A Survey of the Travel Health Experiences of International Business Travelers - April 28, 2000

H. Lynn Rogers, RN, MN, OHNC, President, Workplace Health International, Ltd.

DR. ERICSSON: Our next speaker, Lynn Rogers, R.N., a master's and bachelor's of nursing, is President of Workplace Health International, Calgary, Alberta, Canada. She's been an occupational health nurse from '81 to '84, where she initiated and developed an international travel health program. Later on in the '80s, as a supervisor, planned, implemented and monitored the health services and occupational health programs for an employee population of 2,500 people.

And then on into the '90s, was a coordinator of support services for Petro Canada International Assistance Corporation, and developed and managed international logistics, protocol services, intercultural briefing programs and services for outgoing consultants and incoming trainees and dignitaries.

Later in the '90s, occupational health and safety specialists for Calgary Health Services designed and implemented the first health and safety program for 800 public health and community workers. Obviously, very well-qualified.

Lynn is going to present her results of a survey of the travel health experiences of international business travelers.

Lynn?

MS. ROGERS: Thank you, Dr. Ericsson.

Hi. I'm very pleased to be here today, and I really want to thank the World Bank for inviting me to this event. And I'm very honored to be here.

This is an area of occupational health that I've been involved with for a number of years, and both from the clinical side, as well as just more recently from the research side. So it's an area that I've had a passion about for a long time.

This is a study that I'm going to present that I did as my thesis in the master's program at the University of Calgary in Western Canada, and I would just like to briefly acknowledge some funding support that I received from the University of Calgary, as well as from the Alberta Occupational Health Nurses Association.

I think you will find the results rather interesting just because there was a number of other studies essentially going on right around the same time. Unbeknownst to each of us, the World Bank study that you've heard about and Dr. Reed's study in the U.K. as well. So I think you'll find some of the results are quite similar.

I'm going to briefly give you an introduction of the literature review, some of what you've already heard, and I'll talk a little bit about the design of the study and the methods that I used. I'll explain the sample, and summarize with just some of the key findings. It was quite a large study, so I have quite a bit of data.

I'll round off with some of the conclusions. But I probably will not talk too much about the practice implications because I think we're going to be doing that this afternoon. But you do have a couple of slides in your handout that were part of my discussion and conclusions section.

What I found, when the study started in late '96 and when I got into looking at the literature, as you well know, there just wasn't anything there for occupational health for short-term travelers. There was a lot for long-term travelers. Sorry. There wasn't a lot for short-term travelers, except for tourists. There wasn't a lot in occupational health, nor in occupational health nurses. But there was a lot for expatriate long-term travelers and other long-term travelers, like students, and immigrants and refugee workers. But, essentially, there wasn't anything for short-term from an occupational health perspective.

And until the World Bank study and Kramer, et al., study out of Coca Cola, I think in Atlanta, those studies came out just during the time when I was finishing off mine and looking at my results and drawing some conclusions. So, despite that, the studies for other short-term travelers did tell me that there was a considerable high risk for travel, and that very likely there was a propensity for all travelers to have problems overseas.

For other travelers, just as a quick summary, 30 to 50 percent were experiencing health problems during travel. 30 to 60 percent traveler's diarrhea. And my figures are a little lower in the literature I looked at, I guess, than Dr. Keystone's, but around 6 to 18 percent I found were having injuries. Now, none of those were work-related injuries reported. They were all accidents, typical sports, recreational kinds of accidents.

I did look at the WCB data in Alberta, and looked about 10 years at their data to see what they had collected for international accidents. And, on average, there was about 6 cases reported per year, and we were running around 30, I think, to 35,000 business trips a year out of Alberta. So the reported cases are quite low to WCB.

Also, the psychological data were very almost nonexistent for occupational health. But certainly for some other travelers, there was some important work starting to emerge in the '90s. Out of the U.K., Dr. Macintosh, who some of you probably know and have read some of his work, he was finding, for short-term travelers, around 20 to 30 percent with travel-related worries and anxieties. And he was looking at things like fear of flying, and fear of getting ill, and fear of leaving the family, that sort of data.

And, as well, the culture shock data was quite extensive in other fields in sociology, and psychology, and anthropology. There was a lot of interesting theoretical work done on the U-curve hypothesis. But there was mostly all focused on the long-term traveler. And as you probably well know, with the U-curve hypothesis, it depends on length of time. So it's applicable for long-term travelers, but there was nothing really that came out of the literature for short-term travelers. Nevertheless, it looked like, in the literature, that almost everyone experienced some degree of culture shock. What varied was the degree of it, actually.

So based on the data, then, I was able to identify that this was a population of workers that needed to be studied and that were experiencing, more than likely, some health problems. And there was room for a bio-psychosocial approach. So I was able to look at both the physical and psychological symptoms in the study. And my primary question was what are the travel-related health experiences of business, of international business travelers?

There was enough data there to make some determination about selected factors, as you've heard. And so I was able to pick out some factors to do some correlational analysis as well. I also was interested, from the work-performance perspective, as to whether or not they reported any work-performance problems or issues. And so I was able to look at that, as well, with the relationship with the travel problems.

The study was a descriptive correlational study survey design, and I used both quantitative and qualitative aspects in the study. It was a sampling of 242 employees at two different oil and gas companies in Calgary.

The criteria was that they had to have taken at least one business trip in the time frame of the study, and the study went from the winter of '96 to the spring of '97. And the other criteria was that they had to have traveled short term. So that was less than 12 weeks. And they had to have traveled outside of Canada or United States. There was a few people who did travel into the United States, but most of them were on a business trip on way, en route somewhere else. So some of them had touched down in Houston or whatever. So they were included in the study. But the criteria was they had to be traveling outside of Canada or U.S.

There were no questionnaires at the time. Naturally, I was a bit disappointed, but I did end up having to develop a questionnaire that I used a template from a study by Dr. Getzadahl [ph] in Norway. And once I got the questionnaire translated, I was able to use it as a template and add in a few other scales and build on that questionnaire considerably with some more newly developed questions as well.

So it was essentially asking them to recall what was their most recent trip and to provide data only on that recent business trip. And in the data analysis, I was able to use both descriptive and inferential statistics, with a P level of .05.

The sample, I had a 58-percent response rate, with a final sample of 140 respondents. Eighty-four percent were male and with a mean age of 43. The range was from 25 to 62. The majority were married, 86 percent. Eighty percent were relatively well-educated at the undergraduate or graduate level. Ninety-two percent were nonsmokers. And the majority of them were healthy and considered themselves healthy prior to travel. Fourteen percent had preexisting health problems. Most of those were cardiovascular, high blood pressure, high cholesterol levels.

There was about 32 percent that reported high stress levels prior to travel. With respect to their travel data, they were a relatively experienced group. Most of them had traveled about--two-thirds of them actually had traveled more than ten times in the previous five years. They were frequent flyers, traveling on average about every two months, about 5 to 6 times per year, for an average length of stay of 3 weeks. And most of the destinations, there was about 41 countries that were visited in this study, mostly to the U.K., Middle East, Central and South America, Asia and to Europe, as well. Fifty-eight percent of them went to rural locations.

With respect to their occupational status, the majority of them were managers or professionals with supervisory responsibilities. Twelve-percent were senior executives and about 4 percent were in technical trades.

I collected a fair bit of data with respect to their pre-travel preparation, and I'll give you a little bit of a snippet of that here today. But about 87 percent perceived they had adequate time to prepare, which we know for business travelers is often not the case. They're called last minute to travel. But anyway, the majority did feel they had time to get ready. Despite that, there was about 27 percent that had a pre-travel medical examination, and some of the reasons that they gave for not getting one was that they either just didn't have the time, which sort of counteracts the previous data. But they also considered themselves healthy, and in some cases the company didn't require it, so they didn't see a need to have one.

Seventy percent reported receiving immunization. The question that I had for immunization was rather ambiguous actually. So I wasn't able to really use that data. It was hard to tell whether they were describing immunizations that they had received just prior to that trip or whether it had been their whole history of immunization. So I actually had to sort of throw that data out. But there was 70 percent that did indicate they had received something.

Eighty-seven percent knew that they had additional traveler's health insurance. Both of the companies involved did take out additional health insurance for all of their travelers. So there was about 13 percent that weren't aware of that.

Eighty-eight percent had some pre-travel information. They had reported they received some counseling prior to going on the trip. Now, this question was interesting because I had 24 different recommended pre-travel advice information items for them to choose from, and only 3 percent had received all of those information, and there was about 12 percent who didn't receive any information.

I did, once they were overseas, ask them about some of their self-protective behaviors. Fifty-four percent did not carry a travel kit. About 21 percent reported to using more alcohol than they would normally at home. And about somewhere between 6 and 14/15 percent indicated that they had not used the recommended food and water and antimalarial recommendations for them. And about 6 percent had no time for relaxation.

I used the Karasek & Theorell job strain/job demands model to ask a couple of questions regarding their perception of their work demands. About three-quarters perceived their work demands overseas as either psychologically demanding or hectic; whereas, only about 17 percent found them physically demanding.

With respect to their physical health experiences, I presented them with a list of 25 items of health problems, health symptoms, and asked them to indicate whether or not they experienced the symptom more than they would normally have experienced it at home. So I followed the Getz study model of asking them to be basically their own controls and to indicate whether they experienced the symptom more than or less than at home. And I found that, overall, 76 percent had indicated at least one travel-related problem. There was, on average, about 2.7 problems per person, and no one had over 12 problems.

Excluded from that question was the question about jet lag and traveler's diarrhea. So there were 74 percent who had indicated they were having problems with jet lag, and 45 percent with traveler's diarrhea. And of that 45 percent with traveler's diarrhea, 22 percent of those had severe incapacitating diarrhea associated with a fever. And about 12 to 16 percent indicated that they had sunburn or heat exhaustion problems, as well.

There was about 2 percent that reported injuries, nonwork-related-type injuries: skin, musculoskeletal-kinds of problems, and there were no work-related injuries, there were no cases of malaria. There was one case of cholera.

This was some of the percentages for the list of travel-related health problems. Some of the factors: Age, younger age was significantly related to the traveler's diarrhea, as well as travel-related health problems. As they stayed longer, the travel-related health problems increased, as well as traveler's diarrhea, with stay over 2 weeks. I found a significant relationship with destination, not necessarily surprising, between jet lag and East-West destinations. And I'm not sure exactly why, but there was a significant relationship with traveler's diarrhea and Middle East or North Africa.

With the high-risk behaviors, some of these were a little harder to interpret. They were a bit counterintuitive, but there was a significant relationship between traveler's diarrhea and making their own meals and staying in company facilities and staying in company quarters, which my immediate reaction on that was that very likely the local facilities for preparation of food and whatnot may not have been the local people who may have been hired to be involved in that had not been screened. There was a significant relationship between traveler's diarrhea and also being more careful to observe food and water precautions, and, again, that was kind of a bit confounding but—or a bit confusing, but I think it was—I was really unable to decide whether the behavior started before the traveler's diarrhea or the traveler's diarrhea started before the behavior. So that was a bit harder to interpret.

There was also a significant relationship between those with travel-related health problems and those with pre-travel stress, as well as an increase with travel-related worries.

The psychological data was also another interesting finding in this study. They looked at a number of—I looked at a number of measures for psychosocial health, and I used a scale that was developed by Black and Stevens in the United States here, and they had indicated 12 adjustment—11 adjustment issues, and I had adapted that to about 17, things like environment, crowding, pace of work, that sort of thing. And about 96 percent indicated that there was at least one area that they needed to adjust in their life overseas; 39 percent of those were in the high to extreme range.

With respect to the travel-related worries, I adapted Dr. McIntosh's scale and increased that from six travel-related stressors to 17 areas, and, again, there was a high number, 92 percent had at least one travel-related worry—on average 7.4 worries per person. Mostly these were in safety, security, health, leaving the family, those kinds of—interacting with the cultural, those kinds of things.

I also asked an open-ended question regarding the impact on their family, and listening to the discussions yesterday on the World Bank data, my data is very, very similar. It was surprising how similar our data descriptions from the respondents were.

I was able to determine then there was about 73 percent that were describing essentially a more negative family impact; whereas, about 7 percent were describing a more positive type impact.

And high stress during travel, 34 percent, and 32 percent—I used the scale developed by Dr. Zaff (ph) in Canada that there isn't much out there for culture shock measurement, and his scale looked at a number of feelings and experiences, and I adapted that a bit for this study and found that there was about 32 percent that described negative feelings, and about 6 percent indicated a greater degree of depression during their trip than normally at home.

I'm not going to go into too much of the family life data here, but you would see that it's very similar to the World Bank description of effect on family life and difficulties with readjustments back home.

There were a number of good descriptions about composite of responses to family life as well.

The risk factors for the travel worries and stress: destination was significantly related to travel, not sure exactly why specifically, but the length of stay, those staying longer, was also related to more stress. And this one was very interesting about those who had more travel experience, those staying longer—or those having traveled more than ten times in five years also were more—that group was more significantly related to stress.

A significant relationship with psychologically demand job, a significant relationship with supervisory responsibilities and work relationships, and a significant relationship between those with pre-travel stress and those with stress during the travel.

I also did a number of measures, as I indicated, on work performance. There was about 9 percent reported that the trip was unsuccessful. There was about 29 percent that indicated the enjoyability of the trip was reduced; 4 percent were sick enough to lose time overseas and about 2 percent on their return back home. Four percent changed their plans overseas, and specifically with respect to work performance, I adapted a scale developed by Earley (ph) in the United States here that was developed in the late 1980s and looked at four dimensions of work performance, getting along with others, their overall performance, getting the work done on time, and the quality of the performance. And I was able to develop a composite score and calculated a composite score on that, and overall there was about 15 percent that reported lower work performance.

I'm going to skip over that one.

About 10—just sort of a general kind of question that there was about 36 percent that indicated that there was a high to extreme range of risk and about 45 percent high to extreme risk they perceived for stress.

So, essentially, just to summarize, I was able to demonstrate that work-related travel was not necessarily risk free, that there is a high prevalence of travel-related health problems, higher than showing perhaps in some of the other studies. At the same time, there is a low risk for work-related incidents and accidents. There were no deaths, no serious injuries.

The problems, I rank-ordered them with disruptions in the sleep/rest patterns, with traveler's diarrhea and nutritional elimination patterns, and in their climate adaptation problems. And there is certainly a role for occupational health in preparation, pre-travel preparation.

With respect to the psychological experience, there is also a high prevalence of stress in this group and psychological upheaval for the international business traveler in terms of their anxieties and their worries and concerns regarding adjustment.

The findings demonstrate that there was a persistently high level of stress throughout the travel experience, from pre-travel to during travel to afterwards, and that was roughly about 30 to 35 percent. And I compared that with some Canadian general population data that showed that about 10 percent of the adult population will describe their lives as being very stressful, and basically four types of stress: work stress, travel stress, culture, and stress related to leaving their family.

We'll leave the implications for this afternoon's discussion, so thank you very much.

[APPLAUSE]

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