1. Introduction
Many travellers do not seek pre-travel health advice before travelling overseas, and those who do mainly obtain advice from general practitioners (GP) or travel health clinics [
1,
2,
3,
4,
5]. Reasons given for failing to obtain pre-travel health advice include the travellers’ lack of perception of the risks associated with their destination or difficulties in making appointments with travel health providers [
6,
7,
8,
9]. Pharmacists are often seen as being accessible and convenient due to their extensive opening hours, thus offering an attractive alternative to increase the frequency and quality of pre-travel advice sought by some travellers [
6,
7,
8,
9]. Pharmacists do play a significant role in the provision of travel health services, although the complexity of the travel health services offered by pharmacists varies somewhat from country to country and region to region [
9,
10]. In Australia, although most pharmacists will at least respond to simple travel-related requests when asked, most pharmacists play a limited role, and although pharmacist immunisation with a limited range of vaccines is now common, pharmacists are unable to administer travel-related vaccinations such as cholera and yellow fever [
10]. However, although pharmacists are generally considered to have good knowledge on commonly encountered areas in travel health, such as travellers’ diarrhoea [
11], it has also been suggested that generalist pharmacists may have some knowledge deficiencies, potentially affecting the quality of the travel health information delivered [
12,
13].
Kodkani et al. [
12] examined the knowledge of travel-related health issues amongst Swiss pharmacists and found their overall knowledge to be satisfactory. However, there were areas, such as sun protection, travel vaccinations and malaria prophylaxis, where the information given by the pharmacists was considered lacking. In addition, few pharmacists used specialised travel health information resources when educating travellers and wanted a single, up-to-date, easy-to-use, travel health information resource specifically for use in pharmacies [
12]. Kodkani et al. evaluated the pharmacists’ knowledge of the vaccines and antimalarial agents recommended for two common tropical holiday destinations for Swiss tourists (Kenya and Thailand). They found that only 19% and 31% gave accurate advice for malaria protection, and that only 13% and 3% provided appropriate recommendations for vaccinations for Thailand and Kenya, respectively [
12]. However, 50% of pharmacists said that in practice they would have consulted standard reference materials before answering such questions, which was confirmed on follow-up, where 74% and 93% of pharmacists gave correct advice for malaria protection for Thailand and Kenya respectively [
12].
Another study examining the quality of travel advice given to international travellers by pharmacists was performed in Portugal [
13] where most of the responding Portuguese pharmacists (93%) did not have any additional training in travel health. The study found gaps in pharmacists’ knowledge of travel health and inaccuracies were found in the advice given by the pharmacists [
13]. The researchers concluded that the pharmacists in the study required more training in the area of travel health as the advice they gave was often incomplete and/or incorrect [
13]. Most of the responding pharmacists said that they would like more training or information to use in their practice [
13]. Similar to the Swiss study, it was recommended that pharmacists have greater access to specialised training in travel health [
13].
More recently, Bascom et al. [
14] examined the baseline travel health knowledge of pharmacists’ in Alberta, Canada and their confidence to provide advice, because confidence is required for the successful integration of knowledge in practice. In addition, they also investigated pharmacists’ preferred means of obtaining education on travel health. Although the mean knowledge score was only 27%, two thirds of the pharmacists felt confident that they would be able to source the correct information. However, only 21% were confident in their overall ability to provide travel health advice highlighting the need for both undergraduate and continuing education training programs to accommodate this expanding area of practice [
14]. The aim of this study was to examine the current level of knowledge in travel health of Australian Pharmacists in order to inform training requirements.
4. Discussion
The number of studies examining the travel health knowledge of pharmacists is relatively low [
12,
13,
14] and none appear to have examined the travel health knowledge of pharmacists in Australia. This study examined the travel health knowledge of a sample of Australian pharmacists and, as with comparable studies, some knowledge gaps were identified. A total of 208 Australian pharmacists participated in our study and, although low, the number of participants was comparable to the number of participants (84-251 pharmacists) in similar studies [
12,
13,
14]. Kodkani et al. gave little detail about the demographic characteristics of the participants in the Swiss study [
12], however there are similarities between the demographic characteristics of the participants in this study to those of other comparable studies [
13,
14]. That said, the proportion of female participants was slightly greater in the Portuguese study by Teodosio et al. (79.9%) [
13]. Likewise, the travel health workload of most participants in this study was low, which was comparable to the other studies, with the majority of participants in the Swiss and Portuguese studies (56% and 87.6% respectively)) only giving travel health advice to up to three travellers per month [
12,
13]. Similarly, Bascom et al. reported that 76% of participants in the Canadian study counselled up to one traveller per month [
14]. Finally, Bascom et al. also reported that 43% of participants had not received any formal travel health training [
14]. However, in this study, this was doubled with 97% of participants not having received formal travel health training, which was comparable to the findings (93.2%) of the Portuguese study [
13]. However, the Portuguese and Canadian studies reported that while many participants had not received formal training, many did attempt to stay informed and up to date using a variety of information, self-study and/or online resources. Unfortunately, the participants in this study were not asked whether they undertook self-study or continuing professional development to maintain currency [
13,
14].
Background knowledge of common causes of morbidity and mortality amongst travellers was investigated in this study. Epidemiologically, the most common causes of mortality among visitors to low- and middle-income countries are accidents/trauma or cardiovascular disease with mortality due to infectious diseases being relatively rare [
16,
17]. Malaria is the most prevalent infectious cause of mortality amongst travellers [
16,
17]. Likewise, the most common causes of morbidity in travellers are traveller’s diarrhoea and influenza, with other infectious and tropical diseases having a much lower prevalence. Just over two-thirds of participants (67.8%) in this study were aware that accidents and cardiovascular disease are the most common causes of mortality in travellers. The participants ranking of common health problems experienced by travellers (
Table 1) is similar to their actual prevalence [
16,
17] However, participants ranked some infectious diseases, such as cholera slightly more highly than their actual prevalence. In addition, participants also ranked jet lag and motion sickness relatively highly, which could be because pharmacists tend to give advice about these conditions more frequently. Finally, participants were asked to identity countries in which malaria, yellow fever and typhoid were prevalent from a selection of five destinations.
Table 2 shows that the vast majority of participants (greater than 93%) were aware that these diseases were not prevalent in Japan. Likewise, for Kenya, Thailand, and India, most participants (70.7%–87.5%) selected correct options. However, only 45%–54% of participants selected correct options for Brazil, possibly because participants are less familiar with this destination as relatively fewer Australians visit Brazil [
18]. Finally, participants appeared relatively less knowledgeable about the global distribution of yellow fever compared to malaria or typhoid as over a third (35%) and almost a fifth (18%) of participants incorrectly thought that yellow fever was prevalent in India and Thailand respectively. Likewise, Teodosio et al. examined pharmacists’ knowledge of yellow fever vaccination requirements for visitors to Portuguese-speaking countries. They found that 26.8% of participants reported that they were unfamiliar with the topic and only 8.8% could correctly indicate whether yellow fever was or was not a risk in Portuguese-speaking countries [
13].
Traveller’s diarrhoea (TD) is one of the most common travel-related health conditions. Kodkani et al. [
12] found in their telephone interviews that only 59% of the Swiss participants spontaneously recommended rehydration therapy for TD whereas 100% recommended the use of antimotility agents and only 34% recommended the use of antibiotics. These figures however changed to 90%, 96%, and 39%, respectively, in their follow-up written survey. In comparison, Teodosio et al. [
13] found that Portuguese participants were more likely to recommend the use of antibiotics (57%) than antimotility agents (53%) and only 56% of Portuguese participants recommended the use of rehydration therapy. In our study, all of the treatment options presented to participants included rehydration therapy. However, the two most commonly selected treatment options were rehydration therapy alone (31% Option 1) or a combination of rehydration therapy, antibiotic and antimotility agent (30% Option 3), both of which are clinically justifiable [
19,
20]. In total, 56% of participants chose treatment options that involved the use of antibiotics (Options 3, 4, and 5) and 46% chose treatment options that involved the use of antimotility agents (Options 2 and 3). This implies that the participants in this study are more likely to recommend the use of antibiotics in the management of TD than those in the Kodkani study and equally as likely as the participants in the Teodosio study. However, most participants who recommended the use of antibiotics recommended the use of norfloxacin, an appropriate antibiotic [
19,
20], and only 3% of participants recommended the use of doxycycline, an inappropriate antibiotic [
19,
20], suggesting that participants knew how to appropriately manage TD with rehydration therapy, antibiotics and/or antimotility agents [
19,
20].
The provision of advice relating to the first aid items and OTC remedies travellers should carry is recognised as a key role for travel health pharmacists [
20]. When listed in order of importance, oral rehydration salts and antidiarrhoeal medications were rated relatively highly. Whereas, in contrast, simple analgesics, which are often mentioned as being the most useful items for travellers to carry [
21,
22,
23] were only rated sixth in order of importance in this study. That said, the 10 most frequently selected items chosen by the participants are included in the recommendations for simple travel first aid kits, thereby demonstrating that respondents are capable of advising travellers on the most appropriate items to carry [
21,
22,
23].
Participants’ knowledge about travel vaccines required in relation to travel to Kenya for a 4 week safari were compared with the current CDC and Medical Advisory Service for Travellers Abroad (MASTA) vaccination recommendations for that destination [
15,
24]. At the time of the study these were; typhoid, hepatitis A and B, yellow fever, polio, rabies and meningococcal meningitis plus the standard childhood vaccinations. These recommendations were somewhat aligned with those recommended by the majority of the participants (between 75% and 89%), whose advice included tetanus, typhoid, hepatitis A and B, and yellow fever, with 62% of participants also stating that they would recommend cholera vaccine. Fewer participants recommended vaccinations for polio (49%), rabies (35%) and meningococcal disease (28%). Importantly, although participants were asked to answer questions without referring to reference material, it is unclear how many did not do so. Kodkani et al. also asked respondents in their surveys about the vaccination requirements for travellers to two destinations (Thailand and Kenya) [
12]. Similarly, they found that many respondents wanted to consult information resources before answering, but that in both the telephone and written survey that many did not give correct advice [
12]. With regard to Kenya, only 3% of participants in Kodkani et al.’s study gave accurate advice, whereas 62% said they would firstly consult information resources and 8% gave inaccurate advice. In the written survey, the number giving accurate advice rose to 43%. However, the number giving inaccurate advice also rose to 47% [
12].
Management of a dog bite and dealing with the risk of rabies resulted in participants (56%) selecting the management option recommended in the Australian Immunisation Handbook [
25]. Only 4.3% of the participants chose options in which they would not refer the affected person for further treatment.
There was some concern that 27% of participants appeared to believe that vitamin B
1 (Thiamine) is effective in decreasing mosquito bites, when evidence is limited [
26]. However, in relation to the selection of appropriate agents for malaria chemoprophylaxis, the majority (77%) selected clinically justifiable options [
27]. In the scenario presented, 23% of participants chose less than ideal options, because artemether/lumefantrine is used mainly in the treatment of malaria [
27], and there is significant resistance to the agents chloroquine and mefloquine in the area being visited [
27]. However, 77% chose either atovaquone/proguanil or doxycycline. Atovaquone/proguanil, would be the clinically preferred option as it will not interfere with any of the traveller’s current medications or co-morbidities [
27]. However, it is also relatively expensive, which is possibly why it was only selected by a third of participants (34%). Doxycycline, which may be slightly less ideal than atovaquone/proguanil, is also a lot cheaper which is probably why it was selected by a slightly greater number of participants (43%) [
27]. However, the selection of either atovaquone/proguanil of doxycycline could be clinically justified [
27]. Kodkani et al. [
12] also found the knowledge of Swiss pharmacists in this area to be satisfactory with over 95% being able to name the most important bite prevention methods. However, they too noted that up to 20% of pharmacists also recommended thiamine for the prevention of mosquito bites. When making recommendations for chemoprophylaxis, only 27% and 35% of all respondents were willing to give immediate advice on appropriate chemoprophylaxis for Thailand and Kenya, respectively, in the telephone survey and 19% and 31% of all participants gave acceptable answers [
12]. However, in the follow-up written survey, Kodkani et al. [
12] report that this increased and 74% (Thailand) and 93% (Kenya) of all respondents gave acceptable answers as they could refer to information resources.
This study has some limitations. Firstly, the survey was distributed by two methods and, although pharmacists were asked not to do so, a pharmacist could have completed both surveys. However, there was no evidence to suggest that this occurred. Secondly, participants, may represent those pharmacists that have an interest in travel health, making it difficult to generalise the results to all Australian pharmacists. However, this is a limitation that may be true of many surveys