Multidisciplinary travel health education: current status and rationale for standardized competencies

Abstract

This perspective highlights the inconsistent integration of travel health education across medical, nursing and pharmacy educational programmes globally and calls for standardized travel health competencies based on the International Society of Travel Medicine’s (ISTM) Body of Knowledge to help improve patient care outcomes as global travel returns to pre-pandemic levels.

Disparities in travel health education across health professional programmes may impact the quality of patient care. Travel health experts suggest that clinicians providing travel health services often struggle to provide informed guidance because they are inadequately trained.¹ Indeed, this conclusion is supported by previous studies describing large proportions of physicians without specialized travel health training (~40%) providing travel health services and recommending medications and vaccines inconsistent with guidelines more frequently than trained pharmacists.^2,3 A solution proposed by Flaherty et al. is, ‘to introduce all undergraduate healthcare students to travel medicine, since the majority of medical graduates subsequently train to become general practitioners or family physicians and there is hardly a medical or surgical specialty to which travel health issues are not relevant’.⁴ Here, we call for the development of a standardized set of travel health competencies to optimize travel health instruction across health educational programmes in order to improve patient quality of care.

Existing differences in travel health educational programmes are illustrated by examples of Schools of Medicine that include travel medicine competencies within their global health curricula. In the UK, one study identified 16 core competencies in global health, including the epidemiology of tropical diseases, which is taught in over 50% of UK programmes studied.⁵ In the USA however, fewer global health competencies are routinely taught and may include medical knowledge of international diseases; history and physical examination skills; cultural sensitivity and patient care in the context of the community.⁶ Global health programmes in Schools of Medicine elsewhere in the Americas exist, but the specifics of these programmes and whether they include travel health education are not well reported.⁷ Despite the apparent widespread availability of global health programmes in Schools of Medicine and their inclusion of travel medicine didactics, specific examples of how travel medicine competencies are implemented or how this education is provided to students also do not appear to be well described in the literature.

In contrast, US Schools of Pharmacy have historically reported the inclusion of travel health content in their global health curricula; however, some schools have replaced that content with stand-alone courses which include the American Pharmacists Association’s Travel Health Certificate Training Program, which is a standardized learning module that Schools of Pharmacy can incorporate into their curriculums.⁸ However, existing pharmacy-based travel health courses may also not include such standardized content. In one such study by Franks et al., the development and implementation of a travel health course within a Doctor of Pharmacy programme in Florida was described and found that, post-course implementation, 90% of students reported high levels of travel health knowledge and ability compared to 87% that rated themselves low prior to course implementation.⁹ Unfortunately, few curricular surveys of travel health content in Schools of Pharmacy exist in the published literature; thus the extent, depth and breadth of existing curricula are unknown. One survey of schools however reported that 85.7% (n = 6) incorporated travel health content into their curricula, but that this content was not consistent across all schools. For example, while all schools incorporated the subject of travellers’ diarrhoea, only 57.1% (n = 4) incorporated vector-borne diseases or special travel populations. Furthermore, the curricular structure varied among the schools studied. Five schools covered travel health in a required course while three also covered this material in an elective course. Travel health content in these required courses ranged from only 0.25 to 6 hours of instruction while content in the elective courses ranged from 2 to 40 hours of instruction.¹⁰ Travel health education may also be provided outside of traditional university instruction as is the case in the UK where Patient Group Directions may be utilized by licensed pharmacists desiring to practice in this area, representing greater variability in training.¹¹

Within Schools of Nursing, even fewer published reports describe travel health curricula. One systematic review described 12 global and public health core competencies; of these, the only competency related to travel health was travel and migration, representing an incomplete picture of travel health education.¹² More often, exposure to travel health in nursing appears to occur post-graduation via ‘on the job training’ within the practice setting itself through attendance at educational sessions of variable length or completion of independent training modules.¹³

While separate education and training opportunities in travel health have become more widely available outside of traditional university education with the passage of time, the onus remains on the individual practitioner to pursue them or for the employer to require them. The result of this hybrid educational structure is that travel health education and practice remains variable from country to country and from discipline to discipline.¹⁴ The unintended consequence of the current educational model is that healthcare providers exhibit variable competence when providing travel health services, impacting the quality and outcomes of patient care. Given the return of international travel to pre-COVID-19 pandemic levels and that patients often seek travel health advice from a primary care provider rather than seeking out and consulting a travel health specialist, a pressing need remains for the development of standardized travel health competencies to further advance travel health education across health professions schools.

The development of competency statements would clarify the extent and expectations to which health professional students should be able to provide care to patients in real world settings and would reflect the knowledge, skills and/or abilities that practitioners need to exhibit to provide adequate care to patients seeking travel health advice. We believe that the International Society of Travel Medicine (ISTM) Body of Knowledge (Table 1) is an ideal content source to derive and develop these competency statements as it was created ‘to guide the professional development of individuals practicing travel medicine and to shape curricula and training programs in travel medicine’. Furthermore, the Body of Knowledge has been defined and is regularly reviewed and updated (most recently in 2017) by travel health and medicine experts from the ISTM with additional input from hundreds of ISTM members and Certificate of Travel Health holders worldwide, representing diverse professional backgrounds. Lastly, it has also been recognized by travel health experts Kozarsky and Steffen as suitable for providing an adequate knowledge base for the practice of travel health.¹⁴ As a result, the use of the ISTM’s Body of Knowledge as the basis for these competencies serves as a peer reviewed resource or guidance document for the standardization of practice in travel health worldwide and what we propose as the source of required or mandatory travel health competencies that health professional students would need to attain prior to graduation. For health professional schools with existing travel health curricula, such required competencies could also be utilized to refine and update their existing curriculums to the required standard of practice.

Table 1.

ISTM Body of Knowledge by topic area, subtopics and weighting^a

Topic area	Subtopics	Weightingb
Epidemiology	Basic concepts Geographic distribution of diseases	10%
Immunology and vaccinology	Basic concepts and principles of Vaccine handling, storage, and disposal Types of vaccines	20%
Pre-Travel assessment	Patient evaluation Special populations and itineraries Prevention and self-treatment Risk communication	35%
Diseases contracted during travel	Vector-borne disease Person-to-person diseases Food and water-borne diseases Bites and stings Water and environmental contact	12%
Other clinical conditions associated with travel	Conditions during travel or post-travel Environmental factors Security threats Psychological issues	10%
Post-Travel assessment	Screening and assessment of returned travellers Screening and assessment of immigrants Triage of ill travellers Diagnosis and management	8%
Administrative and general issues	Medical care abroad Travel clinic management Travel information/resources	5%

^aAdapted from the ISTM Body of Knowledge. Available at https://www.istm.org/education-resources/cth-program/istm-body-of-knowledge. Last accessed 08/07/24

^bRelative importance (%) of each of the content areas following input from ISTM members

As examples, competency statements could include: ‘all travel health providers should know the self-treatment and prevention regimens for malaria’ (knowledge-based competency); ‘all travel health providers should be able to administer intramuscular and subcutaneous vaccines’ (skills-based competency) or ‘all travel health providers should be able to review patient medical histories to determine travel-related risks’ (ability-based competency). The development, implementation and widespread adoption of a uniform set of competency statements such as these would ensure that health professional students receive and are able to obtain the necessary knowledge and develop the appropriate skills and abilities to provide consistent and high-quality travel health services as practitioners. As mentioned above, competency statements could also be a resource for standardization of travel health content offered by existing health professional school curriculums to ensure that key topics are taught, such as the pre-travel consultation, risk assessment, vaccine recommendations, management of travel-related illnesses and migrant health. Competency statements may also help facilitate communication and collaboration among healthcare professionals across practice settings by facilitating information exchange and care coordination via uniform awareness of the travel health knowledge and skills expected of each type of health professional. Overall, the adoption of competency statements would help ensure that patients travelling internationally receive accurate, comprehensive, and personalized health advice and services.

In conclusion, travel health education across Schools of Medicine, Nursing and Pharmacy appears to exhibit significant differences in breadth and depth of exposure which may impact the quality and outcomes of patient care. Despite the importance of travel health in managing and preventing diseases associated with international travel, current health professional curricula often provide fragmented and/or variable coverage of important travel health topics or even leave the individual practitioner to seek out their own education and training. Furthermore, the available literature highlights that healthcare providers may lack adequate training in travel health, leading to potential disparities in not only patient care but adherence to guideline-based recommendations. The introduction and adoption of standardized competencies therefore represents an important step towards improving and advancing travel health education. Next steps could include a survey of health professional schools to systematically identify what travel health topics are currently being taught and/or a survey of travel health practitioners to evaluate the relevance of the ISTM Body of Knowledge to their practice. Such efforts to improve travel health education will enhance the individual knowledge, skills and abilities of healthcare professionals and improve patient outcomes as global travel expands.

Funding

None received.

Author contributions

Karl M. Hess (Conceptualization, Literature review, Drafting, Editing, and Finalizing manuscript), Sheila M. Seed (Literature review and Editing manuscript), Eva H. Clark (Editing manuscript), Tara Lombardo (Literature review and Editing manuscript), Francesca Norman (Conceptualization, Literature review, and Editing manuscript), and Gerard Flaherty (Conceptualization, Literature review, and Editing manuscript).

Conflict of interest

None declared.