Caspian Journal of

1.Introduction
Thanks to globalization, industrialization, and advances in technology and transportation, more people are traveling abroad every day for business, education, tourism, or religion [1]. According to the United Nations World Tourism Organization (UNWTO), 963 million people traveled abroad in 2022. This number is expected to increase over the years [2]. As more people travel abroad, researchers are increasingly looking at the concepts of travel health and medicine. Travel medicine provides reliable information on the epidemiology of infectious and non-infectious risks, local and regional health regulations, and vaccination requirements [3]. Travel medicine aims to keep travelers healthy and prevent illness during and after long-distance travel. Pre-travel counseling helps us identify potential risk factors and take precautions against them. It helps us educate travelers and increase their awareness of diseases. It also allows us to provide immunizations and prophylaxis for vaccine-preventable diseases. Ensuring travel safety can prevent travelers from contracting diseases and improve their quality of life during and after international travel. Pre-travel counseling is an integral part of primary health care. It is also essential for protecting, promoting, and maintaining public health [4].
International travel can facilitate the geographic spread of infectious diseases. International travelers are at significant risk for infectious diseases because they can transmit diseases from their home country to another country and/or bring diseases from another country to their home country [5]. The COVID-19 pandemic is a recent example of how international travel can increase the spread of infectious diseases and quickly become a global threat [6, 7]. By vaccinating international travelers, we can control travel-related infectious diseases nationally and internationally [8].
Academicians are university professors, associate professors, graduate students, lecturers, and research assistants [9]. They are more educated than the general public, can influence different segments of society, and act as a bridge between accurate and up-to-date information and society [6]. Academicians are at risk of diseases because they often travel abroad for various reasons (conferences, congresses, Erasmus, holidays, leisure, etc.). Researchers have investigated how aware businesspeople, tourists, and airport workers are of travel vaccinations [10-14] However, no researchers have focused on the level of awareness of travel vaccinations among academicians.
Many infectious diseases are spread geographically by international travelers. Vaccines help us keep infectious diseases under control. Due to frequent international travel, academicians are at increased risk for infectious diseases. Therefore, this study aimed to determine how much academicians know about travel vaccines, how aware they are of them, and how often they get them before traveling. We believe our findings will contribute to the literature and help government agencies develop optimal public health strategies to protect and maintain public health.

2. Materials and Methods
Research type and population
This descriptive and cross-sectional study was investigated to determine how much academicians know about travel vaccinations and how often they get them before traveling. The study population consisted of 547 academicians from Artvin Çoruh University in the 2021-2022 academic year. 
The sample size was calculated using the Equation 1: 
1. n=N (t1-a)² (p.q)/S²2 (N-1)+S² (p.q)m
Where N denote population size (n=550), p was the probability of the occurrence of the event of interest that was conservatively considered as 0.5, S denote sampling error equal to 5%, and t, was the theoretical value of 1.96 corresponding to a degree of freedom and estimated error level. The calculation showed that a sample of 226 would be large enough to detect significant differences [15] The sample consisted of 243 participants. Research data were collected using non-probability convenience sampling method. In this widely used method, everyone who responds to the survey included in the sample. This method was used in the research because it was easy and cheap [16]. This study included academicians who worked at Artvin Çoruh University in Turkey during the 2022-2023 academic year, and volunteered to participate in the study. Participants who didn’t meet these criteria were excluded.

Data collection tools
The data were collected using a personal information form and a travel vaccinations knowledge, awareness, and action questionnaire.

Personal information form
The personal information form was based on a literature review conducted by the researchers [4, 6, 10-14]. The form consisted of two parts. The first part consisted of ten items on sociodemographic characteristics (age, gender, marital status, work experience, etc.). The second part consisted of eight items on travel-related characteristics (history of international travel, frequency of international travel, duration of travel, reason for travel, etc.).
Travel vaccinations knowledge, awareness, and action questionnaire
The travel vaccinations knowledge, awareness, and action questionnaire (TVKAAQ) was based on a literature review conducted by the researchers. The questionnaire consisted of 25 Yes-No questions about academicians’ knowledge, awareness, and action regarding travel vaccinations. The questionnaire included such questions as [1] Do you check vaccination programs and travel guides in destination countries?, [3] Do you get vaccinated before you travel?, [4] Do you always have your immunization card with you?, [5] Do you get check-ups before and after you travel?, etc. “No” answers were scored “0,” while “yes” answers were scored “1.” The total score ranges from 0 to 25, with higher scores indicating more knowledge, awareness, and action regarding travel vaccinations. Five experts with PhD degrees in public health nursing checked the questions for intelligibility and relevance. The draft scale was presented to expert opinion in Davis technique (1=not relevant, 2=relevant to some extent, 3=relevant, 4=completely relevant) [17]. No item was removed or added from the draft scale, as the experts reported highly positive opinions about the intelligibility or responses of the scale (experts used only 3 and 4 points for each item). The questionnaire has a Kuder Richardson-20 (KR-20) score of 0.824.

Data collection
The data were collected online using Google Forms. The researchers emailed all academicians a survey link, including an informed consent form. All of the study sample were briefed on the research purpose and procedure. Those who agreed to participate in the study clicked the “agreed” option and then moved on to the data collection tools. Each participant took 3-4 minutes to fill out the data collection tools. The researchers ensured that each participant filled out the data collection tools only once. The researchers evaluated all participants’ questions and feedback regarding the data collection tools.

Statistical analysis
The data were analyzed using the SPSS software, version 25 at a significance level of 0.05. Mean±SD, numbers, and frequencies were used for descriptive statistics. Normality was tested. The results showed that the data were nonnormally distributed. Therefore, nonparametric tests were used for analysis. The Mann-Whitney U test was used to compare two independent groups, while the Kruskal-Wallis H test was used to compare three or more independent groups. The Bonferroni correction was used for posthoc comparisons. There was no missing data because the data were collected online. No missing data completion method was used during data analysis.

3. Results
The mean age of study participant was 36.61±7.24) years. Sociodemographic characteristics of the study participants are shown in Table 1.


More than half of the participants were men (55.6%). Less than half of the participants were 25 to 34 years of age and had 6 to 10 years of work experience (38.7%). Most participants were married (72%), had no chronic diseases (78.2%), and had previously traveled abroad (82.7%). 
Table 2 presents travel-related characteristics of the study participants.


More than half of the participants travel abroad at least once a year (62.1%). Most participants were concerned about acquiring infectious diseases abroad (89.3%) and believed travel vaccination was necessary (85.6%). Less than half of the participants used the Internet to get information about travel vaccinations (47.3%).
Table 3 illustrates distribution of TVKAAQ responses.




The majority of participants did not receive health (93.4%) and vaccination counseling (94.7%) before traveling abroad. Only a small proportion of the participants checked the travel health manual published by the general directorate of borders and coasts (11.9%). About a quarter of the participants consulted primary healthcare professionals or travel health centers to get international travel consultancy (23.5%). Half of the participants checked the immunization programs of the destination country (50.2%). Less than half of the participants got vaccinated before traveling abroad (44.5%). Less than half of the participants had their travel vaccination cards with them when they traveled abroad (49.2%). 
The TVKAAQ response distributions of the participants are given in Table 3. The highest affirmative answers were related to the question 21 (before traveling internationally, one should ensure that their prescribed medicines are sufficient for the duration of the trip) (99.2%), question 13 (before traveling internationally, one should do research on health care, infectious diseases, etc. in the destination country) (97.1%), and question 17 (getting travel vaccinations before traveling internationally is important for travel health and the control of infectious diseases) (95.9% ) (Table 3). 
Age and gender were associated with participants’ TVKAAQ scores. Participants 35 to 44 years of age (18.5±3.93) had a significantly higher mean TVKAAQ score than those older than 45 years (16.3±4.41) (P=0.04). Female participants (18.8±2.86) had a significantly higher mean TVKAAQ score than their male counterparts (17.0±4.10) (P=0.01). Marital status, academic title, work experience, income, perceived health, presence of children, and presence of chronic diseases were not associateed with our participants’ TVKAAQ scores (Table 4). 


Participants who traveled abroad more than five times a year had a significantly higher mean TVKAAQ score than those who traveled abroad once a year (P=0.02). Participants who were concerned about infectious diseases abroad had a significantly higher mean TVKAAQ score than those who were not (P<0.02). Participants who believed pre-travel vaccination was necessary had a significantly higher mean TVKAAQ score than those who did not believe pre-travel vaccination was necessary and those who had no idea about it (P<0.001). Participants who received information about travel vaccination had a significantly higher mean TVKAAQ score than those who had no idea about travel vaccination (P<0.001). Having been abroad before, duration of travel, and reasons for travel did not associate with participants’ TVKAAQ scores (Table 5).



4. Discussion 
This study assessed knowledge, awareness, and behavior regarding travel vaccination among academicians. The results showed that participants aged 35 to 44 (18.5±3.93) had a significantly higher mean TVKAAQ score than those older than 45. Akodu et al. [1] found that Nigerian travelers aged 51 to 60 had more positive attitudes toward travel vaccinations than their younger counterparts. Zhang et al. [18] also reported that older Chinese travelers were more aware of and had more positive attitudes toward travel vaccinations than their younger counterparts. These findings may be related to many young people engaging in risky behaviors because they believe nothing can harm them. On the other hand, older adults take more preventive health measures to avoid infectious diseases [19, 20]. People who travel abroad are at increased risk of infection, depending on the season, location, activities, and travel duration. Therefore, governments should inform all international travelers, regardless of age, about travel vaccinations according to the destination country’s current conditions and official procedures. In addition, primary care providers should inform patients that travel vaccinations are available and that they can receive them at least 4-6 weeks before travel. In other words, healthcare professionals should raise public awareness about travel vaccinations to increase vaccination rates [18, 20-22].
Female participants had a significantly higher mean TVKAAQ score than their male counterparts. Akodu et al. [1] found that women had more positive attitudes toward travel vaccinations than men. Farnham et al. [19] reported that Thai male travelers engaged in more risky behaviors than their female counterparts. On the other hand, Zhang et al. [18] found that Chinese male travelers had more positive attitudes toward travel vaccinations than their female counterparts. Infectious diseases and travel-related illnesses affect both sexes and reduce their quality of life. Researchers recommend that authorities provide travel vaccination counseling to all men and women and inform people about health protection and promotion, vaccines, and other preventive health behaviors during and after travel [18, 21, 23].
Participants who traveled abroad more than five times a year had a significantly higher mean TVKAAQ score than those who traveled abroad once yearly. Suess et al. [24] reported that people with high travel frequency were more likely to engage in preventive health behaviors, including vaccine-seeking behaviors. Pedersini et al. [25] found that frequent travelers were more likely to receive hepatitis A and hepatitis B vaccines than infrequent travelers. This is likely due to the fact that frequent travelers are more likely to accept vaccines because they seek more preventive health services to protect themselves from infectious diseases [18, 24]. International travel increases the risk of infectious diseases. Greater human mobility increases the incidence and reach of infectious diseases. Therefore, public authorities should provide international travelers with more travel counseling and medicine interventions [26]. Travelers are vulnerable to oral-fecal-transmitted diseases because they frequently eat out, use public toilets (airports, terminals, ships, etc.), and spend hours indoors (waiting rooms, lounges, vehicles, etc.). Therefore, authorities should inform them about hygiene measures and travel vaccinations to protect and maintain their health. We should take the following measures to increase travel vaccination rates in the community. First, we should provide information about travel vaccinations during online ticket purchase/reservation. Second, we should hang posters about travel immunization at transportation points such as airports and bus terminals. Third, primary healthcare professionals should distribute travel vaccine leaflets [14, 18, 21].
Participants who believed travel vaccination was necessary had a significantly higher mean TVKAAQ score than those who did not. Akodu, Ogwu, and Abiola (2019) found that Nigerian travelers had positive attitudes toward travel vaccinations [1]. This finding stems from the fact that people who believe that preventive health practices are necessary and effective are more likely to adopt healthy lifestyle behaviors and get vaccinated [18]. Vaccination is an effective way to protect and promote health and prevent disease. Vaccination prevents 100-150 million deaths annually and significantly reduces economic losses and disability [27]. Therefore, authorities should inform all age groups about the importance and effectiveness of all vaccines in protecting and promoting health and preventing disease [27, 28]. They should raise public awareness that international travel is a risk factor for the transmission and spread of infectious diseases and that pre-travel health counseling and vaccination allow us to maintain quality of life and improve public health. The Turkish Ministry of Health should prepare public service announcements and broadcast them in the mass media to increase travel vaccination rates [21, 22].
Participants who were concerned about infectious diseases abroad had a significantly higher mean TVKAAQ score than those who were not. Bravo et al. [29] found that German travelers who underestimated the risk of diseases were less likely to be vaccinated. On the other hand, Poulos et al. [30] found that German travelers who perceived the risk of disease were more likely to be vaccinated. Heywood et al. [31] reported that Australian students who were not concerned about health threats were less likely to receive pre-travel health advice. These findings suggest that people with high illness perception and anxiety about infectious diseases are more likely to engage in preventive health behaviors [30, 32]. Infectious diseases affect all segments of society, increasing healthcare costs and leading to disability and death [33]. Pre-travel health and immunization counseling helps protect people from illnesses during and after travel. In this context, authorities should inform the public about the importance of health and immunization counseling before international travel. They should provide information on how to protect themselves against diseases that are likely to occur during travel. They should post leaflets on planes, buses, trains, etc. to inform travelers about international pre-travel health counseling, travel vaccinations, and general precautions about infectious diseases [21]. In addition, travelers should visit the official website of the General Directorate of Borders and Coastlines of the Ministry of Health to learn about travel vaccinations, infectious diseases, and health services in destination countries [22].
Participants who received information about travel vaccination had a significantly higher mean TVKAAQ score than those who did not. Heywood et al. [8] conducted research in seven countries and concluded that the main reason for low vaccination rates and negative attitudes toward vaccines was a lack of knowledge. Alqahtani et al. [34] found that Australian pilgrims who received travel health advice were twice as likely to be vaccinated. Heywood et al. [8] reported that travelers who consulted health professionals before traveling were more likely to be vaccinated against hepatitis A/A-B. These findings suggest that travelers who are knowledgeable about travel health and vaccinations are more likely to engage in preventive health behaviors and receive vaccinations before traveling abroad [34, 35]. By providing travelers with travel health and vaccination counseling, we can increase their awareness of infectious diseases and travel vaccinations, resulting in higher vaccination rates. The Turkish Ministry of Health should broadcast public service announcements about travel immunizations. Official organizations (World Health Organization (WHO), Turkish Ministry of Health, etc.) should share information about travel vaccinations on their social media platforms. Primary healthcare facilities should have posters and brochures on travel vaccinations. Healthcare professionals should inform the public about travel vaccinations [21, 22]. Universities should also send reminder cards and messages to academicians about travel vaccinations.
Marital status, academic title, work experience, income, perceived health, presence of children, and presence of chronic diseases did not affect our participants’ TVKAAQ scores. Poulos et al. [30] found that business travelers were more likely to be vaccinated. Wang et al. [35] reported that backpackers were less likely to be vaccinated. Akodu et al. [1] found that married and single Nigerian travelers had similar attitudes toward travel vaccination. On the other hand, Poulos et al. [30] documented that German travelers who were married or living with their partners were more likely to receive travel vaccinations than their single counterparts. Hassan and Afolaranmi [36] found that Nigerian physicians who were aware of travel vaccinations were more likely to vaccinate than those who were not. Researchers have reported conflicting results, probably because they recruited different samples, used different measures, and conducted research in countries with different perceptions of infectious disease risk. Therefore, more research is needed to better understand the effect of sociodemographic characteristics on travelers’ perceptions of travel vaccination. In addition, valid and reliable measures are needed to compare different societies in terms of their attitudes toward travel vaccination.
Our findings are consistent with and add to the literature. Travel counseling and travel vaccination are essential to protect and maintain public health. Therefore, public authorities should educate the scientific community about travel counseling and vaccination. Healthcare professionals should develop interventions to increase public awareness of travel medicine and immunization. The Turkish Ministry of Health should broadcast public service announcements about travel immunization. Public institutions should work together to inform the public about the effectiveness of vaccines. Researchers should investigate whether travel and vaccine counseling helps increase vaccination rates among academics. Researchers should also develop valid and reliable measures to assess knowledge, awareness, and practice of travel vaccination among academics.
This is the first study to investigate the knowledge, awareness, and practice of travel vaccination among Turkish academics. Our results suggest that Turkish academics, who are more educated than the general population, do not know much about travel vaccination, travel medicine, and travel advice. Therefore, further research on this topic is warranted. Although this study contributed to the literature, it has several limitations. First, the sample consisted of Turkish academics from only one public university. Second, we used a self-developed data collection tool because there is no valid and reliable measure in the literature. Third, the data were collected online and based on self-report. Fourth, the COVID-19 pandemic may have influenced Turkish academics’ perception of travel vaccination. Fifth, the results are sample-specific and cannot be generalized to the whole population. It is thought that it would be important to repeat the research in different academic communities and/or different geographical regions.
Considering the importance of travel counseling and pre-travel vaccination practices in protecting health, preventing diseases, and maintaining public health, we should raise academics’ awareness of travel health and counseling and inform them about travel vaccinations.

5. Conclusion 
This study focused on the knowledge, awareness, and practice of travel vaccination among Turkish academicians. Four out of five academicians have traveled abroad (82.7%). Three out of five academics travel abroad at least once a year (62.1%). Four out of five academics believe that travel vaccinations are important (85.6%). Almost none of the academics receive health (93.4%) and vaccination advice (94.7%) before traveling abroad. Two out of five academics receive the vaccines the destination country requires (44.4%). These results suggest that Turkish academics do not have adequate knowledge, awareness, and practice regarding travel vaccinations.

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the ethics committee of Artvin Çoruh University (Code: E-18457941-050.99-38106 & Date: 02.02.2022). Permission was obtained from the university (No.: E-12475423-605.99-38777, Date: 08.02.202). All academics were briefed on the research purpose and procedure. Informed consent was obtained from those who agreed to participate. The research was carried out according to the ethical principles of the World Medical Association’s Declaration of Helsinki.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
All authors equally contributed to preparing this article

Conflict of interest
The authors declared no conflicts of interests. 

Acknowledgements
The authors would like to express their gratitude to the research participants.


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