Travel clinic communication and non-adherence to malaria chemoprophylaxis

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Summary

Many travellers fail to take malaria chemoprophylaxis, despite receiving pre-travel advice. This study examined whether non-adherence could be predicted from verbal communication in the pre-travel consultation, and whether non-adherence was related to the quality of clinician–traveller communication.

The consultations of one hundred and thirty consecutive travellers at a UK travel clinic were audiotaped and a follow-up telephone interview was used to assess adherence to malaria chemoprophylaxis. Experienced travel clinic staff were asked to predict adherence and rate the quality of communication from eighteen transcripts of consultations (nine good and nine poor adherence).

Clinic staff predicted adherence to malaria chemoprophylaxis significantly better than chance. Poor adherence was related to poor quality communication. Clinic staff provided criteria for good quality clinician–traveller communication.

It is concluded that predictors of non-adherence can be identified during the pre-travel consultation. Clinic staff could employ specific communication strategies to improve the effectiveness of consultations.

Introduction

In 2008 there were 1370 cases of imported malaria in the UK and 1298 cases in the USA.1, 2 Adherence to preventative measures is variable, ranging from 13 to 77 percent.3, 4, 5, 6 Certain travellers, such as those visiting friends and relatives, are more at risk for failing to take adequate precautions.7, 8 The pre-travel consultation provides an opportunity to educate travellers about potential risks and influence subsequent health behaviours, including adherence to chemoprophylaxis. However, the extent to which clinicians are able to predict the likelihood of poor adherence, and thus target communication effectively, is currently unclear.

Effective clinician–traveller communication is essential in educating and motivating the traveller to respond to health risks.9, 10 There is evidence that the pre-travel consultation has a significant impact on the traveller’s choice of chemoprophylaxis, with almost half of travellers changing their initial medication preference following discussion with the clinician.11 In addition, certain aspects of communication, such as the number of traveller queries and statements, are positively associated with adherence.12 Furthermore, there is evidence that travellers who adhere poorly expressed their ambivalence during the pre-travel consultation. A greater amount of discussion about adherence in the pre-travel consultation is associated with poor adherence, indicating that travellers’ concerns are raised but not sufficiently resolved.12

Existing guidelines for preventing travel-associated malaria13, 14, 15 discuss the issue of non-adherence to malaria chemoprophylaxis, but do not describe explicit methods for promoting adherence. Guidelines specify the content of advice, but not the process of providing information effectively, engaging the traveller in decision-making and responding to concerns. Current assessments of competence in travel medicine focus predominantly on knowledge of the content of a pre-travel assessment, with less attention paid to the process of conducting an effective consultation.

As pre-travel advice is usually provided during a one-off consultation with no planned follow-up, it is unclear how clinicians can assess the effectiveness of their own consultations in routine practice. Existing evidence suggests that clinicians need to employ effective communication skills to promote travellers’ understanding and motivation to engage in preventative strategies, but there is a lack of specific guidance for responding to travellers ‘at risk’ of non-adherence and for evaluating the quality of the communication.

This study aimed to investigate:

  • (1)

    Whether experienced travel clinic staff could predict adherence to malaria chemoprophylaxis on the basis of verbal communication in the pre-travel consultation.

  • (2)

    Whether travellers’ adherence to malaria chemoprophylaxis is related to the quality of communication in the pre-travel consultation.

  • (3)

    What criteria are used by experienced travel clinic staff to predict adherence to malaria chemoprophylaxis and to define the quality of communication in the pre-travel consultation.

Section snippets

Participants

The participants were travellers attending a travel clinic in a city centre location in the UK, attached to a university teaching hospital. The clinic provided a consultant-led service, with advice given by one medical consultant and four nurses specialising in travel medicine according to national and international guidelines.16, 17 Travellers attending the clinic paid for medications and vaccinations, but not

Clinicians’ prediction of adherence from the verbal communication in the transcripts

Two of the three clinicians were able to predict adherence significantly better than chance (using exact p-values) (Table 1). The third clinician was less able to predict poor adherence. When questioned later, the first two clinicians stated that they had relied on their ‘gut feelings’ and made a decision quickly, whereas the third clinician stated that after a first pass through the consultations, several initial decisions were revised.

Relationship between perceived quality of the consultation and adherence

Clinicians gave significantly higher ratings of quality to

Discussion

This study has revealed that indicators of non-adherence to malaria chemoprophylaxis can be identified during the pre-travel consultation, and that there is a relationship between the rated quality of the consultation and subsequent adherence. This suggests that travellers may be more likely to adhere when they receive a better quality consultation.

The finding that two of the three clinicians could predict adherence better than chance on the basis of verbal communication suggests that factors

Conflict of interest

The authors declare that they have no conflict of interests.

Acknowledgements

The authors wish to thank the travellers and clinicians who participated in the study, the Travel Clinic staff, and Dr Henry WW Potts, who provided statistical advice.

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    Presented as an oral presentation at the 3rd Northern European Conference on Travel Medicine, Hamburg, 26–29 May 2010: Non-adherence to malaria chemoprophylaxis: can it be predicted from communication in the pre-travel consultation?

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