International travel has recently increased in magnitude, speed, and geographical reach, with 940 million arrivals reported in 2010. Every year, as many as 50 million people from the industrialized world cross international borders to tropical or subtropical destinations. These travelers encounter different cultures, social habits, economic standards, and, importantly, a different microbiological environment [1, 2].

The State of Kuwait is a country with a total population of 3.6 million, including approximately 1.2 million Kuwaiti citizens and 2.4 million non-Kuwaitis [3].

An estimated 700 travelers (2–3 visits/10,000 population) visit the Traveler Health Clinic every year. The Traveler Health Clinic (THC) is the only clinic in Kuwait that is accessible by a variety of transportation methods because of its location in the middle of Kuwait City.

The services provided at the THC include immunization, chemoprophylaxis for malaria, and health advice/information for the prevalent diseases/health hazards in the destination country. These services are provided to travelers free of charge, except for yellow fever vaccination [4].

The volume of travelers from Kuwait varies throughout the year and has two peaks: during the summer months and during the midterm vacations of schools and universities [4].

Despite public health efforts designed to make travelers aware of the risks related to international travel, the number of travelers who consult travel clinics remains relatively low. Some studies of travel risk behaviors have reported that between 4 % and 52 % of travelers sought pre-travel advice at travel clinics [5–13].

Although some studies focus on the factors underlying seeking consultation prior to travel, associations between travel clinic consultations and other variables have been brought to the forefront. Time constraints and limited geographical or financial accessibility may constitute barriers to obtaining pre-travel information. Socio-demographic characteristics (e.g., age, sex, education level, and socioeconomic status) do not seem to be significantly associated with seeking pre-travel consultation and prevention, whereas travel attributes (e.g., destination, reason for travel, and trip duration) and traveler characteristics seem to play more important roles [10–15].

To the authors’ best knowledge, no studies have been performed in the Gulf region that address traveler health-seeking behaviors and their determinants. The objectives of this study are to identify the determinants of receiving pre-travel health consultation and the contents of this care.

This study is an analytical, comparative study involving demographic and travel data for travelers visiting the THC (visitor group) and a matched control group (non-visitor group).

The study period was from May 1, 2009 to December 31, 2010.

Figure 1 presents the monthly distributions of both visitor and non-visitor groups, with two peaks in visits to the THC during July and August (summer months) and in the winter months (January, February, and March).

Table 1 shows a descriptive overview regarding some socio-demographic and travel related data among the studied groups. Male gender and active age group (30–45 years) predominate in both groups. White collar occupation are the major occupations for both groups (47.2 % for visitor group and 37.4 % for non-visitors). 59.5 % from visitors and 44.3 % from non-visitors were traveling for the leisure purpose. African countries are the major travel destination for both groups (47 % for the visitors and 34.5 for the non-visitors). Both group are planned to go to urban locations predominantly during their travel. Regarding accommodation planned, 64 % of visitors tend to stay in hotels while 48.6 % of non-visitors plan to stay with their families. Most of visitors (52.5 %) tend to stay between 1–4 weeks however 43.1 % from non-visitors tend to stay more than 4 weeks. Most of visitors and non-visitors had a history of past travels between 1–4 times. 57.3 % from Visitors got their knowledge of THC from sources other than media however 37.6 % from non-visitor had no previous knowledge of THC.

Table 2 presents a bivariate analysis demonstrating that Kuwaiti nationality (68.2 %) significantly affects THC visits (P < 0.001) (OR = 1.79). Participants traveling for work (25.3 %) or leisure (59.5 %) tended to receive pre-travel consultation at the THC (P < 0.001) (OR = 3.83 and 3.43, respectively). Traveling to Africa and/or South America prompted travelers to visit the THC for pre-travel consultation (P < 0.05) (OR = 1.37 and 1.61, respectively). Travelers staying in hotels (64.0 %) and/or camps (20.4 %) were more likely to visit the THC for pre-travel consultation (P < 0.001). Previous knowledge of the services provided by the THC, either from the media or other sources, affected travelers’ tendencies to visit the THC for pre-travel consultation more than those with no knowledge of the THC (P < 0.001) (OR = 2.69 and 4.19, respectively). Blue collar employees, those with a past history of visiting more than four times, and those visiting rural or urban areas and staying between 4–12 weeks were least likely to visit the THC (P < 0.001). Non-significant factors included gender and age (p > 0.05).

As identified by multivariate analysis (Table 3), significant factors from bivariate analysis were used to establish predictors for receiving pre-travel consultation from the THC. Nationality, followed by the purpose of travel, the length of stay, and the choice of travel destination are predictors for visiting the THC (OR = 8.7, 2.2, 1.4, and 1.33, respectively).

Table 4 presents the preventive measures provided to visitors to the THC. Travelers to Africa and South America received yellow fever vaccination. Meningococcal vaccination was administered to a range of travelers (60.3 %- 98.4 %). One-third to two-thirds of the travelers to Asia, Africa, and S. America received typhoid and tetanus toxoid immunizations. The influenza vaccine was given to 10 % to 47.7 % of travelers to all destinations, except Africa. For malaria chemoprophylaxis, mefloquine was administered to 50.7 % of travelers and doxycycline (vibramycine or doxydar) was administered to 26.6 % of travelers to Asia, Africa, and S. America. General health education messages were given to 95.7 % of visitors, including area-specific health education messages (76.4 %).

There are two peaks during the year when more travelers visit the THC: July-August and Jan-March, due to school and university vacations during the summer, midterm, and spring periods [4].

This study found that visitors receiving pre-travel consultations at the THC were 56 % male, which differs from results reported in Quebec [8], Singapore [9], and German [9] studies. These differences might be the result of differences in gender ratios in these countries [3, 17–19].

Nationality significantly affected the likelihood of visiting the THC to receive pre-travel consultation (P < 0.001), which may reflect the higher per capita income of Kuwaitis and the fact that most health services are provided free of charge to Kuwaitis.

Travelers’ ages did not affect their tendency to visit the THC for pre-travel consultation (p > 0.05), although most travelers were from physically and financially active age groups (30–45 years and 45–60 years) [20, 21]. This finding was in agreement with the results of studies from Quebec [8], Singapore [9], and Germany [19].

Our study and a Singapore study [9] found that white collar employees visited the THC more often than individuals with other occupations, which may be attributed to their higher educational levels and higher per capita income, as reported in a Quebec study [8]. However, these differences were not significant.

Our study demonstrates that those traveling for leisure and work visited the THC more than others (P < 0.001), which is comparable to results reported by Vernon J. Lee and colleagues in 2006 [9] in Singapore and Susanna Flec and colleagues in 2005 [19] in Germany. This relationship might be due to an association between travel purpose and a greater likelihood of exposure to travel health hazards.

Travel destinations in Africa and South America significantly affected travelers’ tendency to visit the THC (P < 0.05), which is consistent with the results of other studies [5, 9, 19]. This finding might be attributed to the fact that visitors perceived the destination-specific risks of Africa and South America as higher, and so sought pre-travel health consultation at the THC; traveling to Asia, Europe, or North America was not perceived as high risk [5, 22–25].

Travelers staying in hotels visited the THC more often (p < 0.001), similar to results found in the Singapore study [9] in 2006, which could be attributed to the higher social class of these travelers and/or the request of travel agencies for International Travel Certificates and travel advice [16, 26].

Travelers with stays longer than 4 weeks were more likely to be frequent travelers and were less likely to visit the THC (p < 0.001), as was found by other studies [5–7, 9, 19]. Frequent travelers may become reluctant to seek preventive measures due to their earlier travel experiences or may have previously received travel health advice and immunizations.

Previous knowledge of the services provided by the THC significantly affected its utilization, as was also found by Vernon J Lee in Singapore [9].

Multivariate analysis identified predictors of THC attendance, including nationality, purpose of travel, accommodations, length of stay, and travel destination. Similar results were reported by the study performed in Singapore [9].

The provision of preventive services could be attributed to travelers’ perceptions of destination-specific risks and the WHO recommendations on the IHR (2005) that place greater priority on diseases such as meningococcal meningitis, yellow fever, and malaria prophylaxis for specific destinations [16, 26]. These results differ from those of another study performed in Singapore in 2006 [9], in which travelers most commonly received typhoid vaccines, hepatitis A vaccines, and D-T toxoid. This difference might be due to difference in travel destinations as in the Singapore study, the travelers traveled to Asian countries principally however in our study the traveled to African countries principally.

The present study examined factors affecting visits to the THC and provided a clear perspective of travelers’ profiles and the services provided by the THC in Kuwait. Nationality, purpose of travel, length of stay, and travel destination are predictors for receiving a pre-travel consultation from the THC. More studies of the travel habits of Gulf Countries populations are required, especially with the increasing affluence and diverse travel habits of the region.

Health education programs must be thoroughly and extensively designed and directed to the targeted population by various educational means (mass media, audiovisuals, newspapers, magazines, posters, etc.).

Ibrahim Shady, Phone: +96566791792, Phone: +96550809023, Email: ebrshady@hotmail.com.

Mohammed Gaafer, Email: moh_gaferwissam@hotmail.com.

Lamiaa Bassiony, Email: lamiabasiony@yahoo.com.