The knowledge, attitudes and practices of wintersun vacationers to the Gambia toward prevention of malaria: is it really that bad?

van Genderen et al. Malaria Journal 2014, 13:74 http://www.malariajournal.com/content/13/1/74 RESEARCH Open Access The knowledge, attitudes and practices of wintersun vacationers to the Gambia toward prevention of malaria: is it really that bad? Perry JJ van Genderen1,2*, Paul GH Mulder3, David Overbosch2 and on behalf of the Dutch Schiphol Airport Study Group Abstract Background: Each year clusters of imported malaria cases are observed in Dutch wintersun vacationers returning from The Gambia. To gain more insight in the travel health preparation and awareness of these travellers, the knowledge, attitudes and practices (KAP) of this travel group was studied by analysing the data of the Continuous Dutch Schiphol Airport Survey. Methods: In the years 2002 to 2009 a questionnaire-based survey was conducted at the Dutch Schiphol Airport with the aim to study the KAP, i.e. accuracy of risk perception (“knowledge”), intended risk-avoiding behaviour (“attitude”) and use of personal protective measures and malaria chemoprophylaxis (“practice”) toward prevention malaria in travellers to The Gambia. Travellers to other high-risk destinations served as controls. Results: The KAP of travellers to The Gambia toward prevention of malaria was significantly better than that observed in other travellers. Trend analyses indicated that attitude improved over time in both groups but knowledge did not change. Only in travellers to high-risk countries other than The Gambia significant increases in protection rates were observed over time. Conclusions: The KAP of travellers to The Gambia toward prevention of malaria was better than that observed in travellers to destinations other than The Gambia. Trend analyses revealed a significant improvement of intended risk avoiding behaviour but not in protection rates or risk perception. Keywords: Malaria, Traveller, Travel, Risk, Knowledge, Attitude, Practice, KAP, VFR, Gambia, Tourist Background In the Netherlands, vacations to The Gambia are frequently marketed as attractive last-minute ‘winter sun’ alternatives for the Canary Islands, Portugal or Spain. However, being located in West-Africa, travel to The Gambia requires not only proof of protection against yellow fever but has also strict indications for malaria chemoprophylaxis throughout the year. However, many travel brochures and booking agencies underexpose the need for malaria prophylaxis and proper travel health advice [1]. As a consequence, travellers to The Gambia are considered to be at an increased risk for * Correspondence: 1 Institute for Tropical Diseases, Havenziekenhuis, Haringvliet 72, 3011 TG Rotterdam, The Netherlands 2 Travel Clinic Havenziekenhuis, Rotterdam, The Netherlands Full list of author information is available at the end of the article contracting malaria because of this lack of awareness and prophylactic measures. In fact, clusters of imported malaria cases in wintersun vacationers returning from the Gambia were described in several European countries, including the Netherlands [2-4]. Last-minute booking, not seeking or adhering to travel health advice and not taking any or using inappropriate malaria chemoprophylaxis as well as a high case-fatality rate were the common denominators among these cases [2-4], stressing the need for proper preventive measures and increased awareness of the potential lifethreatening dangers associated with travel to West Africa for this group of travellers. In an effort to gain more insight in the travel health preparation and awareness of particularly wintersun vacationers to the Gambia, the knowledge, attitudes and practices (KAP) of this travel group was studied by © 2014 van Genderen et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. van Genderen et al. Malaria Journal 2014, 13:74 http://www.malariajournal.com/content/13/1/74 analysing the data of the Continuous Dutch Schiphol Airport Survey. In this annually repeated questionnairebased survey, the main determinants that constitute the traveller’s personal risk profile toward travel-related infectious diseases like malaria were systematically evaluated in passengers waiting to board on flights to various destinations with a risk for contracting malaria and provide important feed-back on their travel health preparation, perception of risk as well as risk-seeking or risk-avoiding behaviour. Methods Questionnaires and survey The survey was conducted as previously described [5-8]. However, for the current study only travellers to a destination with a designated high risk of malaria were included based on maps published by the Center for Disease Control, Atlanta, USA [9]. In brief, self-administered, anonymous questionnaires were randomly distributed at the departure gate of Schiphol Airport, Amsterdam, The Netherlands, while passengers were waiting to board. Intercontinental flights to destinations with an intermediate or high risk for hepatitis A, hepatitis B or malaria were preferably selected. The survey was always done in the same period of the year, namely the months October or November in the years 2002 to 2009, except in year 2006. Travellers participated on a voluntary basis; no incentive was provided, except for a leaflet with information on hepatitis A, hepatitis B and malaria. Trained interviewers were present to distribute the questionnaires, to answer questions if necessary and to check the completeness of the responses collected. When possible, these interviewers copied the information from the travellers’ vaccination records. Travellers were allowed to participate if they were 18 years of age or older, and able to fully understand the language of the questionnaires. They also had to be resident in the Netherlands; thus, nationals of a developing country were only asked to participate if they were actually living in the Netherlands. These criteria were checked by the interviewers when distributing the forms. Afterwards, completed questionnaires from travellers who did not meet all the inclusion criteria were either excluded by the interviewers or rejected from the final analysis. The malaria questionnaire focused on malaria and its prevention and treatment and these questionnaires were distributed only to travellers with destinations in or close to malaria-endemic areas. A part of the questionnaire dealt with personal characteristics (age, gender, nationality, residence, profession), with information regarding the travel (destination, duration, purpose, travel companions) and its preparation, and with the travellers’ inte (...truncated)