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Health of Overseas Services Bureau Travelling staff

Natasha J. Aylen, Paul G. Buntine, Nicole M. Henry, Kathryn J. Rainsford, Michelle L. Schlipalius

Internet publication: 23 March, 1998

Abstract:

The purpose of this project was to investigate health issues relevant to travelling Overseas Services Bureau staff. We interviewed twenty two members of staff who had travelled during the course of their work since January 1993 and analysed our findings. We compiled and tested nine hypotheses and from this we produced five recommendations to the staff. These were presented on a health promoting poster. Three recommendations to the management were also made.

Areas in which staff recommendations were made are as follows: insect protection, immunisations, first aid kits, safety and first aid skills, stress and coping mechanisms.

Recommendations to the management were:

• Adequacy of health information provided to staff

• Debriefing methods employed on staff return from overseas

• Staff desire for first aid knowledge.

KEY WORDS:

Accident prevention, Emotional stress, First aid, Health promotion, Immunisations, Insect bites and stings, Questionaries, Risk factors, Travel.

Introduction

Background

The Overseas Service Bureau (O.S.B.) aims at providing skilled Australian workers for developing communities in positions requested by these countries. It therefore provides unique experiences to Australian people and assists in overseas aid provision. O.S.B. is an independent organisation with offices in each state funded by the government through the Australian International Development Assistance Bureau (A.I.D.A.B).

The staff are largely based in the national headquarters in Fitzroy, Melbourne. In contrast, the volunteers are firstly recruited and briefed, then placed abroad for a minimum of two years, being paid the local wage. Throughout this process they are overseen by the O.S.B. staff.

Issues

Our role was to look at the previously unaddressed issue of health concerns specific to O.S.B. staff travelling overseas. We chose this because these people are exposed to a number of risks and different environments during the course of their employment1,2,3,4,5,6. Furthermore, it was accessible and achievable to complete the project in the time allocated.

Priority Population

This group consisted of twenty-two staff who had travelled overseas in the course of their employment since January 1993 (see appendix one). Thirteen field officers were included as well as nine unit managers and administrators. The role of a field officer is to help select and visit volunteers, deal with employers, promote O.S.B., extend the list of potential employers and monitor regions for overseas program priorities. Managers deal with government officials and employers and coordinate their particular unit. The administrators are involved with in-country meetings for O.S.B. volunteers.

The time frame was set so that the study was relevant to the issues facing current employees.

Aims

Phase One - Research

To assess the current health issues faced by travelling O.S.B. staff. In doing this we put forward the following hypotheses:

That;

1. there is a high incidence of travel related accidents and trauma amongst the staff whilst working overseas.

2. immunisation knowledge is limited and not all staff have appropriate immunisation status for the regions they visit.

3. Overseas Service Bureau travelling staff do not always use adequate protection against insects or malaria prophylaxis in the areas of potential exposure.

4. staff experience high levels of stress in the course of their overseas work.

5. there is insufficient staff orientated health advice provided by the Overseas Service Bureau.

6. existing chronic health problems place staff at risk whilst overseas, and thus interfere with their work.

7. emotional debriefing provided to staff on return from overseas work is inadequate.

8. a lack of first aid kits and first aid skills is an issue concerning travelling staff.

9. staff travelling overseas have a high rate of sickness attributed to their travels.

These hypotheses were then analysed.

Phase Two - Health Promotion

As a result of our research we identified the key health issues affecting the target population, developed and presented recommendations regarding health issues discovered and presented these in the form of a poster and handouts. We also presented relevant findings to the O.S.B. management.

Phase Three - Presentation

A general presentation of our findings to the staff and management.

Strategies and Methods

Phase One

In this phase, our objectives were to assess the current health issues affecting travelling O.S.B staff.

Step one: We met with Dr. Tilman Ruff, the coordinator of our health promotion exercise, to discuss his ideas on topics and possible hypotheses to test.

Step two: The group formulated a list of topics considered to be relevant from our initial discussion, forming the basis for preliminary research. We performed initial investigations to discover which health related issues the staff felt to be important whilst overseas. Through informal discussion with several members of the O.S.B. staff (without using leading or closed questions), we allowed for the introduction of new issues while confirming which of our previously selected issues were important. Our result was a short list of topics, forming the basis for our final survey.

Step three: A final survey was drafted. The style was based on open questions where possible to allow for additional input from the staff. We added some direct questions so that the staff's responses to certain issues vital to our research would be recorded in a standardised manner. We then consulted with Dr. Ruff, who edited the survey and suggested that it be trialed. Unfortunately, time constraints did not allow for this. The final survey was instituted using a list of travelling overseas staff provided by the management. Approximately thirty minutes was spent with each staff member, reading the questions to them to be sure they were properly understood. The results were recorded verbatim on our questionnaire sheet (see appendix three).

Step four: We recorded the results obtained from surveying twenty-two staff who had travelled overseas in the course of their work since the start of 1993. Our group tabulated this information in a form that allowed for comparison between different variables. This was done to enable us to test our hypotheses, as well as to use the data to find links between certain behaviours and their outcomes.

Phase two

In this phase our objectives were to analyse our results and provide them (along with recommendations), to the staff. The aim of this was to promote their health.

Step One: We analysed the results achieved from the survey, noting areas of interest. These included:

• areas of special concern to the staff, (eg. safety whilst travelling).

• areas of health in staff needing improvement, (eg. stress whilst overseas).

• areas where preventive methods needed to be promoted, (eg. immunisation).

Five main categories were isolated for recommendation to staff and three for recommendation to management (see Recommendations).

Step Two: We designed a poster with the specific aim of providing our results to the staff (see appendix five). This was done with the aim of informing staff of their current health status/knowledge and thus motivating them to make improvements.

Step Three: Research regarding the five major groups was performed, with the aim of producing recommendations for the improvement of health. We consulted several medical authorities (see Acknowledgments), as well as utilising information from texts provided for volunteers at O.S.B.a and (Cossar, 1992)b. These recommendations were presented on the poster in a simple and eye catching form.

Step Four: We displayed the poster with detachable first aid kit lists at O.S.B. A small sheet was added for comments and feedback from the staff.

Step Five: We conveyed the three major points to the management, outlining issues considered important by staff. This presentation was in the form of a group discussion.

Phase Three

(To be planned at a later date).

Results

All results can be found in appendix four.

Results which warrant specific mention include:

• The majority of staff purify their water (appendix four, table one).
• A significant number of staff that are at risk of malaria do not use antimalarial drugs (appendix four, table two).
• A significant minority of staff had experienced accidents or trauma whilst overseas (appendix four, table three).
• Many staff felt they did not receive adequate health information on joining O.S.B (appendix four, table four).
• Few staff have first-aid qualifications and many staff expressed interest in completing a first aid course if given the opportunity (appendix four, table five).
• Most staff take some form of a first-aid kit with them when travelling overseas (appendix four table six).
• Many staff did not use travel related safety methods, such as seat belts, even if they were available (appendix four table six).
• Only some staff members attended the Travellers Medical Vaccination Centre or a doctor every time before going overseas (appendix four, table four).
• Many staff experienced emotional stress. The majority of staff coped using non-substance methods, although a significant minority used substances (appendix four, table seven).
• The majority of staff believed a travel preparation checklist would be useful (appendix four, table six).

Discussion

Each of our hypotheses will now briefly be examined:

1) That there is a high incidence of travel related accidents and trauma amongst the staff whilst working overseas.

As shown in appendix four, table three, there is an average of one travelling accident for every ninety-seven weeks spent overseas. This is high enough to warrant concern, especially since the low availability of motor-cycle helmets and seatbelts creates potential for serious injury.

2) That immunisation knowledge is limited and not all staff have appropriate immunisation status for the regions they visit.

The major finding of our survey in regard to immunisation status was that there was uncertainty amongst staff. Firstly, uncertainty as to whether a particular immunisation had been received secondly, the date of this immunisation and thirdly whether it was current. We were not prepared for this uncertainty and thus did not have a uniform approach for dealing with it across all interviewers. Some interviewers assumed 'yes' if the staff member thought that they were immunised, whilst other interviewers only answered 'yes' if the staff member was definite. As a consequence, our results may be unreliable and little statistical value can be placed on them. (Results are shown in appendix four, table eight).

3) That Overseas Service Bureau travelling staff do not always use adequate protection against insects or malaria prophylaxis in areas of potential exposure.

One third of staff at risk7 do not take anti-malarial medication. In addition a significant proportion do not use adequate insect protection. Over half do not wear long protective clothing or use mosquito nets. (See appendix four, table two).

One reason for this inadequate level of insect protection and malaria prophylaxis may have been the length of the trip and the regions visited. The average trip length was three weeks and of this usually only a few days were spent in the comparatively high risk rural areas. Thus staff may have felt that the need for protection was so minimal that it was not worth worrying about, however, we believe that any period of exposure warrants protection, whether malarial related or not.

4) That staff experience high levels of stress in the course of their overseas work.

High levels of stress were reported by staff in the course of their work overseas.

The main stressors (in order of prevalence) were:

• the pressures volunteers placed upon staff,

• job pressure,

• personal issues of loneliness and separation from family and friends,

• emotional trauma due to horrific situations (eg famine, poverty, war),

• culture shock and

• change in climate.

See appendix four, table seven for specific details of stressors.

There was a significant difference in stress levels between males and females and between staff members with different roles. Females had higher stress levels than males, and field officers had higher levels than managers and administrators (refer to appendix four, table seven). The higher levels of stress in field officers were not related to the higher proportion of female field officers (refer to appendix one). Rather, stress levels experienced by field officers can be seen as a direct result of their different role, longer trip length, more varied living conditions and more frequent dealings with volunteer problems.

Coping mechanisms discovered ranged from the use of substances (tobacco, alcohol, sleeping tablets) to exercise, rest and others (see appendix four, table seven).

The staff's experiences when they return may have shaped their perceptions of stress in their overseas work. These experiences would depend on the level of emotional debriefing they received. The atmosphere of the unit also influences this - whether it is a 'caring' or 'coping' environmentb.

5) That there is insufficient staff orientated health advice provided by the Overseas Service Bureau.

Of the staff interviewed, fifty-five percent felt that any health advice received on joining O.S.B. was inadequate. They thought they should have been made more aware of the various risks and issues that may confront them in the course of their work. This was especially the case with staff who had no prior experience overseas. (Many of the staff had formerly been volunteers with O.S.B. or had lived in the countries they were to visit).

The source of this health advice was varied (appendix four, table four), demonstrating that there is no formalised system for the giving out of health advice.

6) That existing chronic health problems place staff at risk whilst overseas, and thus interfere with their work.

Forty-one percent of the staff interviewed mentioned having some form of health problem that could affect their work whilst overseas (see appendix four, table three). Approximately half of these reported experiencing actual symptoms, although not of a nature sufficient to interfere with their work. From these results and additional comments made during interviews, it would appear that any impact chronic health problems had on staff's functioning capacity whilst overseas was minimal or non-existent. It should also be mentioned that none of the staff felt that their conditions were of a nature that placed them in any significant danger.

7) That emotional debriefing provided to staff on return from overseas work was inadequate.

Thirty-five percent of staff felt that emotional debriefing on return to Australia was of a very low level (see appendix four, table nine). Even many of those who felt that it was adequate for their own needs believed more emphasis should be placed in this area. Issues that staff faced which they believed required emotional debriefing or counselling included;

• dealing with dangerous or emotionally traumatic situations whilst overseas.

• reintegration problems on return to Australia.

• relationship problems resulting from frequent trips overseas.

Although some emotional debriefing was available from Unit Managers, staff often felt reluctant to divulge information that they felt might place their job in jeopardy. The call for an impartial body whom they could safely approach with no threat to their job was common. It should also be mentioned that some Unit Managers found that although they were involved in debriefing Field Officers, they had no-one to turn to themselves.

8) That a lack of first aid kits and first aid skills is an issue concerning travelling staff.

Of all the staff interviewed, only three felt that first aid skills were unimportant to them whilst overseas. These three were all managers or administrators. Of the remaining staff interviewed, seventy-three percent would participate in a first aid course if it were made available to them and eighteen percent already had some form of first aid qualification (see appendix four, table six). Thus it would appear that the vast majority of staff saw first aid skills as being important. This was not surprising, considering the remote locations visited and the situations that staff (especially field officers) often faced.

First aid kits were commonly taken by staff, with eighty-one percent carrying some form of kit. However, the contents of these kits was highly variable with many lacking even basic items such as bandages. Thus, there is a need for a standardised kit to be recommended to all staff.

9) That staff travelling overseas have a high rate of sickness attributed to their travels.

Staff were found to have a high rate of sickness attributed to their travels. In order of prevalence, staff were inflicted with: diarrhoea; upper respiratory tract infections; vomiting; other infections; headache; fatigue; bites; skin disorders and constipation. Surprisingly, one-fifth did not experience any form of illness in their travels (appendix four, table three). Of those experiencing illness, few cases were severe enough to interfere with working capacity.

Thus we have proven eight of our hypotheses. Number two, concerning immunisation status, remains inconclusive.

The Health Promotion Experience

The following discourse highlights the advantages and disadvantages of the interviewing procedure:

In the planning of this project we decided against handing out questionnaires for staff to complete. We felt that structured individual interviews would give superior results. The main reason for this was that it allowed us to guarantee one hundred percent participation. It also ensured that responses were appropriately thorough and that any ambiguities (both in questions and answers), could be clarified. However, there were also disadvantages. A face to face interview may have decreased staff members freedom to speak frankly, despite assurances of anonymity, and allowed our own interpretation of answers to bias our results. The later was exacerbated by having five different interviewers who were randomly assigned to interviewees. Attempts to minimise this were made by writing responses verbatim and avoiding facilitation. Another complication of having several interviewers was that each individual interviewer emphasised questions differently.

Unfortunately, due to time constraints, preliminary planning and trialing of our interview questionnaire was limited. The effects of this became evident once questioning began. A major problem was that the wording of our questions was not specific enough. For example the questions on stress whilst overseas should have been relative to stress levels experienced whilst not travelling.

Another problem involved standardisation of responses, which was absent or poor in many areas. An attempt was made to standardise responses to the questions regarding health upon return to Australia by a numerical scale (refer to appendix three). However, this was a failure due to the difficulty of placing a numerical value on a subjective feeling.

There was also difficulty with open-ended questions, as they did not provide specific information which may have been achieved using closed questions.

Evaluation Design

Evaluation of our poster and recommendations to the management were beyond the time constraints of our health promotion project. However, we have included below a possible evaluation design.

Evaluation of the poster would include a survey to be distributed amongst travelling O.S.B staff. It would include the following points:

• exposure to the poster

• attention to the poster

• understanding issues on the poster

• acceptance of changes to be made

• intention to change behaviour

• trial change in behaviour

• success in changed behaviour

• maintenance of changed behaviour

Research has indicated that if there is a fifty percent achievement rate in each of the first seven steps in the hierarchy, only 0.75 % of people exposed will succeed in changing their behaviour8.

Evaluation of our recommendations to the management would involve a discussion including:

• interest in recommendations

• consideration of recommendations

• changes actually made by the management in response to our recommendations.

Determining the practicality of these suggestions rests with O.S.B.

Recommendations

To Staff:

We outlined the results of our research in a poster, as follows:

1. Insect Protection.

Although drugs are available for the treatment of malaria and other insect-borne diseases, it is far better to avoid the disease in the first place. Therefore we recommended for areas of risk: the use of an insect repellent (eg: Rid), long sleeves and long pants; the use of a mosquito net at night, decreased perfume use and the use of anti-malarials (in malaria prone areas).

2. Immunisations.

Due to the uncertainty of current immunisation status, we provided an example of the Traveller's Medical and Vaccination Centre (T.M.V.C) Immunisation card, and details of immunisations required. Information regarding the use of the T.M.V.C was included, along with recommendations regarding attendance before travelling overseas and on return.

3. First Aid Kit.

Due to the wide variety of kits being taken by staff, a list of first aid kit contents was provided. This was provided in a 'tear-off' form.

4. Safety & First Aid Skills.

Due to the high number of car crashes reported and general concern for safety and personal security, we outlined the precautionary measures which should be taken where possible (eg: seat belts, helmets, avoiding dangerous situations). The recommendation of gaining basic First Aid skills was also included.

5. Stress & Coping.

We outlined methods of avoiding stress: time allocation, rest, diet, exercise, avoidance of drugs and alcohol. We also listed some healthy coping mechanisms for stressful situations.

Refer to appendix five for a photograph/plan of our poster.

To Management:

We also isolated three areas of importance to staff which could be recommended to the management of O.S.B, rather than to the staff directly. These were:

• health information adequacy on joining O.S.B,

• debriefing methods employed on staff return from overseas

• desire for first aid course.

Acknowledgements

We would like to thank the following people for their assistance:

• Drs. Tilman Ruff and Fran Leslie, our project coordinators, for providing us with any information we required and for their constructive criticisms.
• Ms. Sharon Bygate at O.S.B, for organising appointments with staff.
• The O.S.B. medical panel, for offering their advice, and inviting us to dinner.
• The staff at O.S.B for their cooperation and eagerness to participate.
• The Travellers Medical and Vaccination Centre, especially Dr. Robert Grenfell, for answering our questions regarding immunisation and health knowledge.
• Betatene Ltd, for providing us with the use of their snazzy and suave colour printer.
• Dr. Bridget Hsu-Hage, our Health Promotion Unit Coordinator.

References

Published works

1. Berger S.A, Giladi M, Shapiri I. Health concerns of Israelis travelling to third world countries - experience of a travel advisory clinic. Harefuah 1994 ; 126 (7) : pg.410-412, 427.

2. Nettleman M.D. Practicing empariatrics : basic sources of information on travel medicine. Infect. Cont. Hosp. Epidemiol. 1993; 14 (6) : pg.342-344.

3. Bryant H.E. Csokonay W.M, Love M, Love E.J. Self-reported illness and risk behaviours amongst Canadian travellers while abroad. Canadian Journal of Public Health. 1991; 82 (5): pg. 316-319.

4. Steffen R. Travel medicine - prevention based on epidemilogical data. Trans. R. Soc. Trop. Med. Hyg. 1991; 85 : pg. 156-62.

5. Graiter P.L, Bernard K.W, Vander Hugt T. Injuries in Peace Corps volunteers. Travel Med. Int. 1989; pg. 153-6.

6. Storti C. Culture shock and cultural adjustment : the psychological dimentions of the overseas sojourn. Travel Medicine 2. Atlanta; International Society of Travel Medicine : pg. 16-9.

7. Tibbiks D, Howden L, Cross G, Denham I, Plummer D. Microbiology Reference Notes. Monash University Printing Services. 1994: pg. 76-77.

8. Egger G. Health Promotion Lecture Series 1994. 'Health Promotion - The Fun Way'. July 21.

Unpublished works

a. Overseas Service Bureau. General Health Information and Vaccination Advice. 1993.

b. Cossar J. Briefing and debriefing - policy and procedure. Community Aid Abroad/ Freedom From Hunger. 1992; pg.11

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