ABSTRACT
This study aimed to assess the attitudes and awareness of medical doctors practicing in Turkey about the discipline of travel medicine (TM).
This study was a cross-sectional survey conducted via the internet for 1 month between January 10, 2020 and February 10, 2020. The study participants were medical students or graduated medical doctors. The questionnaire used for the survey was broadly structured to measure participants’ education on TM, perception of TM, and general knowledge about TM.
A total of 502 participants were included in the study, of which 188 (37.4%) were medical students and 314 (62.6%) were medical doctors. Forty-nine out of 82 (60%) medical faculties’ students or graduates took part in this study. Experience in medicine was significantly associated with education and perception of TM but not with general knowledge about TM.
Our data indicate that medical doctors in Turkey are not familiar with the discipline (60%) and that the medical doctors believe that the importance of TM is increasing (58.4%). In total, 93.2% participants believe that social awareness about TM is insufficient. A total of 69% participants believe that infectious diseases make up the bulk of TM. To the best of our knowledge, this study is the first study to assess the awareness and attitudes of medical doctors in Turkey about TM.
Keywords: Travel medicine, medical education, migration medicine, Turkey
INTRODUCTION
Travel medicine (TM) defines all travel-related health and illness conditions. It is a medical discipline that can be dealt with in a wide range, from infectious diseases such as malaria, tourist diarrhea, yellow fever to problems encountered during travel such as trauma, embolism, jet-lag, sunburn, and all similar travel-related conditions (1,2). Although TM is a comprehensive discipline, one of its main components is infectious diseases (3,4). Among these infectious diseases, parasitic and tropical diseases are the major causes of mortality and morbidity (5-7).
International travel is one of the most important routes for the spread of infectious diseases (8). It is reported that in 2018, 1.4 billion people traveled internationally and the world tourism volume exceeded $1.7 trillion (9). TM, which is a relatively new field of medicine, is a discipline that directly affects more than 1.4 billion people all over the world and indirectly concerns the whole world population. TM is expected to develop rapidly due to reasons such as increased travel opportunities and facilitation of international travel in general (10). There are travel disease clinics and centers in Europe, Australia, and North America, and collaborations such as GeoSentinel and EuroTravNet try to provide worldwide surveillance (3,4).
Turkey is situated as a geographical bridge between three continents; Asia, Africa, and Europe. Owing to its geographical location, it is a major route for displaced people like migrants, asylum seekers, and refugees to get to Europe. According to the United Nations Refugee Agency (UNHCR), 57% of UNHCR refugees came from 3 countries; Syria, Afghanistan and South Sudan (11). Turkey is the main route for Syrian and Afghan refugees to get in Europe and thus Turkey is the World’s largest refugee-hosting country with more than 3.7 million refugees (11). There have been several reports of imported cases of malaria and leishmaniasis, both among refugees and Turkish residents (12,13). In addition to that, with its temperate climate, long coastal line, and rich cultural heritage, Turkey is an important destination for international tourists. According to the World Tourism Organization’s latest report, Turkey is the 6th top destination for tourist arrivals worldwide, receiving more than 46 million tourists in 2018 (9).
This study aims to assess the awareness and attitudes of medical students and medical doctors practicing in Turkey, about the discipline of TM.
METHODS
Design
This study was a cross-sectional survey that was distributed via the internet for one month between 10 January and 10 February 2020. The participant’s consent was obtained by the acceptance for the completion of the questionnaire and all the participant’s e-mail addresses were demanded for the authentication via e-mail. All the participants were informed that the answers would be published anonymously.
Subjects
The targeted participants were either medical students or graduated medical doctors over 18 years of age. Medical students were grouped as; 1st-3rd grade and 4th-6th grade medical students and medical doctors as; to 10 years after graduation, 10 to 20 years after graduation and 20 years or more after graduation.
Questionnaire
The questionnaire was pretested for the validity of questions by a group of ten physicians with clinical experience in the field of TM. This group of physicians consists of infectious diseases, internal medicine, emergency medicine, clinical microbiology and clinical parasitology specialists working in various clinics around Turkey.
The questionnaire was broadly structured in three objective categories to measure participants’; A. Education on TM, B. Perception of TM, C. General knowledge about TM. The statements in the questionnaire were randomly placed and participants were asked to answer the statements from a five-point likert scale. The participants were asked to give points to each statement, from 1 to 5 where the numbers stand for; 1. Strongly disagree - 5. Strongly agree. The statements in the questionnaire are shown in Table 1.
Statistical Analysis
Descriptive data analysis of means was conducted using the Statistics package (SPSS Statistics 22 version). Multinomial logistic regression was used with the reference category ‘‘medical student 1st-3rd grade’’. Results were depicted with B coefficients, and 95% confidence intervals. Statistical analysis of each objective category for every participant group has been conducted. Five participant groups have been compared based on the experience level (years passed in medical practice starting from the 1st year of medical faculty).
RESULTS
There were 502 participants included in the study. The participant’s answers to statements between Statement-1 (S-1) and S-15 from a scale of 1 to 5 respectively are provided in Table 1. Of all participants (n=502), 22.7% were medical students in the 1st-3rd grade and 14.7% were 4th-6th grade. Participants who are medical doctors who have less than 10 years of experience, 10-20 years of experience and more than 20 years of experience make up 35.9%, 9% and 17.7% of all participants respectively (Figure 1).
Fourty-nine out of 82 (60%) Turkish medical faculties’ students or graduates have taken part in this study. These medical faculties are distributed across all geographical regions of Turkey.
The average points given to every individual statement by participant groups have been compared statistically. Mean value has been calculated for each objective category (A, B, C) based on the relevant statements. The mean value for each objective category is presented for each participant group in Figure 2.
Statistical analysis of each objective category for each participant group based on their experience levels have been calculated (Table 2). Experience in medicine was significantly associated with education on TM (x2: 12.8, df: 4, p=0.01), and perception of TM (x2: 13.0, df: 4, p=0.01). The association between experience in medicine and general knowledge about TM was below the significance level (x2: 9.06, df: 4, p=0.06). Detailed statistical analysis reports for each statement and objective category has been provided as Supplementary material.
DISCUSSION
Travel history is a very important component of anamnesis. Every physician, regardless of their specializations, institutes or positions, should include travel history for every anamnesis they take (10). A thorough travel history will enable the physician to better identify the possible causes of the illness and enable him/her to contain it in cases of infectious diseases (14). The current Coronavirus disease-2019 (COVID-19) pandemic displays the fragility of our global health administration mechanisms against novel or re-emerging infectious agents (15). Health professionals and, medical doctors in particular, are the main actors for the prevention and management of epidemics or even pandemics caused by these agents. Therefore, their awareness and knowledge about TM is crucial to prevent and contain these situations.
Interpretation of our data indicates that most of the medical doctors in Turkey have not received any education about TM (84.4% of participants) but they are aware of the need for education possibilities about it. Perception of TM (Category B) was the highest-ranking objective category for all the study groups, while education on TM (Category A) was the lowest, pointing out the awareness of medical doctors about TM (Figure 2). Among all study groups, 70% of the participants believe that the necessary curriculum for TM was not available to them. Our data also shows that even if most of them are not familiar with the discipline of TM (60%), most of them believe the importance of TM is increasing (58.4%) and they are willing to participate in educational works about TM (55.8%). 93.2% of the participants believe the social awareness about TM is insufficient which in our opinion points out to the fact that if physicians’ awareness is improved, social awareness about TM will improve proportionally. Most of the physicians in Turkey believe, infectious diseases make up the bulk of TM (69%) and TM is important for the amelioration of human health (63.6%).
Our study indicates that TM education should be included in the curriculum of medical faculties in Turkey. Several studies have been conducted about the importance of TM education in medical faculties. A single question travel history is no longer sufficient for coping with travel-related medical conditions and especially for the emerging and re-emerging diseases (16). A recent study by Flaherty et al. (17) discusses the benefits of integrating special study modules to undergraduate medical curriculum. In addition to that, general practitioners’ awareness and knowledge about TM should be constantly increased and kept up-to-date (18).
CONCLUSION
Data of this study was collected in a unique interval between January-February 2020, just weeks before World Health Organization declared COVID-19 as a pandemic. Our study outlines the need for TM education both for undergraduate and graduate medical doctors. There is significant difference between undergraduate and graduate medical doctors for the awareness or attitudes about TM which points out to the fact that medical doctors’ awareness of TM is increasing with work experience. Considering Turkey’s geopolitical position, tourist potential, İstanbul’s possible role as an important hub in terms of airline traffic, and the ongoing global refugee crisis, TM clinics are considered to be a necessity for Turkey.
Our study is the first study to assess the awareness and attitudes of medical doctors about TM in Turkey and to the best of our knowledge in the literature.
ACKNOWLEDGEMENTS
The authors would like to thank Dr. Sıla Selin Tunalı for her invaluable help in distributing the questionnaire nationwide and Dr. Umut Kırlı for assessing the data. We also would like to thank Turkish Society of Microbiology Study Group for Infections Related to Migration and Travel for their support.
* Ethics
Ethics Committee Approval: This study was a cross-sectional survey that was distributed via the internet for one month between 10 January and 10 February 2020.
Informed Consent: Informed consent was obtained.
Peer-review: Internally peer-reviewed.
Financial Disclosure: The author declared that this study received no financial support.
