know anything about it. I don’t know.
Apart from physicians, no spontaneous mention was made of hepatitis A as a travel health concern, and no traveler reported first-hand experience with hepatitis A. When queried about it directly, most respondents said they hadn’t heard of it, that no one had mentioned it to them in the context of travel, or that it wasn’t common. A pharmacy student at a local university said she hadn’t included hepatitis A in her list of pre-travel worries “because I’ve never really had any incident or anybody in my close family . . . have had anybody who’s come out with that.”
Travel Health-Related Knowledge Travelers were far more knowledgeable about malaria than they were about either typhoid or hepatitis. The role of the mosquito in transmitting malaria was well-known, and the signs and symptoms of infection were also widely known and quickly recited. This is not to say, however, that malaria-related knowledge is either universal or perfect. Multiple respondents indicated that immunity to malaria (as well as to other
35 travel-related problems) is built up through frequent travel. Others said that in its chronic state malaria turns into yellow fever. Some took curative doses of drugs, such as Fansidar, upon arriving in Nigeria and again upon leaving the country with the belief that this would protect them from contracting malaria for an extended (e.g., up to 4 months) period of time. The vast majority of respondents did not know how hepatitis A was transmitted. One informant said he thought it might be “transferred” from mosquitoes, but most did not hazard guesses. By contrast, the modes of transmission for typhoid were generally well-known, with tainted water cited most frequently. Informants with friends or family members who had suffered from typhoid described the symptoms as being similar to malaria, or in general terms: “it weakens your body,” and you “lose weight.” Both infections were considered rare. Physicians noted that travelrelated cases of hepatitis A affected the “odd person” or were seen only “now and again.” Travelers believed that typhoid was also relatively rare; only one that we interviewed had been diagnosed with it. (The one focus group participant who was diagnosed with typhoid and hospitalized in Houston upon his return from Nigeria believes he got it from the “rust” under a soft-drink bottle-top that he failed to wipe off.) Physicians, too, rarely encountered cases of typhoid in Houston. One remembered only a single case, diagnosed at a local hospital where he was in training, and characterized it as “a very big deal.” Perceived Severity of Travel-Related Diseases Travelers acknowledged that malaria is something they think, and even “worry,” about, but where travelers’ perceived susceptibility to malaria was generally high, the perceived severity of contracting malaria was not. Typhoid, when mentioned, was considered to be more life-threatening than malaria. Many downplayed the significance of getting malaria by describing it as commonplace, “normal,” or “expected.” Most had first-hand experience of malaria, and some had extensive histories. Malaria was often portrayed as a part of life and of the environment (“it’s been there a long time”) in Nigeria, and as a routine or habitual problem that respondents knew how to deal with. Thus, while malaria was a potentially undesirable consequence of travel, it was not necessarily feared or protected against: I think the westerners are scared of malaria. We’re not scared of malaria and never were . . . because
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Leonard and VanLandingham we’ve been immune to malaria. Anybody can survive from malaria any time.
old kid with her. So she just told me that she still has some medication, medicine, and to take it.
It’s like a flu. I mean, when I was in Nigeria, I had malaria three or four times in a month. It’s normal. To me, it’s normal.
So I went [to the pharmacy]. He told me how much I was supposed to take to get myself ready to go to Nigeria.
. . . I don’t think the incidence of malaria is such a big problem generally for the simple reason that people know just how to take care of it without letting it be a problem.
Deciding Whether to Access Pre-Travel Care Sources of Pre-Travel Information and Health Care A limited number of sources of pre-travel health care in Houston were cited by participants in this study. These included the public health clinics that provide, in principle, vaccinations required for international travel (yellow fever, typhoid, and cholera) as well as a select number of Nigerian physicians whose names surfaced repeatedly. Even though physicians were named by many travelers as key sources of information for travel and travel-related precautions, physicians themselves speculated that only 10–20% of Nigerians returning home consulted a medical professional pre-travel. Many of our physician key informants related conversations they had with friends, family members, and personal acquaintances who called or contacted them for information, advice, or reassurance, often outside the context of a patient–provider encounter in a medical office or health-care setting: When a few family friends are going, to just kind of call to find out whether it is the right thing to do . . . “Just remind me again when are we supposed to start this thing?”
Yet, preventive advice or information comes through a variety of networks, many of which are unrelated to the health care system. Travelers reported that other key sources of information and advice include friends and family members, embassies, company manuals and documents, the CDC’s travelers’ hotline, and pharmacists: Here, believe me. I just get on a plane. I just get on a plane . . . I have never called anybody . . . I know what I’m going to encounter there . . . I don’t talk to anybody unless it’s a travel agent. Most of it . . . if you don’t get sick, mostly we don’t ask . . . [My aunt] just said . . . because she went last year and she had to take precautions because she had a 4-year
Health-Care Seeking and Type of Illness A clear gradation is apparent in both the salience and the amount of information that travelers have regarding the three infectious diseases of interest in this study, and in preventative action taken by travelers. This differential in accessing pre-travel care by type of illness was summarized most succinctly by one of the physicians interviewed: But I learned the Nigerian public is becoming more and more aware of different malaria prophylaxes, because they don’t want to come back sick with malaria. But whether they have knowledge of typhoid or typhoid vaccine, they do not. Hepatitis—not at all.
Many thought that Nigerian travelers were aware of the need to take prophylactic measures for malaria, and obtain medication either in the United States prior to travel or upon arrival in Nigeria. Most Nigerians know that when they get to Nigeria, [malaria] is a special problem . . . They know what to do.
However, they also indicated that knowledge about what to do did not always translate into action. Nearly all of them know that they have to take something, but do they? They don’t.
Perceived Barriers to Accessing Pre-Travel Health Care Cost. The minority of travelers who obtained pre-travel health advice often reported that they didn’t follow the recommendations they received. Cost was the most obvious and salient barrier, both to seeking advice in the first place and to following it once received. One physician estimated that 50% of travelers who called to inquire about the cost of an office visit were unable to afford it. In Theresa’s case, the malaria prophylaxis recommended on the CDC’s travelers’ hotline was too expensive; she opted instead to buy medication upon arrival in Nigeria. Many travelers are uninsured or have plans that don’t cover office visits, immunizations, or prescriptions related to overseas travel. Out-of-pocket expenses for health
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Adherence to Travel Health Guidelines care compete with other costs related to travel, and sometimes tip the scales: It’s expensive. And that’s enough to discourage some people. If you’re traveling and paying for the airfare, and then you’ll spend some more money when you get there. That’s a lot of money to . . . Unless you’re really aware of the problems that you’re going to have if you don’t take the precautions, you may say, ‘No.’ You may let it go.
The cost of prophylactic medications is seen as particularly difficult to justify given the availability of the same, or similar, drugs in Nigeria for a fraction of the price. A student who found the cost of malaria prophylaxis in Houston prohibitive reported buying the same medication from a pharmacy in Nigeria for one tenth of the price, and a pharmacist estimated that Larium was about 45 times more expensive in the United States than in Nigeria. Availability. The experiences of travelers and their health care providers suggest that obtaining adequate protection is not only costly, but timeconsuming, and requires patience and perseverance. Travelers have to contend with vaccine shortages and with pharmacies that don’t stock their prescriptions or formulations. Few pharmacies, for example, carry Lariam; this and other malaria prophylaxes often have to be ordered. A physician described difficulty in finding chloroquine in suspension (liquid) form for her son: . . . It took the pediatrician a long time to get this medication. I was surprised. I mean, there she was. She was like, ‘OK, chloroquine phosphate,’ and I went to Walgreens and they have the big book and it’s not there. I mean, then they look for something else. ‘Oh, we don’t prepare it.’ And I’m like ‘We need this thing’ . . . Then [the pediatrician] found out that . . . there was this pharmacist . . . that mixed this and I had to go all the way to [the other end of town] and get him to mix it for my son . . . So it wasn’t easy . . . So when we went home the last time, I just got the chloroquine from there. That’s what I did, and with the expiration date 2001, and then brought it back. And that’s what I did with my son. I’m not going to take that chance, you know. I was actually just passing time, and you can’t keep traveling all the way from [one end of town to the other] to try and get it.
Another recounted the difficulties her patients have in getting properly vaccinated and her frustration with the city health department’s failure to provide, on a consistent basis, access to immunizations at a reasonable cost: We double-check [the patient’s] immunization, and then we’ll send them to the health department, the in-
37 ternational one, for the yellow fever, typhoid. And it used to be very easy. You go to [the city clinic] once a week and get all of that. At a reasonable fee. But lately, it’s almost impossible. . . . They’re not stocking it. They don’t have it. And when they go to private group doctors who have it, it’s over $500 . . . And many are not getting it . . . That’s my pet-peeve. Because it should be cheap, because all of us are going to get sick . . . They didn’t have it. And this is not a question of one month, or two months—no. This has been going on for a long time.
Four months after this interview, the city health department clinics reported that they were still out of typhoid vaccine and would not have it in stock until it was approved by the city council. Normally, the city provides typhoid vaccine for just over $20US; private clinics, where patients are referred in the interim, quoted prices that are at least double, and in some cases many times the city’s price. Common were stories of patients who had searched, without success, for typhoid vaccine in multiple locations throughout the city. In response to the frequent shortages of vaccine in the public sector, a pharmacist we interviewed began carrying oral pills. In some cases, receipt of optimal pre-travel care requires travelers to access services at least several weeks before their scheduled departure. Travelers often seek preventive care too late (physicians report that the bulk of their patients schedule office visits less than one week pre-travel and some report sameday calls); in the long list of pre-travel preparations, the receipt of health care is “down at the bottom.” The lack of availability of vaccines and prophylactic medications only compounds the timing problem. Side Effects. Few travelers reported side-effects associated with vaccines or malaria prophylaxis, and only rarely did they report that these experiences impeded use of preventive measures. When discussing malaria prevention, itching was the only adverse reaction mentioned, and this was associated exclusively with the use of chloroquine. One woman was hesitant to use insect repellant because of possible side-effects, saying “nobody really knows if it has side effects or anything.” However, curative doses of malaria medications, taken by some to prevent infection, were reported to cause “headaches” and “drowsiness.” Physicians reported side-effects associated with doxycycline (burning or itching and gastrointestinal complaints) and with vaccines (cholera injections “hurt” and typhoid vaccine can “make you sick”), but respondents, most of whom had no experience with these treatments, did not.
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Protection for Children Those traveling with children tend to be more likely to seek pre-travel health care, at least for their children. Theresa was not atypical in this regard; she initially sought information through the city health department, and later through the CDC’s travelers’ hotline, because she wanted to be sure that her 11month-old daughter was properly immunized. Physicians were most likely to receive calls from travelers worried about the health of their children, and individuals in this study who intended to travel and planned to seek pre-travel advice were parents who wanted to know how to protect their children: Well, I plan on talking to somebody before [traveling]. I don’t know what I should give them, because of the age. And then I’m going to go with a lot of the bug repellents, so everybody’s safe. You know, they’re kind of like if they are bringing their kids to visit their grandparents for the first time, and, ‘What do we do to prevent it?’ because they do know it’s a problem when they get there . . . The impression I get is they are a lot more protective of the kids because these kids have, you know, they fall sick or anything they’re like ‘Where do we go? What do we do?’ And if you’ve been out of the system for a while, it might be difficult like trying to get health care immediately at that point. So for kids especially, you try to take a lot of things from here. If you travel with your kids, you go with the medications ready. You go with things.
Children heighten travelers’ awareness of potential health threats and sometimes serve as an important gateway to travel-related health care for adults. A pediatrician we interviewed indicated that she takes the opportunity of an office visit for the child to ask parents about the precautions they are taking for themselves: They treat [kids] better. As far as the prophylaxis is concerned, yes definitely. I sometimes have to tell them, because many adults don’t have doctors. . . . I ask them. “Do you want me to prescribe you one?”
Yet, limited resources sometimes compel travelers to make choices. Some clients fill only part of their prescription, buying fewer pills than would be required for optimal protection, at times indicating that they intend to buy the complement upon arrival in Nigeria. In other cases, priority is given to ensuring that children are adequately protected, while coverage for adults is dropped: So whenever a child is involved really there is always, there’s an incentive to make sure everyone is
protected kind of thing . . . Some of the ones that go home without [children], that are kind of nonchalant about taking anything, are those that are going by themselves. Mostly men. . . . Or I actually have some people bring in their prescriptions and say ‘Well, I know the prescription is for all of us, but why don’t you just give me the prescription for the children . . . I can manage. You know, just make sure the children are OK.’
Required Immunizations as a Gateway to Care Required immunizations provide another opportunity for travelers to interface with health care providers, although these occasions are becoming increasingly rare. Yellow fever vaccine is not required (but is recommended) to gain entry into Nigeria from the United States; however, physicians report that not all travelers are aware that vaccination is no longer mandatory, and fear that as this information spreads, “nobody’s going to go out of their way to spend $70–$80 to get those things.” In the meantime, physicians sometimes capitalize on these moments to provide additional travel–health advice and information: I say, “Listen my friend. Are you going home?” “Yes.” “You need to start [malaria prophylaxis].” “I’m leaving tomorrow.” I say, “Well, you can start it today . . . it would have been nice if you started a week or two ago, but you can start it today.”
Quality of Pre-Travel Care A handful of physicians and pharmacists in Houston’s Nigerian community are trusted sources for travel health information, advice, and care. Those we talked to were generally well-informed about the types of health hazards confronting travelers to Nigeria. By contrast, travelers are skeptical about the knowledge and experience of most health care professionals who “read about [malaria] in a book” and for whom travel health is “a low interest and a low priority.” In spite of this overall high level of expertise and patient satisfaction, our interviews identified a few shortcomings. Physician Inexperience with Some Health Threats Physicians had little experience giving hepatitis A vaccine (most did not mention either hepatitis A or the availability of a vaccine to their patients), and many were not as aware of the specific features of
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Adherence to Travel Health Guidelines the disease or the precautions travelers should take as they were for the other diseases. Some physicians suggested that they omit mention of hepatitis A when advising their patients because the same precautions urged for the prevention of typhoid would serve to protect travelers from hepatitis A. Others thought that their patients were likely to have been exposed to hepatitis A, or reported that they never saw it in clinical practice and therefore thought it was quite uncommon. Inconsistent Recommendations In most cases, the physicians interviewed for this study recommended Larium to their patients for the prevention of malaria. However, there were exceptions. Two physicians noted that Larium is not effective for all types of malaria parasites, although one continues to recommend it to his patients. Another preferred to reserve Larium for treatment purposes and to prescribe a twice-weekly 500 mg dose of chloroquine—his personal regimen—rather than the usual weekly dose. The Impact of Cost on Quality of Care Cost looms large not only in patients’ decisions to purchase prophylaxis, but also in their (and their providers’) decisions about which course of preventive treatment to pursue. In particular, a problem most physicians faced was patient complaints about the cost of Larium. The physician who prescribes twiceweekly chloroquine does so because “[Larium] is expensive, so they come back and you need to treat them [for malaria].” Travelers expressing intentions to purchase prophylaxis upon arrival in Nigeria sometimes find that they are too late: I’ve actually had some people that have gone home, and by the time they get the malaria medication, they’ve already come down with malaria.
In other cases, physicians are forced to prescribe affordable alternatives, with the recognition that some protection, or even prompt treatment of infection, is the best that can be hoped for: Some of them will really come tell me they cannot afford the Larium for prophylaxis. So what I end up writing for them, or advising them to do is to go ahead, when they get to Nigeria or any of these other countries, to buy the Fansidar. And then give them the instructions as it relates to what are the signs and
39 symptoms [of malaria]. Because I prefer for them to use [Fansidar] for management of malaria rather than for prophylaxis . . . These are the symptoms, and if you get this, go ahead and use this . . . So advice for those that cannot do this, you know, the prophylaxis, because I know it’s expensive.
In-Country Precautions When discussing in-country precautions, travelers, with few exceptions, expressed greater confidence in their ability to control their exposure to typhoid than to malaria. Nathan attributed typhoid to “carelessness.” Similarly, many of his fellow travelers described typhoid as a consequence of individual choices and actions about what and where to eat and drink in Nigeria, and most expressed confidence in their ability to exercise control over these factors: It’s like the typhoid is a more active thing. Like you go out to drink water there and you can do something to prevent typhoid, like no drinking the water. You’re more in control of whether I get typhoid or not, to a certain extent. But with malaria, it’s the bugs. So there isn’t much you can do about that.
Respondents did not speak about malaria and malaria prevention in this way, although there were notable exceptions. A businessman and frequent traveler to Nigeria, who takes no prophylactic measures for malaria, asserted that his “lifestyle” and hypervigilant attitude toward his environment serve to protect him, while agreeing, at least tacitly, that those less careful or aware might benefit from prophylactic measures: As we say, sometimes it’s a lifestyle. I am actually very cautious of my environment. I can control—I can control mosquitoes from coming, getting to my environment . . . That’s the way I live my life. When it comes to personal hygiene, I do not compromise at all. I don’t care how much it costs me to stay in the most exclusive area to avoid something. I do it. I spend the money. It’s like protection. Like security. You cannot spend enough to bring the security to one’s self . . . I’m not saying [prophylactics] are unnecessary. What I’m saying is that for somebody that is not as cautious of one’s self as I am, it can . . . Some people don’t have such strong instincts as such. I have very strong instincts. And that’s the way I live as a person . . . Even here in the United States, I can control where I work, where I live, the people I see. If I don’t want to go downtown for the next 20 years I can avoid going downtown for the next 20 years. That’s the way I operate in Nigeria also.
While vaccination for hepatitis A and typhoid was rare, many travelers did report taking in-country
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precautions—boiling or buying water, being careful about food preparation and consumption, and vigorous hand-washing: Boiling. Boiling water. I think that takes care of it. Well, as for typhoid I don’t worry about it. Because I know I’m going to be very careful with the water I drink. Typhoid happens to live in water. So since we’re buying the drinking water, I don’t worry about it.
Physicians also counseled patients about preparing and storing food, boiling water, buying water filters, and avoiding the use of ice cubes. Vaccines or pills were generally discussed as back-up strategies or as “added” protection, in part because they were considered less than fully effective: And the thing is you never have—I think it boils down to eventually just not thinking of—I mean, if I avoid those kinds of things whether I’m vaccinated or not, I guess that’s the bottom line. So I’m not really sure about how efficacious [the vaccine] is, whether it’s the same people that take it, but then they kind of absorb the effective measures. So they don’t get it or whether they’ve been exposed to it if that can help them in any way. It’s hard to say. So we go over the water. You know, the usual things. And then immunization as an added. . . .
sick. Mostly the people I see are people with malaria. Many times I send them to get diagnosed. When they call me and describe it, I will immediately know that it’s malaria. Sometimes they’ve been to other physicians who just treat them for flu and then they realize that they have malaria.
In reflecting on the telephone queries he receives and on the prescriptions he reads, one Nigerian pharmacist assessed the quality of care provided by local physicians this way: They don’t know a whole lot about [malaria]. Especially the non-African doctors don’t know a whole lot about malaria at all. The tropical diseases, they don’t. I do get calls here . . . Well some of them don’t really exactly know what to prescribe. I just kind of give them alternative options really. I try not to give them too many options. . . . Well I see any time, medications for anti-malarials. And there are some doctors that have actually written for some kind of . . . quinine . . . Well, I just call them back and say this is kind of an obsolete kind of thing. That’s not going to be effective any more really, so let’s just go ahead and use . . . and decide what I would recommend. And they might ask a few other questions and still recommend what I—you know, still prescribe what I recommend for them.
Delayed Diagnoses and “Irrelevant” Tests
And even here in Houston, you’d be surprised to know that some of the doctors see people with malaria and don’t know what they have. They don’t know what they have . . . They say, ‘This guy’s from Nigeria. What do you think? He just came back and said, ‘I don’t feel wonderful.’ And most likely it’s malaria.
In fact, travelers worry that if they fall ill in the United States and are treated by a non-Nigerian physician, it will take a long time to reach a diagnosis of malaria. Their physician will want to rule out other possible causes of the symptoms, and may initially attribute them to conditions—like allergies and the flu—that are more common in Houston and with which they are more familiar. Patients often have to wait, sometimes for days, for the results of their tests, because hospitals are “not equipped to do tests on the spot.” At least one physician we interviewed agreed that delays in diagnosis pose a problem, but said that familiarity with malaria, in particular, has increased in the last two years, and that such delays are on the wane. There is at least case study evidence in the literature as well to suggest that malaria diagnoses are sometimes delayed (9). This experience of falling ill in the United States stands in contrast to travelers’ experience of falling ill in Nigeria. Participants argued that self-monitoring, diagnosis, and treatment is the preferred approach. One compared it to the management of a chronic condition:
When [a Nigerian traveler] is sick, that’s when they call me. That’s when they get to me. When they’re
I think having malaria in Nigeria is just like somebody who has diabetes. You know when your insulin
Post-Travel Treatment Coming down with travel-related diseases either in Nigeria or upon return to the United States presented a number of concerns for travelers. Lack of Familiarity with Travel-Related Diseases Among Health Care Providers Nigerian pharmacists and physicians often describe themselves as playing an advisory role, not only to patients, but to (mostly non-Nigerian) physicians and pharmacists trying to prevent, diagnose, or manage malaria or other travel-health problems. Patients, in particular, count on them to understand and to recognize the problem:
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Adherence to Travel Health Guidelines is shot. You just get that shot to break up your carbohydrates just like that. When you have malaria and you know the symptoms kind of. You just go get whatever you normally take. It comes every three months. Every three months or every month.
At the same time, there is widespread acknowledgement that self-diagnoses are not always accurate, and that malaria is likely to be suspected even when it is not, in fact, present. When travelers feel tired or feverish or have body aches, “the first thing they think about is malaria and they go ahead and treat themselves.” Physicians and other clinicians in Nigeria are more familiar with the signs and symptoms of malaria than those in the United States:
41 when you get to a doctor that knows about it, you’re going to get treatment immediately, straightforward, no tests. Because you know what’s wrong with you. He knows what’s wrong with you, you know? Speaker 1: I’ve heard of people who have died of malaria here. Did you hear that someone died of malaria back home? Speaker 2: Who would die of malaria back home? Anybody can treat malaria back home. But here, they die of malaria just because they’re not getting the right treatment at the right time.
Availability and Cost of Drugs Sometimes [if you had malaria in Nigeria] you wouldn’t even have to go to the hospital or to a clinic to be cured. Because they’re familiar with it, right? Somebody who recognizes that you have malaria from the reaction of the symptoms you’re having. And recommend something or go to the chemist and have something for you immediately. Once you begin to feel like you are having these early symptoms. Like the weakness . . . the shivering. When you get some of the cold shivers and the sweating. . . . Because the doctors, they are very conversant. They know about this treatment. By seeing you, if they’ve seen you, they know what that is and they give you the right prescription. And you get the shots and you’re OK. Once it’s quickly detected. So when you have it, it seems no big deal. . . . Here, they are not familiar with the disease. You know, with the malaria symptoms. So they might be thinking, maybe it’s allergy. . . . Or you’re having the flu or something.
One general problem of unfamiliarity with these travel-related diseases is the risk that an incorrect diagnosis may result in the consequences becoming exacerbated, and that it will take longer to fully recover from the illness. There is also widespread concern about undergoing painful and perhaps unnecessary (“irrelevant”) diagnostic tests. One man described submitting to a lumbar puncture, and to tests that physicians waited to conduct until he was at the height of his fever, when he was “shivering to the bone” because “they don’t know what’s going on in your system.” Speaker 1: Another thing is malaria may be that mild in the beginning, but it can really get worse. Because if you get to [local hospital], they might end up wasting your time doing tests that are irrelevant . . . Speaker 2: Giving you the wrong medicine. Speaker 1: Yeah, but by the time you have malaria, as mild as it comes, it can get really dangerous when it gets to the brain. And so
In addition to unfamiliarity, delayed diagnoses, and superfluous procedures, travelers are worried about the availability of medications for the treatment of malaria. In Nigeria, participants report obtaining drugs easily, without a prescription: I could just get up. I know where to go, get to the pharmacy. “This is what I need.” And you know, sometimes you don’t even have to have a formal pharmacy. I know where to get it. . . . And the prices are reasonable. All you have to watch out is look at and check your expiration dates, which they try to check too, you know? And that’s it. I’d rather have [malaria] there. (Because I’m sure it’ll be over in hours compared to here. All the restrictions and everything. I wouldn’t want to deal with it here.)
One of the physicians we interviewed recounted the case of a pregnant 27-year old woman that occurred “8, 10 years ago.” Upon her return from Nigeria she was hospitalized with a severe case of malaria. At the request of the patient’s family, the physician went to the hospital, and found that the woman was being given Quinidine because the hospital had no access to injectable chloroquine. The patient later died, and for many years after this incident, the physician regularly purchased injectable chloroquine in Nigeria and “smuggled” it into the United States. While most physicians agree that treatment of malaria has improved dramatically in the last decade, stories like these continue to circulate in the broader community. They surface in travelers’ narratives, and impact beliefs, attitudes, and practices about travel health. Some respondents reported a preference for getting sick with malaria while in Nigeria rather than in the United States due to the vast differential in treatment prices. The cost of curing a bout of malaria in Nigeria was estimated at $1 to $2US—the cost
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of the medication—while in the United States, the cost of an office visit and prescription drugs was estimated to be around $350. A number of interviewees argued that drug choice is limited in the United States—medications commonly available in Britain and in Nigeria (e.g., Daraprim and Halfan) have not been approved for sale—resulting in reduced competition and higher prices. Some equated limited choice with limited interest in infectious diseases, like malaria, that are largely confined to other areas of the world. Stigma Like Nathan, many of the travelers we talked to reported regularly purchasing curative doses of Fansidar or Halfan while in Nigeria and bringing the medication back to the United States with them. That way, if they fall sick, they can not only circumvent expensive office visits, “irrelevant” tests, and long periods of waiting for their results, but also the “embarrassment” of being treated as infectious. Some travelers were afraid of being “quarantined” or “isolated” in airports or hospitals by people unfamiliar with malaria. Others described incidents at local hospitals or clinics in which sick relatives or friends were humiliated and mistreated, suspected of being HIV+, and put at further risk by delays in diagnosis and treatment: My sister, she almost lost a baby. She was pregnant. She came back and she had malaria. And she was taken to the hospital. The husband told her that was the right thing to do. And they were running all these series of tests, and AIDS-related and all that. Because most of them haven’t even seen it. They’ve not come in contact with someone who has these chills, or maybe has a major cold, you’re breaking into sweats and all that. And there she is—because she’s a pharmacist . . . She told them she has malaria. She knows the symptoms. It was, it just took a critical break-in by a German doctor that saved the situation. He explained to them, this was a tropical disease. This is malaria she has and all she needed was just pills, not all the injections and giving her all these complicated things. . . . The physicians need to be aware that there’s something that’s malaria and it’s not the same as AIDS. Because that’s the way they treat it here. It has similar symptoms at the beginning, you know? Loss of appetite and all that. It comes with all of that. Night chills, sweats, all that. They need to know about that and what they could give to alleviate the symptoms and to help a person.
Disparate Cultural Views of Illness In addition to bringing back their own medications, travelers who fall ill report that they would seek out Nigerian physicians (even if it meant paying out of their own pocket), who are expected to be more skilled, knowledgeable, and sympathetic to their problems than others. For travelers, finding a physician whose estimation of the severity of the problem matched their own was important; a taxi driver said he didn’t want to consult a physician who would think malaria was “something big” when he knows “it’s not that big of a deal”: I think I would have gone to a Nigerian doctor [if I came home sick]. He knows much about malaria and knows much about health issues. So I think . . . and he’s much qualified to handle it. Because if you go to the other hospital or the general hospital, I mean, you’re given bad—because of malaria. How they would treat you. They would isolate you . . . So that’s going to embarrass me. For one thing, it is common in our area. We know right away how to treat it, like somebody who has epilepsy or diabetes. So you cannot embarrass me. So we are going to [the Nigerian doctor] . . . I think to save myself from embarrassment I would probably go to see him.
DISCUSSION The purpose of this study was to examine the ways in which Nigerians living in Houston think about and act on risks to their health when traveling home, and to identify the obstacles to following the CDC’s preventive recommendations for malaria, typhoid, and hepatitis A. Because the way people think about health and risk is highly context dependent, we approached these questions inductively and used qualitative methods of data collection. The conduct of focus group discussions and one-on-one interviews allowed us to tap norms and attitudes related to travel health and to elicit concerns and issues salient to the prevention of infectious disease. However, the methods we used are not suitable for assessing the frequencies of the attitudes and behaviors described, or for discerning the distribution of these outcomes in the population. The organizing framework we used helps us to see the prevention of travel-related health problems as occurring on multiple, inter-acting levels. At the individual level, it is clear that members of the Nigerian community in Houston, as well as other travelers, would benefit from information on the health risks
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Adherence to Travel Health Guidelines associated with travel and their prevention. Other than malaria, travel-related health threats were not particularly salient. Information about hepatitis A was especially lacking; no participants mentioned it unprompted, and even after prompting, few were familiar with it. Typhoid was considered a serious problem for those who get it, but the risk was thought to be slight, and most were quite sanguine about their ability to avoid it. Paradoxically, malaria is seen as a very likely, but not a very serious, threat to health. Participants were quite nonchalant about the risk of malaria, with one notable exception: travelers feared contracting it in the United States, where they would run the risk of misdiagnosis, delayed and inappropriate treatment, and stigma. Education of individual travelers could reduce the gaps in knowledge and the misconceptions—that feed assessments of personal risk and, ultimately, behavior—uncovered in our interviews. Some of the most urgent messages to convey are the most basic: the latest recommendations for malaria prophylaxis, the number of weeks pre- and post-travel these medications need to be taken, the availability of typhoid and hepatitis A vaccine, and the duration of the interval before these vaccines take full effect. Most Nigerian travelers do not access the health care system prior to travel, and therefore, the dissemination of this information is more appropriately promoted through alternative networks. A wide range of regional, ethnic, religious, and special-interest groups bring together a large segment of the Nigerian community in Houston on a regular basis; these forums were suggested by many of our interviewees as the most appropriate venues for getting information out about travel health. In fact, “word-of-mouth” was repeatedly emphasized as the means by which news and information spreads through the community; the narratives collected for this study also indicate that current travel health practices are very much influenced by the advice provided through informal networks. Yet, raising awareness of the problem and encouraging individual citizens to take precautions will do little good if the needed services remain inaccessible to most. Some barriers to access appear more amenable to change than others. Affordable vaccines, for example, are supposed to be available through the public sector, though in reality ruptures in stock are frequent and long in duration. Malaria prophylaxis is available only through the private sector, and at rates many times higher than those charged in Nigeria for the same medications. Community organizing, lobby-
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43 ing, or advocacy work designed to impress upon city health officials and legislators the importance of continuous access to vaccines through the public health care system might be an effective local solution to this problem. The cost of health care more generally, and the coverage provided by insurance providers for travel-related care are obviously more complex and intransigent issues with a significant impact on the incidence of the diseases discussed here. In the absence of reform in these systems, it is perhaps unrealistic to expect that optimal travel health care for all will be attained; however, remedial, or harm-reduction measures might be considered. One such measure is to struggle with the question of what physicians can do when patients are unable to obtain optimal protection because of cost, lack of availability, or other barriers. The creation of an hierarchy of options may ensure greater overall protection of travelers. For example, it is unclear how many of the patients who receive prescriptions for Larium actually fill them; pharmacists tell of customers deterred by cost, and travelers themselves, like Theresa, describe opting to wait until they arrive in Nigeria to purchase more affordably priced medication. Few physicians told us that they discuss alternative therapies with their patients, and the desire to provide the best clinical advice and medical care is, from one perspective, at odds with a harm reduction model. Yet, a frank discussion of the costs of the medication during the patientprovider encounter may help physicians assess the likelihood that their patients will be able and willing to afford the treatment they prescribe and consider alternatives if necessary. Similarly, advice about typhoid prevention might incorporate hygienic measures, oral pills, and vaccination as possible strategies, depending on local availability, cost, and assessment of risk. Most primary care physicians see very few patients seeking travel-related health care in their practices, and are therefore unfamiliar with the problems likely to be encountered or the latest recommendations for preventive (or curative) care. The result is sometimes prescriptions for medications that are no longer effective or delayed diagnoses, and, perhaps more importantly, the widespread perception among Nigerian travelers that most physicians know little about travel-related illnesses, and particularly malaria. A handful of physicians and pharmacists have become central to the provision of preventive and curative care for Nigerian travelers in Houston, and serve as important resources, both to their colleagues in the medical community and to travelers.
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44 Different resources for and approaches to these two groups of physicians would seem to be indicated in order to improve the quality of travel health services. Even those physicians most closely connected with the provision of travel health care see, with few exceptions, relatively few patients with travel-related queries or complaints. Travel to Nigeria is seasonal; during peak travel times—the summer holidays and again in December and January—physicians might see a single patient per week, while in the off-season office visits are exceedingly rare. Given the infrequency of such consultations, physicians find it frustrating to keep up with what they perceive to be “forever changing” recommendations, particularly those related to malaria prophylaxis. Most received updates and other travel-health news from one or two primary sources, among them grand rounds at local teaching hospitals that featured travel health topics on occasion, “throw-aways,” scientific journals, vaccine suppliers, and the internet. Physicians concurred that they would benefit from short, concise updates, available in an easy-to-digest format. Given the frequency with which the information changes, some thought the internet would be the most appropriate means of disseminating current recommendations. Physicians providing travel health services, and most especially their patients, could also benefit from a list of local pharmacies or other sources of commonly prescribed travel medications and various formulations of these medications. Some physicians named a pharmacy where they often directed patients, but, in general, they knew little about where their patients went to fill their prescriptions or even if the prescription provided was filled once the patient left their office. A resource list of this type might also help patients locate needed medications more quickly and with less hassle, and thereby enhance their chances of obtaining and adhering to preventive regimens. Physicians with little or no training in or experience with the types of travel-related infections discussed here need help to properly diagnose and treat patients—notably those with malaria. The Nigerian physicians and pharmacists interviewed for this study report frequent calls for assistance from their colleagues and fellow Nigerians. Making this resource more widely available to the medical community in Houston is one means of improving the quality of care currently available. Prevention is not a linear process that starts with informed and motivated individuals, despite the tendency in many western models of health promotion to conceptualize the process in this way. The prevention
Leonard and VanLandingham of malaria, typhoid, and hepatitis A requires multiple lines of action that are best carried out simultaneously. Many of our interviews demonstrated how the different domains of experience included in our organizing framework are tightly intertwined and reciprocally determined. We described, for example, how physicians counseled patients—who were seeking vaccination for yellow fever or care for children—about the need for malaria prophylaxis. Access to care—in this instance contact with the health care system—carries with it the possibility to enhance individual knowledge, alter individual attitudes toward susceptibility, and ultimately modify the travel health practices of individuals. Improving the health of travelers by encouraging adherence to the CDC’s recommendations requires a multi-pronged strategy: educating travelers about disease risks, motivating them to seek pre-travel preventive care, improving their access to care, including affordable, effective, and acceptable prevention and treatment services, and training physicians and other health care providers to provide better quality services. APPENDIX A Summary of CDC recommendations for travelers to West Africa (4). Malaria: Prescription anti-malarial drugs are recommended; travelers should also protect themselves from mosquito bites. “Most travelers to malaria risk areas in this region should take mefloquine to prevent malaria.” Typhoid fever: Vaccine is recommended. Travelers are also recommended to avoid potentially contaminated water and food (“Boil it, cook it, peel it, or forget it”). Hepatitis A: Vaccine is recommended. Travelers are also recommended to avoid potentially contaminated water and food (“Drinking water (and beverages with ice) of unknown purity, uncooked shellfish, and uncooked fruits or vegetables that are not peeled or prepared by the traveler should be avoided”). ACKNOWLEDGMENTS This study was funded by a contract from the Malaria Section of the Centers for Disease Control and Prevention (CDC). The authors gratefully acknowledge the advice and commentary provided by Dr. Lawrence Barat on the interview guides and on
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Adherence to Travel Health Guidelines the drafts of this paper. We also thank all of the men and women, travelers and health professionals, who kindly agreed to participate in this study.
45 4. 5.
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