Primary health care needs for travel medicine training in Britain

Australian Pharmacists' Perceptions and Practices in Travel Health

Worldwide, pharmacists are playing an increasing role in travel health, although legislation and funding can dictate the nature of this role, which varies from country to country. The aim of this study was to explore the current and potential future practices in travel health for pharmacists in Australia, as well as the perceived barriers, including training needs, for the provision of services. A survey was developed and participation was sought from a representative sample of Australian pharmacists, with descriptive statistics calculated to summarise the frequency of responses. A total of 255 participants, predominantly female (69%), below 50 years (75%) and registered less than 30 years completed the survey. Although over two-thirds (68%) provided travel-related advice in their current practice, the frequency of advice provision was low (less than 2 travellers per week) and limited to responding to travellers questions. Although Australian pharmacists are currently unable to administer travel vaccines and prescription only medications without prescription, they still consider travel health to be an appropriate role and that their clients would seek travel health advice from pharmacies if offered. Currently, key roles for Australian pharmacists are advising travellers who do not seek advice from other practitioners, reinforcing the advice of other health practitioners and referring travellers needing vaccinations and antimalarials. In order to expand these services, the barriers of workload, time, staffing and the need for training in travel health need to be addressed. In summary, the travel health services provided by pharmacies in Australia still have a way to go before they match the services offered by pharmacies in some other countries, however Australian pharmacist are keen to further develop their role in this area.

Providing travel health care--the nurses' role: an international comparison

BACKGROUND

In many countries, the responsibility for travel health lies with medical practitioners who delegate certain tasks to nursing staff. Elsewhere, nurses have taken a leading role and work independently in private or hospital-based clinics, occupational health departments and general practices. The purpose of this study was to examine the roles and challenges faced by nurses providing travel health care in Australia, Japan and the UK, and to compare educational and professional needs.

METHODS

Nurses involved in travel health care were invited to complete an online questionnaire with multiple choice, open-ended, and Likert Scale questions. SurveyMonkey's statistical facilities analysed quantitative data; thematic content analysis was applied to qualitative responses.

RESULTS

Differences and similarities between the three countries were conveyed by 474 participants focusing on current positions, work arrangements, and educational and practical concerns. Clinical practice issues, including vaccination and medication regulations, were highlighted with the differences between countries explained by the respective history of travel health care development and the involvement within their nursing profession.

CONCLUSION

The call for more educational opportunities, including more support from employers, and a refinement of the role as travel health nurse appears to be international. Nurses require support networks within the field, and the development of a specialist "travel health nurse" would give a stronger voice to their concerns and needs for specific education and training in travel health care.

Travel health: sun protection and skin cancer prevention for travellers

The UK population likes to travel to sunny parts of the world, where the risk of sunburn is greater than it is at home. Sunburn and the cultural desire for a tan is one of the risk factors for the increase in skin cancer. The rise in foreign travel has resulted in an increased demand for pre-travel health services, with nurses in primary care acting as the main providers.Within these consultations, the traveller and their travel plans are risk assessed.Travel health consultations give an ideal opportunity to discuss and advise the public regarding sun burn and skin cancer protection. However, there are also other ways to impart safety in the sun message to travellers. Skin protection is a health promoting activity provided as a part of public health provision and all nurses can play a role in prevention.

Past, present and future of travel medicine in Japan

At present, more than 17 million Japanese travel overseas annually, and one out of seven Japanese now travel abroad. Accordingly, an increasing number of these travelers contract diseases, but the practice of travel medicine is not common in Japan yet. However, travel medicine societies and the like have been established in Japan since the late 1990s, and Japanese medical professionals are becoming increasingly interested in this field of medicine. In this paper, the past, present and future of travel medicine in Japan is reviewed.

Imported malaria in children: incidence and risk factors for severity

To assess the incidence of imported malaria in children and to determine the frequency of delayed diagnosis and risk factors for severe malaria, we performed a retrospective multicenter cohort study in the northern region of France and included all children with a positive test for malaria from 2000 to 2006. The incidence of imported malaria in children <18 years, the frequency of a delayed diagnosis, and the risk factors for severe malaria were determined. The study identified 133 children with imported malaria. The mean incidence of this disease was 1.9/100 000 children <18 years (95% confidence interval [CI], 1.6-2.2). Detailed data were available for 120 children. Disease was considered severe in 19% of cases. The diagnosis was delayed (> or =1 day after the first medical contact) in 31% of cases, and this delay was the only independent risk factor identified for severe imported malaria in children (adjusted odds ratio, 3.2; 95% CI, 1.2-8.8; P = 0.02).

Does registration of professionals improve the quality of travelers' health advice?

BACKGROUND

The objectives of the Dutch National Coordination Center for Travelers' Health Advice (LCR) are to improve the uniformity of travelers' health advice in the Netherlands and to enhance its quality. The LCR offers national guidelines and quality criteria, as well as a telephone consultation service, where health professionals can pose questions regarding travel medicine. Since 2005, a register for qualified travel health professionals has been in place. We studied the quality and relevance of the telephone consultations, to see whether there was a difference between registered as qualified and nonregistered health professionals.

METHODS

Telephone questions regarding pretravel advice were logged in September 2007. The questions were categorized as basic or advanced and compared by the profession of the caller, type of institution, and LCR registration of the responsible physician.

RESULTS

In 2007, 85% of travel clinic physicians, 42% of general practitioners, and 31% of travel clinic nurses were registered with the LCR. A total of 146 telephone consultations were included in the analysis. Significantly more callers from travel clinics posed advanced questions than those from general practices [odds ratio (OR) 7.6; 95% confidence interval (CI): 3.6-16.1; p= 0.000]. More callers who were registered asked advanced questions, although this difference was not significant (OR 1.7; 95% CI: 0.9-3.3; p= 0.124). Assistants from general practices asked significantly less advanced questions than physicians or nurses.

CONCLUSIONS

Opening a register for travel health professionals has led to a large increase of professionals who follow courses and register as travel health professionals. A positive association was found between the quality of the questions and the registration of the responsible physician. The quality of travel health advice given in general practices needs increased attention.

Analysis of yellow fever vaccination practice in England

BACKGROUND

Prior to initiation of a program of registration, training, standards, and audit for yellow fever vaccination centers (YFVCs) in England, the National Travel Health Network and Centre (NaTHNaC) assessed the current practice and resource needs of these centers.

METHODS

A questionnaire was sent to all YFVCs on the English Department of Health (DH) database in November 2004. It surveyed type of practice, administration of travel vaccines, training and duties of staff, vaccine storage and record keeping, access to travel health information, and resource and training needs.

RESULTS

The questionnaire was completed by 69% (2,933 of 4,242) of YFVCs on the DH database. Nearly all (94%) YFVCs were part of general practice; centers were widely distributed throughout England. A median number of 35 doses of yellow fever vaccine (YFV) were given every year, with 75% of centers giving less than one dose per week. Nurses administered YFV more frequently than physicians (96% of nurses vs 49% of physicians, p < 0.0001). More nurses in YFVCs had received travel health training compared with physicians (95% vs 57%, p < 0.0001). Study days run by pharmaceutical companies were the most frequent source of training. Most YFVCs properly refrigerated vaccine and maintained vaccination records. Of the centers that reported using Internet resources for every patient, the Travax (Health Protection Scotland) (64%) and DH (England) (48%) Web sites were most frequently accessed. YFVCs cited training opportunities, information for travelers, and specific travel medicine advice as resources that would be most helpful to them.

CONCLUSIONS

The NaTHNaC program of registration, training, standards, and audit should help to meet important needs in practice settings and contribute to an improvement in travel health.

Quality of travel health advice in higher-education establishments in the United Kingdom and its relationship to the demographic background of the provider

BACKGROUND

The number of international trips undertaken by residents of the United Kingdom has risen dramatically over the past 50 years. Likewise, the numbers studying in higher education have also shown a huge increase. This study aimed to assess the appropriateness of advice given to traveling students by higher education-based health services and to relate this to the demography and experience of the professionals involved.

METHODS

A postal questionnaire describing three hypothetical groups of students traveling to different parts of the world was sent to 335 doctors and nurses. These clinicians belonged to the British Association of Health Services in Higher Education. They worked in 105 practices that serve higher-educational establishments in the United Kingdom. Main outcome measures included whether appropriate immunizations were advised and given correctly through the National Health Service (NHS) or privately, and whether appropriate advice was given regarding malaria, human immunodeficiency virus (HIV), and miscellaneous risks. The sources of information used to advise travelers were also asked, and the effect of demographic characteristics of the respondents on the quality of advice was investigated.

RESULTS

Two hundred fifteen (64%) questionnaires were returned. The mean score for whether the correct immunizations were advised was 77%, and for whether these were given correctly through the NHS or privately was 79.6%. For malaria, HIV, and miscellaneous risks, the scores were lower at 65%, 38%, and 32%, respectively. The score for correct immunizations was significantly affected by sex, with females respondents scoring higher (p = .036). Previous training in travel medicine improved scores for immunizations (p = .034) and for the correct choice being given through the NHS or privately (p = .006). Age, hours worked, role, and size of practice had no influence on scores. Charts in the general practice free newspapers were the most popular source of information.

CONCLUSIONS

Practices serving higher-education establishments usually give appropriate advice to travelers in terms of the immunizations required, whether these are available through the NHS or privately, and about reducing risks of malaria. This is not the case regarding advice pertaining to HIV and miscellaneous risks. Previous training in travel medicine seems to correlate with the giving of more appropriate advice.

Nationwide survey of the role of travel medicine in primary care in Germany

BACKGROUND

With more persons traveling to (sub)tropical destinations, travel medicine is an increasing challenge for the health care system in many countries. This study investigated the role and scope of travel medicine provided by general practitioners (GPs) in primary health care, assessed the determinants of specific prophylactic recommendations, and identified the needs of GPs regarding training and cooperation in travel medicine.

METHODS

A national survey was conducted among randomly selected GPs in Germany. Information on the type and extent of activities in travel medicine, the number and characteristics of patients, the use of specific information systems, and training and cooperation, was obtained with a standardized postal questionnaire. Representativeness was assessed by a computer-assisted telephone survey among nonrespondents. Univariate and multivariate statistical analysis was performed.

RESULTS

Of all GPs (n=1,320), 95% provided medical pretravel advice or post-travel counseling (13.2 patients/month). The most common topics in pretravel consultation were immunizations (95%), malaria chemoprophylaxis (94%), advice on exposure prophylaxis (41%), and advice on protection from sexually transmitted infections (STIs) (43%). GPs frequently advised certain patient groups (e.g., cardiovascular patients 68%, pregnant women 20%). Travelers' diarrhea was the most common topic in post-travel consultation (89%), followed by fever (38%). Of the GPs, 25% cooperated regularly with institutions with special expertise in travel medicine or tropical diseases. Sixty-four percent had received some training in travel medicine, and 86% stated a need for additional training. In the multivariate analysis, independent determinants for advice on exposure prophylaxis and STI risks included special training in travel medicine, use of country-specific information sources, and location of the practice in the former West Germany and urban areas.

CONCLUSIONS

Travel medicine is of importance in primary health care in Germany. There is a need for improved counseling on exposure and STI prophylaxis. GPs' training in travel medicine and cooperation with institutions such as institutes, clinics and laboratories for tropical medicine should be improved.

A description of travel medicine in general practice: a postal questionnaire survey

BACKGROUND

Travel-related diseases are important aspects of public health. The number of UK residents traveling abroad is increasing at a rate of 16% a year, thereby increasing exposure to travel-related morbidity. Provision of comprehensive pretravel health advice is essential to reduce this trend. In the UK, pretravel health advice is predominantly provided through general practices.

METHODS

A postal questionnaire was sent to all 91 general practices in South Cheshire Health Authority. The questionnaires were to be completed by the lead advisor in travel medicine for each practice. Questions were asked on service provision, training and reference resources used, subjects advised on, and health promotion material used. Nonresponders were contacted and sent a further questionnaire.

RESULTS

A response rate of 86% (78/91) was achieved. Of the lead advisors, 97% were nurses and 3% general practitioners. Thirty-eight sources of advice were quoted, the commonest of which comprised wall immunization charts (72%). Duration of consultation ranged from less than 5 min to over 30 min, with a median and mode of 11 to 15 min. Most respondents reported advising on most travel-associated risks, 40% of practices lacked a protocol, and 83% of providers had attended a training course on travel medicine for 2 days or less.

CONCLUSIONS

This survey identified inadequacies of training and use of multiple sources of reference which may lead to inconsistencies in advice. Most practitioners could not define their workload in travel medicine. For effective protection of travelers, a careful risk assessment, clear risk communication and health education with detailed health promotion are necessary, but these are not likely to be provided within an average consultation time of 11 to 15 min. There is no evidence of consistent governance, planned training and monitoring of service quality of travel medicine practice. This may be due to lack of a national policy on best practice and guidance in this subject. National protocols with validated information resources, set standards of training, along with adequate consultation time for educating, advising, and prescribing, will lead to improved health of the traveling public.

Referral of travellers from Australia by general practitioners for travel health advice

Background. General practitioners (GPs) may refer travellers to practice staff and to outside agencies to assist in the provision of travel health advice and preventive measures. In Australia, little is known about the referral patterns of travellers for travel health advice by GPs in the Australian context. This study was designed to investigate how frequently GPs' practice staff became involved in providing basic travel health advice and travel vaccination and to identify referral sources and how frequently GPs referred travellers to these sources for travel health advice. Method. In 2000, 433 GPs from western Sydney and Townsville were randomly selected from the register of the Australian Medical Association's Medical Directory of Australia database and sent self-administered questionnaires. Two reminders were sent. Results. Two hundred and thirteen questionnaires (43%) were returned. Approximately two thirds of the sample were male (133/207, 64.3%) and one third female (74/207, 35.7%). The mean age of the GPs was 46.7 (SD+/-12.1) years. About one tenth of GPs reported having a Yellow Fever Licence (11.3%, 23/203). The majority of GPs did not use their practice staff for giving travel health advice (60.7%, 122/201) or giving travel vaccinations (55.7%, 112/201). More than three quarters of GPs would never refer their patients for travel health advice to GPs with a special interest in travel medicine (76.4%, 152/199), specialists (76.8%, 152/198), or other agencies (77.8%, 63/81). Almost half of GPs stated that they would refer to travel clinics at least sometimes (46.6%, 95/204). Conclusions. GPs do sometimes refer travellers to specialised practices for travel health advice, especially to travel clinics, but also to other agencies, possibly for specialised services, such as yellow fever vaccination. Further studies may be needed on capacity of general practice staff to contribute to the travel health consultation and also the reasons and the appropriateness of the referral to outside agencies, where this occurs. Practices may need to consider further training of their auxiliary health staff in travel medicine, so that they can become more involved in the provision of travel health advice and immunization, where possible.

Sources of health advice given to travelers

One of the biggest problems for health professionals and the travel industry has been getting travelers to present for pretravel health advice from a qualified source. Behrens1 stated that one of the most important factors in whether travelers seek health advice at all was the perceived risk and severity of tropical diseases. Travelers may obtain this health advice from the travel industry itself, or from health professionals in travel clinics, hospitals, public health units, general practices or other centers. They may also obtain advice by telephone directly from these areas. It is likely however that travel agents and the travel industry, especially various publications, are an important source of preliminary information on health and safety for travelers.

Training, experience and interest of general practitioners in travel medicine in New Zealand

BACKGROUND

In New Zealand, general practitioners (GPs) are a major group of travel health advisers. This study was designed to investigate the prevalence of training, experience, and interest in travel medicine or related areas, interest in undertaking training in travel medicine and how training might be best delivered.

METHOD

Four hundred GPs were randomly selected from the register of the New Zealand Medical Council and sent self-administered questionnaires. Two reminders were sent.

RESULTS

Three hundred and thirty-two (83%) GPs responded and these GPs advised an average of two travelers per week. Most GPs (257/282, 91%) reported that they had no training in travel medicine/related area. Training in travel medicine/related areas was significantly associated with age group (x2=14.09, df=6, p<.05), with the proportion of GPs with training in travel medicine/related area tending to be higher in the 45-49 and 50-54 years age groups, and also with GP college membership/fellowship (x2=6.39, df=1, p<.05). Forty-one percent (121/298) of respondents stated that they had previous experience working in tropical medicine/developing country. There was a significant association between GPs having experience working in tropical medicine/developing countries and training in travel medicine (x2=14. 19, df=1, p<.001) and those who were non-New Zealand graduates (x2=7. 84, df=1, p<.01). Forty-four percent (131/300) of respondents stated that they had an interest in travel medicine. Nearly two thirds of respondents (200/309, 65%) indicated that they would be interested in undertaking various types of travel medicine training, with a short course most commonly identified (159/309). The interest for training in travel medicine was significantly associated with those GPs with an interest in travel medicine (x2=26.45, df=1, p<.001), in younger age groups (x2=41.30, df=6, p<.001), a lower mean number of years since graduation (t value=5.70, df=297, p<.001), a higher mean proportion of patients who were travelers (t value=23.15, df=303, p<. 01), and a higher mean number of travelers seen per week (t value=22. 94, df=303, p<.01). The most common postgraduate qualification amongst GPs was membership/fellowship of a GP college (85/282, 30%), which was significantly more prevalent amongst the older age groups (x2=18.18, df=8, p<.05). Membership of travel medicine was very low.

CONCLUSIONS

This cross-sectional study found that most GPs in New Zealand did not have any formal training in travel medicine, although more than two fifths of GPs indicated an interest in travel medicine and experience in tropical medicine/related area. GPs mainly wanted continuing medical education (CME) on travel medicine in the form of short and certificate level courses. As membership in GP colleges and other organizations was limited, other providers of CME should also be considered for providing more of these courses, such as universities and pharmaceutical companies. Providers of CME may target less experienced GPs and those GPs who may be seeing more travelers and use various approaches. Undergraduate and postgraduate medical curricula may also need to include more training in travel medicine.