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Travel health clinics: communicating with patients

Liz Rosies RGN MSc(TravelHealth) PGCE
Travel Health Nurse

Offering the highest-quality consultation involves constantly evaluating what we do in travel health and communicating effectively with our travellers to ensure effective health education outcomes

Research has shown that nurses who give travel health advice on a regular basis feel confident in their ability to do so. However, it is also observed that there are high levels of
inconsistency in the advice communicated.1

Further studies have suggested that travellers receive inconsistent advice, often having an inaccurate perception of the risks involved, either through being under-cautious for some high-risk destinations, or being overly concerned when visiting low-risk malaria regions.2

Communicating risk
Effective communication has to begin with an understanding of the risks involved and a correct interpretation of that risk before it is discussed with the traveller. This then has to be communicated to the traveller in a way that is understandable to them. Recent unpublished research conducted by MASTA suggests that nurses use several key sources to help ascertain risk, with the majority using Travax and the National Travel Health Network and Centre (NaTHNaC).

However, it was also seen that even when nurses were using these same resources the communication of the risk to the traveller was variable. When nurses were presented with a scenario related to an older traveller going to visit relatives in Ghana for a month, using their preferred information sources to guide them, there was variability in terms of vaccinations and other health advice that would be discussed with the traveller.

In fact, only 12 of 94 nurses considered all eight diseases that were relevant for this trip scenario.1 Some sources used in travel health consultations offer alphabetical listing of risks related to a destination. If a nurse only sees this information when the traveller arrives for the consultation, time is already a factor.

With time restraints so often impeding effective communication, we need to consider other methods of interacting with travellers and not rely solely on the consultation time. Considering the use of alternative tools for communicating, such as DVDs in the waiting room, leaflets, email and web-based communications can offer other ways of managing a travel health consultation. Encouraging travellers to obtain some information on the health risks they may face, as well as consider some of the pros and cons of any available vaccines before arriving at the clinic might allow more time to consider the quality of the consultation. If quality is our goal we have to begin thinking outside of the realms of normal day-to-day practice and the routine of a 'normal' travel
health consultation.

An excellent consultation is about effective communication of risk. Being able to assess how far the traveller will go towards implementing the advice given is also part of the risk assessment. We need to be able to ascertain the patient's perception of risk.

An example of this might be in the area of sun care. Advising a sun-worshipping traveller going to a tropical beach destination to stay out of the sun might prove ineffective. However, accepting that sunbathing will be part of their holiday and discussing alternatives with the patient might prove a more effective method of communication.

Risk assessment sometimes has to involve compromise with individual travellers. Offering a two-way consultation, which allows for effective understanding of the concerns and values of the traveller, is known to greatly affect concordance. It is about assessing the risks, determining which are most important for that individual traveller and communicating with bite-size pieces of information. Get the traveller on board by allowing for open discussion promoting and negotiating behaviour change, rather than preaching the facts.
 
Type of traveller
Communicating with different age groups requires a variety of strategies and can be difficult. Research has shown that younger travellers have a very different perception of risk to the older traveller, requiring different methods of communication. Many younger travellers gain most of their information from colourful travel guides and web-based applications using social media to share experiences from recent trips that are not always research based. These are the clients who run into the travel clinic at the last minute and need to be provided with information that is both up to date and motivational. Pointing younger travellers to web-based travel health databases, which can be regularly updated while they travel, will keep them up to date and provide a communication strategy that they are able to relate to.3

The type of traveller also poses communications issues; specifically, visiting friends and relatives (VFR) travellers. This area of communication still needs exploration as we are seeing rising numbers of vaccine-preventable disease and malaria in VFR travellers from the UK.4 Many issues affect communication to this group of travellers, including preconceptions and beliefs about disease, and assumed immunity, as well as language and cultural barriers.

Recent increases in imported malaria highlight the need for better methods of communication across all areas within our society. While many practices have set up initiatives to reach out to VFR travellers within their community, much of this work is within large cities and needs replication and evidence-based sharing of information and strategies across the country as a whole.

Sharing effective information
Where care is shared between a general practice clinic and a clinic offering a specialist travel health service, communication barriers can occur. A traveller told one thing by their practice nurse may be told another in a specialist travel clinic.

If a practice nurse is only seeing a handful of travellers each week and needs the traveller to visit a specialist travel clinic for further advice or additional vaccines they should consider sending the traveller to the specialist clinic first and see the traveller afterwards. This can be used as an opportunity for improving communication and discussing the traveller's plans by reinforcing the information the traveller has already been given. While part of the success in communicating to patients is in the area of understanding it is also important that the client retains the information. A study from Australia revealed that when a traveller is presented with multiple risk avoidance strategies, retention of information is often incorrect, leading to ineffective outcomes.5 Again, this highlights the need to consider alternative methods for communication.

In the area of sun safety, for example, advice that has been communicated will need to be retained while the patient is away from home, often in a relaxed, uninhibited environment, absent from all social restrictions that they might live by at home. If the same patient needs to remember numerous other aspects of safety from a travel health consultation they rushed to after a long day at work, we need to be realistic in what will be remembered and even whether that information will actually be correct. Considering who we are communicating to, what is important to communicate and how we communicate is essential.

Many health professionals talk about the knowledge-behaviour gap.6 This relates to the gap between giving information and knowledge to the patient and then seeing a change in behaviour.

A large gap has shown to be evident in many areas of travel medicine and leaves us with the question as to whether we are actually making any difference in the work we do. If not, what can we do to change things?

Conclusion
If we are able to communicate effectively we will be part of the way towards the highest-quality travel health consultation. Good communication will empower nurses and the travellers they see. If we are consistently looking for ways to improve how we communicate, this can only lead to excellence in travel health and ultimately help close the knowledge-behaviour gap in travel health promotion.

References
1.    MASTA Travel Health Advice Survey. Unpublished.
2.    Zuckerman et al. Knowledge, attitudes and practices in travel-related infectious diseases: the European Airport Survey. Journal of Travel Medicine 2004;11:3-8.
3.    Han P et al. Travel characteristics and risk-taking attitudes in youths traveling to non-industrialised countries. Journal of Travel Medicine 2010;17:316-21.
4.    Health Protection Agency (HPA). Foreign travel-associated illness - a focus on those visiting friends and relatives 2008 report. Available from: www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1231419800356
5.    Shemer S1, Johnson D1, Richards J. Immediate recall of health issues discussed during a pre-travel consultation. International Society of Travel Medicine Conference; 2011.
6.    Bauer IL. Educational issues and concerns in travel health advice: is all the effort a waste of time? Journal of Travel Medicine 2005;12:45-52.