Abstract
Introduction
Preventive health care measures are defined as intervention in the internal or external environment of a person to prevent illnesses or any other negative health issues. With preventive health care measures we are trying to eradicate or suppress illnesses, eliminate or to the highest extent reduce their consequences, or slow down their progression. There are two basic principles: a) the population principle, which is directed towards the population with the goal to reduce the risk for negative health occurrences; and, b) the individual principle, which is directed towards individuals with high risk potential, where the goal is to protect the individuals from acquiring diseases or reduce the risk of acquiring the disease. Just as with preventive health care measures we also have two different approaches towards preventive health care, a) general or nonspecific measures, which are directed towards prevention of various diseases and their consequences and b) special or specific measures, which are directed towards prevention of specific type of diseases and its consequences [1].
The desire to make it possible for people to travel healthy and safe has lead the National Institute for Public Health of Slovenia to prepare a promotional campaign entitled “Zdravi na pot+nazaj” with the main goal of promoting preventive health care before and while traveling. The main target groups of this campaign were determined to be: a) passengers, who want to obtain the right information about potential health hazards before traveling; and, b) public health workers, tourist workers, tour guides, who they want to educate about their role in promoting safe and healthy travel thus giving them the necessaryinformation [2].
Tourism can be defined as activities an individual partakes in outside of his or her standard living environment, that have a relatively short time span, and for purposes related to relaxation, getting to know new places, people, culture and heritage [3]. In every shape and form tourism includes some kind of travel, thus we can relate tourism to the travel industry [4]. However, as tourism is interconnected with various other activities as well, we cannot simply say that it is the same as the travel industry [5]. In a time of globalization, tourism has taken on a completely new meaning. Tourist travel is now accessible to everyone, leading some to say that “tourism is everything and everything is tourism” [6]. The beginnings of tourism can be found in ancient Greece, where people started to work on the concept of spending their free time actively [7]. Evidence of early tourism can also be found in the late middle ages, when children of rich families traveled to countries like France and Italy after completing their education to learn first-hand about the culture and the history of these countries [8].By the late nineteenth century, the first businesses specializing in tourism evolved into travel agencies in Great Britain, at first offering vacation in the south of Great Britain. It was not until after the First World War that tourism as a business really took off [8]. This was also when the need for individuals who organize and accompany people while traveling occurred. “A tour guide is a person who is qualified to accompany and guide tourists on shorter trips or longer travels, organized by travel agencies” [9]. A Tour guide is expected to be a good organizer, commentator, psychologist and also a diplomat. Aside from the knowledge required in different fields in order to do his or her job, such as geography, history, and art, tour guides must also have at least a basic knowledge about the health in event that they are called on to act as a nurse [10].
In this article, the theoretical aspects of preventive health care in traveling are discussed, and then the empirical findings of the research conducted among Slovenian tour guides and tour managers. The main purpose of this research was to find out how well tour guides and tour managers are acquainted with the risk of some travelers’ diseases, how proficient they are at recognizing the symptoms of such diseases, and how aware they are of preventive measures that can be taken regarding certain diseases.
Theoretical background
Travelers’ diseases and preventive measures
While traveling, passengers, tour guides and tour managers, are exposed to certain travelers’ diseases. Several of the most common ones are presented in this chapter.
Intestinal infectious diseases
Infectious intestinal disease is still one of the most common infectious diseases [11]. All intestinal infectious diseases have a common way of transmission; in most cases people get them through infected water, food or unclean hands. Most symptoms are the result of infection of the gastrointestinal tract, and include nausea, vomiting, high body temperature, and diarrhea. As far as prevention goes, it is most important to take care of basic sanitary measures and careful selection of prepared food and drinks [12]. Among intestinal infectious diseases the most common is so-called “travelers’ diarrhea”, which affects almost every third passenger traveling to underdeveloped countries. Often we can also see infection with hepatitis type A also known as epidemic or viraljaundice [12].
Diseases transmitted by insects
Insects can transmit various serious and contagious diseases, such as malaria, yellow fever, dengue, TBE and others. Malaria remains a significant health threat to the world’s population. Increases in international travel and migration, climate change, and resistance to insecticides and antimalarial drugs all contribute to the enduring nature of the disease [13]. Preventive measures are mainly focused on preventing the insects from coming in contact with a person; the most common is the use of netting on doors, windows or over sleeping areas. Another very common way to protect yourself is to use repellents and personal protection gear such as bright color clothing and insecticides. Specific measures come into consideration for specific diseases, such as antimalarial medication before and while traveling to areas in which malaria is endemic, and mandatory vacations before traveling to areas with increased risk of yellow fever [14].
Diseases which are transmitted through contact
Some diseases of the skin and mucous membranes are contagious and transmitted from person to person through direct contact and through contact with objects with surfaces contaminated by fungi, bacteria or viruses. The most common diseases transmitted through contact are scabies, herpes, ulcerated skin infections, and fungal infections of the skin and nails. Though not acquired the same way, rabies and tetanus are also one of the diseases transmitted through contact. In most cases, preventive measures include avoiding contact with animals and preventive hygiene. For some diseases, such as rabies and tetanus, vaccination is available and it is recommended for those people who are going to travel to exposed areas for longer periods of time or work with animals that pose a high risk [15]. There are also diseases that are transmitted through blood and sexual contact, and are caused by bacteria or viruses. Through contaminated blood or sexual contact a person can get HIV/AIDS, hepatitis type B and C, and the Ebola virus. Hepatitis type B, HIV and syphilis can also be transmitted through objects that have been contaminated with contaminated blood, and by exposure through acupuncture, piercings, tattoos and medical equipment. Among these diseases, hepatitis type B is the most common, and it is estimated that more than 5% of the world’s population is infected. In most cases there are no direct preventive measures; however, for some diseases there is a possibility of vaccination, which is recommended for people traveling to more exposed areas where hygiene standards in health care are lower than in the developed world [16]. These types of diseases make up a large portion of infectious diseases and are a significant public-health and financial burden on society worldwide [17].
Respiratory disease
Influenza (flu) is a contagious acute respiratorydisease caused by a virus and is transmitted by infected droplets. The most common way of transmission is through air, large droplets separated from the respiratory tract by direct contact with people and infected objects. Primary preventive measures are related to increasing resistance through proper food, exercise, avoiding stress and exposure to tobacco and alcohol. Some types of influenza can also be stopped with vaccination [18]. Chronic respiratory disease is among the leading causes of death worldwide. Developing countries are experiencing a dramatic increase in the prevalence of respiratory diseases and projected trends of severity and frequency are likely to pose a public health challenge [19].
Preventive health care at work
There is a wide array of services intended to promote a healthy work environment. So called occupational health services are intended to be a resource for companies in the prevention and elimination of hazards at work, and are endorsed by the World Health Organization [20].
When it comes to questions regarding about the well-being of employees, every employer’s desire should be to have healthy employees. In order to achieve this it is important to change from a focus on reactive medical care and services towards a greater emphasis on promotion and prevention services [21]. Promotion of preventive health care is of paramount importance when it comes to professions with greater exposure to certain health care risks than others, as tour guides and tour managers are due to the nature of their work.
Tour guides and tour managers
Tour guides and tour managers have a hard and demanding profession, and those who wish to work in it need certain predispositions in order to be successful. An individual working in this profession needs to have excellent communication skills, a positive attitude towards work, calm personality, good self-organizational skills, and ability of systematic thinking [22].
In the Republic of Slovenia, the profession of tour guides and tour managers is only partially regulated [23], and these regulations are more or less related to acquiring a license to be able to work as a tour guide or a tour manager. Applicable laws [23] specify entry criteria that limits who can actually obtain a license as a tour guide or a tour manager, and differentiates the roles of each. In this sense, the role of tour managers is to manage the administration of the tour while the content of the tour is done by local tour guides at the area of travel. Tour managers combine these two roles into one person. We have to understand that obtaining the license for a tour guide or a tour manager is only “the first step in this world that demands from a person to do much more studying before he or she can become a good tour guide or a tour manager” [22]. In its current form, education for tour guides and tour managers in Slovenia includes no content related to health care as we have established in the previous research [24]. Tour guides and tour managers clearly report that they would need more practical knowledge, and this also supports the initial thought about the lack of knowledge in this area [22].
Resarch method
Description of research instrumentand sample
Data used in this research is a part of a wider survey conducted among tour guides and tour managers in the Republic of Slovenia as a specific work group that is exposed to certain diseases related to traveling to a larger extent than an average work group. The wider survey also included questions regarding guiding techniques, satisfaction with certification process and general job satisfaction of tour guides and tour managers. The wider survey had all together 100 questions asking about various topics mentioned above and additional 7 questions regarding demographics. The survey was piloted before being conducted on a full scale (n = 30), the results of the pilot survey are not included in the data presented in this article, and the respondents who had been a part of the pilot survey were also excluded from the main survey.
For the purpose of the research we have created a questionnaire divided into several parts. In the first part, we wanted to know how well tour guides and tour managers know certain typical diseases related to traveling. In the second part of the survey, we wanted to know how well tour guides and tour managers know the symptoms of certain diseases related to traveling, In the third part, we wanted to know what types of preventive measures tour guides and tour managers use or would use if they were traveling into high risk environments. At the conclusion of the questionnaire, we also asked the tour guides and tour managers some general questions related to demographics including age, gender, level of education, the amount of days they work, and areas in which they work.
Excluding questions regarding demographics, all other questions were formed as statements, and we asked interviewees to answer them by indicating to what degree they agree with the statement. Grades were given on a five point Likert scale of 1 to 5 where 1 presented a value “I do not agree at all” and 5 “I agree completely” or any other value in between.
The research was conducted between January 29, 2014, and February 28, 2014, among 500 randomly selected tour guides and tour managers. The survey was made online and the e-mail addresses of the tour guides and tour managers were gathered through the publicly accessible web page of the Chamber of Commerce [25]. A link to the online questionnaire was sent out via e-mail to the randomly selected tour guides and tour managers asking them to participate in the study.
As of December 31st 2013 there were 1978 tour guides and tour managers licensed and registered in Slovenia [26]. The randomly selected sample of 500 interviewees represents 25.27% of the entire population, by the end of the survey we have gathered 120 valid answers, this represents 24.00% of the selected sample or 6.06% of the entire population.
For the analysis of the data we have used SPSS for Windows program pack, as far as methods goes we have used descriptive statistics and t-test, we have also tested the questionnaire with Cronbach Alpha coefficient. The value of the Cronbach Alpha coefficient was measured at 0.863, and this confirms the high reliability of the measuring instrument.
Sample validity
Research sample included 43.6% (n = 41) male and 56.4% (n = 53) female respondents. The average age of the respondents was 42.16 years of age.
For the values of gender and average age we could compare our sample to the population; calculation of chi-square (χ2) goodness of fit test for the variable gender showed the value of 0,130 and the significance of p = 0.719, with variables that have one degree of freedom the value of chi-square (χ2) lower than 3.8415 at the significance value higher of 0.05 (or 5%), shows a valid sample. For the average age we have calculated with the help of one sample t-test the value of t = 0.705 and the significance 0.482, which again confirms that our sample is valid.
Other demographic data for the population were not available, therefore could not be compared to the population, and showed that among the respondents there were 23.2% (n = 22) of those with high school education, 67.3% (n = 64) with undergraduate education and 9.5% (n = 9) with some kind of postgraduate education. Among the respondents there were 72.6% (n = 69) of tour guides and 27.4% (n = 26) of tour managers. We have also asked the respondents how many years they have been working in this profession, 45.4% (n = 43) of the respondents have been working as tour guides or tour managers for less than 10 years, 38.3% (n = 36) of the respondents have been working as tour guides or tour managers between 10 and 20 years, 11.7% (n = 11) between 21 and 30 years and 4.3% (n = 4) for more than 30 years. More than half of the respondents 55.8% (n = 53) do up to 50 days of work as tour guides or tour managers per year, 23.1% (n = 22) do between 50 and 100 days per year and 21.1% (n = 20) do more than 100 days per year.
Research question and hypothesis
The main research question of this article is: “How much do tour guides and tour managers know about diseases that they may encounter in the course of their work?” Since it is impossible to analyze all travel related diseases we have decided to analyze only the ones mentioned already above in the theoretical part, these are; malaria, yellow fever, rabies, hepatitis type A, hepatitis type B, dengue, traveler’s diarrhea and repertory disease (influenza), we will from this point on refer to them as certain travel diseases.
For the purpose of answering the research question of this article we have created the following research hypothesis: H 1: Tour guides and tour managers awareness of exposure to certain travelers’ diseases is evaluated on average higher than 3.50. H 2: Tour guides and tour managers evaluate their knowledge of the symptoms of certain travelers’ diseases above the average grade of 3.00. H 3: Tour guides and tour managers would in majority of the cases select the appropriate primary preventive protection measures against certain travelers’ diseases. H 4: Tour managers are better acquainted with exposure risks for certain travelers’ diseases better than tour guides.
Results analysis
Analysis of individual variables
The first step was to analyze the mean values and standard deviations with certain variables, in the first step we wanted to know to what extent the respondents are acquainted with certain common diseases that they can be exposed to while traveling. The results are shown in Table 1.
The mean values themselves indicate that in the majority of cases the respondents are familiar with the risk of exposure to certain travelers’ diseases. Exception here is very obviously dengue, where mean value is the lowest and standard deviation is the highest; because of these two values we decided to look into the answers about dengue more specifically. We have found out that 47.4% of the respondents are not familiar with the risks of exposure to dengue, further 16.4% of the respondents know very little about dengue, 12.1% have indicated that they know something about dengue, 9.5% of the respondents have stated that they know quite a bit about dengue and only 14.7% of the respondents are well aware of the risks of exposure to dengue.
Furthermore we wanted to know how well the respondents know the primary symptoms of the common diseases that they can be exposed to while traveling. The results are shown in Table 2.
In this segment the mean values themselves indicate that in the majority of cases the respondents are not familiar with the symptoms of certain travelers’ diseases. In this case dengue also has by far the lowest mean value and a high standard deviation, thus we decided to look into the answers about dengue more specifically. We have found out that 62.7% of the respondents are not familiar with the symptoms of dengue, further 14.7% of the respondents know very little about the symptoms of dengue, 8.8% have indicated that they know something about the symptoms of dengue, 6.9% respondents have stated that they know quite a bit about the symptoms of dengue and only 6.9% of the respondents know the symptoms of dengue very well.
In the third part we wanted to know what type of preventive measures the respondents would use to be safe from certain travelers’ diseases. The results are shown in Table 3.
As we can see the most common way of protection selected by the respondents is vaccination for yellow fever, rabies and hepatitis type A and B. As the most common way of protection against malaria the respondents have selected antimalarial drugs, against traveler’s diarrhea and respiratory diseases the respondents have selected the answer “hygiene (boiling of water, washing hands)”, and against dengue the majority have selected just caution since in their understanding protection against dengue does not exist.
Analysis of statistically significant differences
In the last fourth part we wanted to know if there are any statistically significant differences regarding their knowledge of exposure risks regarding certain travel diseases between tour guides and tour managers. The results are shown in Table 4.
With the help of a t-test we have determined statistically significant differences between tour guides and tour managers when it comes to their knowledge about exposure to certain travel diseases. A statistically significant difference was noticed with yellow fever (t = –2.063, p = 0.045), where tour managers evaluate their knowledge about exposure to yellow fever higher (3.80) than tour guides (3.13). We have also found statistically significant differences with hepatitis type B (t = –2.246; p = 0.031), where tour managers evaluate their knowledge about exposure to hepatitis type B higher (3.18) than tour guides (2.45). In all other cases there were no statistically significant differences, however in all cases tour managers evaluated their knowledge about certain travel diseases higher than tour guides.
Interpretation of results and discussion
Through research we have discovered that tour guides and tour managers are familiar with some of the common travelers’ diseases relatively well. The highest mean value was noted at traveler’s diarrhea (4.35), followed by influenza (flu) (4.30) and rabies (3.83). The lowest value was noted with dengue (2.28). This last data could be marked as alarming, since dengue is one of the world’s fastest spreading diseases [27], and the last information shows that it may be found relatively nearby in the southern Mediterranean area. We believe the answer to why tour guides and tour managers know dengue so poorly is that most of the symptoms are relatively similar to malaria, though it is not the same disease. Based on the findings of the first segment we can retain H1: Tour guides and tour managers’ awareness of exposure to certain travelers’ diseases is evaluated on average higher than 3.50, since in the majority of cases the measured value exceeds the value set in the hypothesis.
Later in our questionnaire we questioned how well tour guides and tour managers know the most common symptoms of the common travelers’ diseases. The highest mean value was noted at traveler’s diarrhea (4.34), followed by influenza (flu) (4.27) and malaria (3.15). The lowest value was noted again with dengue (1.80). We have to be aware that in quite some of the cases the symptoms are similar, high fever, malaise and so on. For confirming individual diseases modern medicine uses blood tests and it is of course not reasonable to expect from tour guides or tour managers to recognize individual diseases based only on the visible signs. Although based on the mean values in this second segment we can reject H 2: Tour guides and tour managers evaluate their knowledge of the symptoms of certain travelers’ diseases above the average grade of 3.00, since the majority of mean values has been below the mean value of the scale.
In the third segment we wanted to see to what extent tour guides and tour managers know the recommended primary preventive protective measures against certain travelers’ diseases [28]. In the case of malaria, primary protection selected by tour guides and tour managers is antimalarial drugs (39.4%), which is also what experts recommend. As a secondary protection, tour guides and tour managers would select vaccination (38.5%), which does not exist. In the third place, we found repellents (spray & dry stick) (14.7%), which is a recommended secondary mean of protection by experts.
In the case of yellow fever, primary protection selected by tour guides and tour managers is vaccination (80.8%), which is also what experts recommend. As a secondary protection tour guides and tour managers would select hygiene (boiling of water, washing hands) (7.7%), this is not defined by experts. Only in the third place did we find repellents (spray & dry stick) (3.8%), which are a recommended secondary mean of protection by experts.
In the case of rabies, primary protection selected by tour guides and tour managers is vaccination (64.1%), which is a secondary mean of protection according to experts. As a secondary means of protection tour guides and tour managers would select caution (28.2%), and this is a primary mean of protection according to experts.
For hepatitis type A tour guides and tour managers would primarily use vaccination (71.0%), which is also a primary protection recommended by experts. As a secondary means tour guides and tour managers would use hygiene (boiling of water, washing hands) (18.0%), which is also a secondary mean of protection recommended by experts along with caution.
As for hepatitis type B tour guides and tour managers would primarily use vaccination (75.8%), which is also a primary protection recommended by experts. Second on the list is hygiene (boiling of water, washing hands) (14.1%), which is not defined by experts as a means of protection. However, caution is recommended and it placed third (6.1%) by tour guides and tour managers.
In the case of dengue tour guides and tour managers would use caution as a primary protection (25.6%), which is by experts defined as a secondary protection. Repellents (spray & dry stick), which are recommended by experts as a primary protection were only found in the third place (20.9%). Tour guides and tour managers positioned vaccination in between (22.1%), despite the fact that it is not an option.
For traveler’s diarrhea, tour guides and tour managers would use hygiene (boiling of water, washing hands) (68.2%) as a primary protection, which is also the primary protection defined by experts. This is followed by antimalarial drugs (19.1%) which are also the secondary protection recommended by experts along with cautiousness.
The last disease we looked into was influenza (flu) where hygiene (boiling of water, washing hands) (35.2%) is the primary choice of protection by tour guides and tour managers, followed by cautiousness (24.1%) and vaccination (19.4%). Due to a wide spectrum of causes for this disease experts do not have any specific recommendation.
Based on the findings in this segment we can retain H 3: Tour guides and tour managers would in majority of the cases select the appropriate primary preventive protection measures against certain travelers’ diseases, since we have found out that in five out of eight cases tour guides and tour managers would have selected the primary protection measure recommended by the experts.
In the final segment we have tested statistically significant differences between types of license. We have found out that tour managers evaluate their knowledge about exposure to yellow fever (mean values 3.80 and 3.18) and hepatitis type B (mean values 3.13 and 2.45) better than tour guides. It is true that yellow fever and hepatitis type B are the only two diseases where we could prove statistically significant difference, but in all other cases tour managers evaluated their knowledge about certain travel diseases higher than tour guides. These differences can be explained by the fact that by law tour managers usually take tours to less developed countries where local tour guides take over the role of guiding [29], whereas tour guides more often do tours in developed countries with no local tour guides. Based on this finding we can retain H 4: Tour managers are better acquainted with exposure risks for certain travelers’ diseases better than tour guides.
Conclusion
Common travelers’ diseases are certainly something that tour guides and tour managers are exposed to due to their profession. It is interesting to note that we were able to find no similar research that would focus on the same problem and research group as we have chosen.
However, preventive health care is in this sense very important for this group since it directly impacts their well-being, performance, and also indirectly, their career. Based on all of this it is reasonable to expect that tour guides and tour managers would know common travelers’ diseases, their symptoms, and above all the means of how to protect themselves and their passengers from these diseases. It is of course not reasonable to expect that tour guides and tour managers would have the in-depth knowledge in the field of medicine, but some basics are expected.
When it comes to travelers diseases there are certain regulations that some countries impose (for example mandatory vaccination before travel to certain areas) this can be seen as public health issue, since regulations are in place to prevent public health issues, but when it comes to those diseases that are not transmitted between humans directly in vast majority of cases individual is on his or her own to make sure that he or she is protected and it is in this case we can truly argue that we cannot generalize travelers diseases to public health issue alone but it is also a great deal of prevention on individuals part.
This brings us to our research question: “How much do tour guides and tour managers know about health-related diseases that they may encounter when doing tours?” Through the research we have seen that tour guides and tour managers are relatively well acquainted with common travelers’ diseases and their symptoms. On the other hand, the research also showed that tour guides and tour managers have quite a lack of knowledge when it comes to identification of symptoms. When it comes to selecting the primary preventive measures for these same diseases we can say that tour guides and tour managers have some knowledge, but results could be much better, and this is what is alarming. Next to the concern for their own health, tour guides and tour managers are also responsible for their passengers. This is not a legal responsibility (legal responsibility is on the shoulders of travel agencies) but more a moral one since passengers can reasonably expect that their tour guides or tour managers will have the knowledge of the area they are taking them to, including knowledge about relevant basic preventive health care issues.
The results of this research may be useful primarily to tour guides, travel agencies, professional associations, and also to the Chamber of Commerce of the Republic of Slovenia for preparation of additional seminars and educational material in this field. In the modern world of travel, knowledge of preventive healthcare cannot be neglected.
We must also indicate some of the limitations of our research regarding the diseases included as we have selected diseases that we are not commonly exposed to in the wider area in which we live. However, we have incorporated a broad cross-section of tour guides and tour managers that travel to areas with greater risk, and the most common forms of traveler’s diseases. Another limitation is also the size of the research, since we have conducted the research only on Slovenian tour guides and tour managers. As far as future research goes, it would be interesting survey tour guides and tour managers internationally that travel to areas with greater risk of disease and see how well they are educated about such risks, symptoms and preventive protection.
Conflict of interest
The authors have no conflict of interest to report.
Footnotes
Acknowledgments
Firstly, we would like to thank all the tour guides and tour managers for answering our questionnaire; this helped us to obtain the information that was the foundation for this research. This also helped us to give our small contribution in shining some light on this potential problem. We would also like to thank to the reviewers for their contribution and to the editorial board that took time to look into our article. Without your valuable suggestions this article would have never come out as it has. Thank you all.