Traveler’s knowledge, attitude, and practice about travel health insurance: A community-based questionnaire study

Chia-Jung Yang; Chia-Wen Lu; Chien-Hsieh Chiang; Hao-Hsiang Chang; Chien-An Yao; Kuo-Chin Huang

doi:10.1371/journal.pone.0281199

. 2023 Feb 9;18(2):e0281199. doi: 10.1371/journal.pone.0281199

Traveler’s knowledge, attitude, and practice about travel health insurance: A community-based questionnaire study

Chia-Jung Yang ^1,², Chia-Wen Lu ^3,⁴, Chien-Hsieh Chiang ^3,^4,⁵, Hao-Hsiang Chang ^3,⁴, Chien-An Yao ^3,⁴, Kuo-Chin Huang ^2,^3,^4,^6,^*

Editor: Andrea Cioffi⁷

PMCID: PMC9910690 PMID: 36757921

Abstract

Background

Travel, especially international travel, has become one of the most popular leisure activities in the world. The risk of accidents and travel-related illnesses, including infectious and non-communicable diseases, should not be neglected. To provide a more comprehensive pre-travel consultation to international travelers, this study aimed to investigate the knowledge, attitude, and practice of travelers about travel health insurance.

Methods

This was a cross-sectional study. Anonymous structured questionnaires were distributed to 1000 visitors to the Taiwan International Travel Fair in May 2019.

Results

The top three important travel health insurances were accidental death and disablement insurance (92%), accidental medical reimbursement (90.4%), and 24-hour emergency assistance (89%). In addition to education level, travel-associated illness, and special activities during travel, a significant association was observed between the willingness to buy various travel health insurances and the willingness of pre-travel consultation.

Conclusions

Most travelers would buy travel health insurance; however, disproportional respondents understood the content of travel health insurance. Most travelers considered travel clinics to be the most reliable information source regarding travel health insurance. Therefore, travel medicine specialists are encouraged to offer more information about travel health insurance during pre-travel consultation.

Introduction

International travel is appealing owing to globalization and the increasing trend of international tourism. According to the World Tourism Organization, the number of international arrivals was 1.442 billion in 2018 [1]. As international tourism increases and travel destinations diversify, more travelers acquire infectious diseases, which are not endemic in their home countries [2]. Up to 6%–87% of travelers became ill during or after their travels [3]. Keeping travelers healthy is the health providers’ mission and the responsibility is shared with travelers and health providers. However, 80% of European travelers were found to be non-compliant with the traditionally recommended dietary restriction, and 20% of all travelers did not carry any antimalarial drugs [4]. Most of the travelers did not follow the suggestions even though they received suggestions about disease prevention from their healthcare providers. Besides, accidents happen even when one is well-prepared. Approximately 20%–25% of travelers’ deaths were caused by injuries, and road traffic injuries were its leading cause [5]. Travel insurance is one of the most important safety nets for travelers and should be reinforced by travel health advisers [6].

Recent studies have shown that approximately 60% of General Practitioners in New Zealand [7] and 39% of travel clinics worldwide [8] usually advise travelers to buy travel insurance. Furthermore, as our previous study has shown, overseas emergency medical assistance services (EMAS) were considered important to travelers, but approximately 20%–30% of travelers lacked awareness about EMAS [9]. Since travel medicine services have also been indispensable in the COVID-19 pandemic, we realized that pre-travel healthcare will be even more vital in the future [10]. However, there is limited evidence regarding the willingness and the awareness of travelers about travel health insurance. Moreover, the travelers’ sources of buying travel health insurance and the correlation between the willingness to seek pre-travel consultation and the willingness to buy travel health insurance have not been well investigated. Therefore, this study was conducted to investigate the travelers’ knowledge, attitude, practice, and sources about travel health insurance to help healthcare workers provide more comprehensive pre-travel consultation to international travelers.

Materials and methods

Design

This study was a community-based, cross-sectional questionnaire survey. The questionnaire was self-administered and anonymous. The study was approved by the Institutional Review Board at National Taiwan University Hospital in Taiwan (201902070W) before the study was conducted.

Subjects

This survey included visitors who attended the Taiwan International Travel Fair in May 2019. Inclusion criteria were as follows: aged >20 years, willing, and able to complete the questionnaire. All respondents gave verbal consent before they fulfilled the questionnaire.

Questionnaire

The four-part questionnaire included questions on socio-demographical characteristics, knowledge of travel-related diseases and vaccines, attitudes, awareness, and willingness toward visiting travel medicine clinics and buying travel insurance. The questionnaire was pretested for face validity by a committee of ten physicians. The members of the committee were from National Taiwan University Hospital (NTUH) and Centers for Disease Control (CDC), Taiwan who were experienced in the clinical practice of travel medicine. Literature review was conducted and consensus opinion from three physicians at NTUH and CDC, Taiwan, was taken for testing the content validity of the questionnaire.

The socio-demographical characteristics included sex, age, education level, occupation, medical history, and special activities during travel. The other three parts of the questionnaire included the following components:

The knowledge of travel-related disease: 10 questions about vaccination, malaria, yellow fever, cholera, measles, hepatitis B, rabies, meningococcus, and influenza. Each question was scored 1 point for a correct response, with a total score of 10 points. These questions tested the respondents’ knowledge regarding the epidemiology, medication, and vaccination of travel-related disease.

Attitude toward travel medicine clinics and travel health insurance: This part examined the participants’ perceptions regarding to the importance of travel medicine clinics and travel health insurance. It included questions regarding: (1) travel medicine clinics, (2) pre-travel vaccination, (3) accidental death and disablement insurance, (4) accidental medical reimbursement, (5) overseas sickness coverage, (6) 24-hour emergency assistance, and (7) travel inconvenience insurance. The scoring system used a five-point Likert Scale, ranging from “very unimportant” (1 point), “unimportant” (2 points), “no comment” (3 points), “important” (4 points), to “very important” (5 points). Higher scores indicated positive attitudes regarding the need of certain services.

Awareness and willingness toward visiting travel medicine clinics and buying travel health insurance: This part sought the information on whether the participants heard about the abovementioned five different kinds of travel health insurances and travel clinics and whether or not they will use the service.

Statistical analysis

Data were presented as mean ± SD for continuous variables and numbers (%) for categorical variables. The chi-square test was used to compare the proportion of the willingness to buy travel insurance between different socio-demographic variables. One-way analysis of variance and independent t-test were used to clarify the relation between the knowledge of travel medicine and socio-demographic variables. A p-value <0.05 was considered statistically significant. Statistical analysis was carried out using the statistical software, Statistical Package for the Social Sciences 19.0 (version: 19.0, IBM Corp., Armonk, NY, USA, 2017).

Results

A total of 1,000 participants were randomly administered the questionnaire, and 927 visitors responded (response rate = 92.7%) to it. The high response rate and unbiased selections represented good internal validity. After eliminating 99 incomplete questionnaires, the final analysis included 828 respondents (303 males and 525 females).

Table 1 shows the demographic characteristics of the respondents. The mean age of the respondents was 44.7 ± 14.0 years. Among the respondents, 32.1% (n = 266) reported a medical history of chronic illnesses and 19.2% (n = 159) reported a previous experience of travel-associated illness. Additionally, 38.4% (n = 318) of the respondents planned to join group tours and 53.9% (n = 446) planned a self-guided tour. Furthermore, a total of 22.1% (n = 183) of the respondents planned to participate in activities that may increase their risk of health problems, such as mountain backpacking or scuba diving, during their travel.

Table 1. Basic characteristics of survey respondents (N = 828).

Characteristic	Number	Percentage (%)
Age (mean = 44.7±14.0 years)
20–29	127	15.3
30–39	202	24.4
40–49	209	25.2
50–69	149	18
60–89	141	17
Sex
Female	525	63.4
Male	303	36.6
Education level
High school or below	172	20.8
University or college	532	64.2
Graduate school and higher	124	15
Medical history ^a
No	562	67.9
Yes	266	32.1
Purpose of trip (multiple choices)
Self-guide tour	446	53.9
Group tours	318	38.4
Business travel	32	3.9
Visiting friend and relatives	21	2.5
Study abroad	7	0.8
Live abroad	7	0.8
International volunteering	4	0.5
Travel-associated illness ^b
No	669	80.8
Yes	159	19.2
Planned special activities ^c
No	645	77.9
Yes	183	22.1

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^a Hypertension, diabetes, hyperlipidemia, cardiovascular disease, gout, chronic renal disease, liver disease, chronic urticaria, thyroid disease, vasculitis, sleep disorder

^b Common cold, influenza, travelers’ diarrhea, trauma, herpes zoster, conjunctivitis, animal bite

^c Mountain backpacking, scuba diving, river rafting, snow skiing, surfing, marathon, cycling, glacier hiking

Table 2 shows the association between the willingness to buy different types of travel health insurances and demographic characteristics. A statistically significant association was observed between the willingness to buy travel inconvenience insurance and educational level (p-value = 0.001). The willingness of pre-travel consultation was associated with various travel health insurances (p-value < 0.001), and travel-associated illness was associated with the willingness to buy a 24-hour emergency assistance (p-value = 0.031). Furthermore, planned special activities during travel were associated with accidental death (p-value = 0.006) and disablement insurance (p-value = 0.043).

Table 2. Association between various characteristics and the willingness to buy different travel insurances (N = 828).

Variable	Number	Accidental death and disablement insurance			Accidental medical reimbursement			Overseas sickness coverage			24-hour of emergency assistance			Travel inconvenience insurance
Variable	Number	Unwilling N (%)	Willing N (%)	P Value	Unwilling N (%)	Willing N (%)	P Value	Unwilling N (%)	Willing N (%)	P Value	Unwilling N (%)	Willing N (%)	P Value	Unwilling N (%)	Willing N (%)	P Value
Age(years)				0.748			0.311			0.346			0.415			0.097
20–29	127	1.6	78.7		7.1	73.2		7.1	66.1		7.9	64.6		9.4	70.1
30–39	202	2	77.2		3	75.7		5.9	66.8		7.9	66.3		5.4	74.8
40–49	209	1.9	77		1.4	77.5		4.3	67.9		2.9	73.2		6.7	67.5
50–59	149	3.4	81.2		4	77.9		6.7	69.1		7.4	68.5		8.7	73.8
60–89	141	4.3	75.9		5.7	76.6		9.9	72.3		7.8	70.9		14.2	66
Sex				0.78			0.276			0.579			0.53			0.667
Female	525	2.5	78.7		3.2	77.9		6.9	69.1		6.7	60.1		7.8	71.2
Male	303	2.6	76.6		5	73.6		5.9	67		6.3	67		9.6	69.3
Educational level				0.115			0.077			0.085			0.091			0.001⁺^*
High School or below	172	4.7	73.3		6.4	70.3		8.1	63.4		7.6	65.7		14.5	62.8
University or College	532	2.3	78		3.6	76.7		6.8	67.7		7.3	68		7.5	70.1
Graduate School and higher	124	0.8	83.9		1.6	83.1		3.2	78.2		1.6	77.4		4	83.1
Medical history				0.271			0.087			0.518			0.785			0.195
No	562	2	78.8		2.8	77.2		5.9	68.5		6.2	68.7		7.3	71.9
Yes	266	3.8	75.9		6	74.4		7.9	68		7.1	69.5		10.9	67.7
Willingness of pre-travel consultation				0.000^**			0.000^**			0.000^**			0.000^**			0.000^**
Yes	493	1.8	86.8		3.4	85.4		5.7	79.7		4.5	81.3		6.7	79.5
Undetermined	307	2	64.5		3.3	62.9		6.8	50.5		7.8	50.8		9.1	58
No	28	21.4	67.9		17.9	64.3		17.9	64.3		28.6	50		32.1	50
Travel-associated illness				0.082			0.235			0.182			0.031^*⁺			0.249
No	669	2.2	76.8		3.4	75.9		6.3	67.3		6	67.7		7.9	70.1
Yes	159	3.8	82.4		5.7	78		7.5	73		8.8	74.2		10.7	72.3
Planned special activities during travel				0.006^**			0.068			0.076			0.043^*			0.307
No	645	1.7	77.5		3.3	75.7		5.7	67.8		6.4	67.1		7.8	70.5
Yes	183	5.5	79.2		6	78.7		9.3	70.5		7.1	75.4		10.9	70.5

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The chi-square test was applied to compare the proportion of the willingness to buy travel insurances between different socio-economic variables.

*p value < 0.05;

**p value < 0.001

Table 3 shows the comparison of the mean scores of the knowledge of travel medicine with socio-demographic variables. The knowledge of travel-related infection, vaccine, and diseases was significantly associated with age, medical history, and travel-associated illness.

Table 3. Comparison of mean scores of knowledge of travel medicine with socio-demographic variables.

Variable	Number	Mean(±SD)	P value
Age(years)			0.000^**
20–29	127	5.6(±1.68)
30–39	202	6.13(±1.75)
40–49	209	6.68(±1.85)
50–59	149	6.81(±2.02)
60–89	141	7.5(±1.94)
Medical history			0.000^**
No	562	6.38(±1.87)
Yes	266	6.89(±2.0)
Travel-associated illness			0.035^*
No	669	6.48(±1.91)
Yes	159	6.83(±2.0)
Planned special activities during travel			0.532
No	645	6.52(±1.9)
Yes	183	6.62(±2.1)

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One-way analysis of variance and independent t-test were applied to clarify the relation between the knowledge of travel medicine and socio-demographic variables.

*p value < 0.05;

**p value < 0.001

Table 4 shows the source and subjective trust of travel health insurance information. Most respondents obtained their information from social media (45.9%), insurance company (45.4%) or travel agency (35.9%). However, the majority of respondents appraised healthcare workers (44.1%), and insurance company (42.5%) as the most reliable sources.

Table 4. Source and subjective trust of travel health insurance information (N = 828).

Variable	Source	Subjective trust
Social media	45.9%	31.3%
Insurance company	45.4%	42.5%
Travel agency	35.9%	30.1%
Family or friends	24.2%	18.8%
Healthcare workers	10.7%	44.1%

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Discussion

In our main findings, we clearly demonstrated that travelers when asked about the most important insurances or to rate the insurances, 92% answered accidental death and disablement insurance, 90.4% answered accidental medical reimbursement, and 89% answered 24-hour emergency assistance. Risk management is an important issue for travelers, since accidents and injuries are important causes of morbidity and mortality [11, 12]. Buying travel health insurance is one of the methods to reduce the risk of loss. There were few studies investigating travel health insurance, and most studies were conducted from the health advisor’s perspective [7, 8]. Our study focused on another viewpoint from the travelers.

We found that the percentage of willingness to buy travel health insurance was high, about 60%–80% in this study. However, previous study showed that most travelers tend to consider the price instead of the service details and the quality coverage when purchasing travel insurance [13]. Besides, the low percentage of travelers (59.5%) willing to seek pre-travel advice described in the literature contrasts with the percentage (62.8–86.8%) of those motivated to buy travel health insurance in this study. In another view, it’s a good opportunity to raise their awareness of pretravel consultation when travelers purchase travel health insurance. If the two disciplines cooperate, travelers can receive more comprehensive health care.

Our study revealed only 31.5%–44.7% of respondents understood the content of travel insurance very well, whereas 9.5%–17.3% expressed their ignorance. The previous study showed only two-thirds of travel insurance claims were fully approved, and most refusal was due to pre-existing conditions and poor documentation [14]. During the COVID-19 pandemic, many insurance companies discontinued selling travel health insurance, or any coverage related to COVID-19 [10]. Therefore, travelers must be aware of the health insurance policy, especially the coverage when infected with newly emerging infectious diseases or pre-existing condition while abroad [15, 16].

Additionally, we found that fewer respondents were willing to buy overseas sickness coverage (68.4%) and 24-hour emergency assistance (69%). However, emergency medical evacuation from a low-income nation costs $50,000 to $75,000 or more [17]. Although less than 0.5% of travelers need medical evacuation, there were still considerable cases in the booming generation of tourism [18]. According to the statistics of International SOS Group of Companies, they received 4 million assistance calls until 2022 [19]. The demand of 24-hour emergency assistance is quite a lot. Overseas sickness coverage and medical evacuation are crucial while traveling during the Covid-19 pandemic since local healthcare capacity can be overwhelmed [20].

Travelers with high educational levels, willingness to pre-travel consultation, travel-associated illnesses, and planned special activities during travel were more willing to buy travel health insurance. In addition, travelers with older age, medical histories, and travel-associated illnesses were significantly associated with a higher knowledge of travel medicine. In other words, those travelers who have the willingness to buy travel health insurance may not have good knowledge of travel medicine. Compared with a previous study, approximately 40% of European travelers could not assess the risk of infectious diseases accurately [21]. Buying travel health insurance without adequate consultation is not enough for travel health and safety. Strengthening travelers’ awareness about travel-related diseases is also important.

It is not surprising that most respondents reported that the source of their travel-related and insurance knowledge was social media or insurance company, but they thought that healthcare workers were the most reliable source. However, little nonmedical health advice was offered to travelers by healthcare workers in general practice. Previous study has also shown that the variance in medical coverage of different travel health insurance is complex [14]. Therefore, healthcare workers are encouraged to be equipped with the knowledge of travel health insurance to help travelers.

Limitations

This study has some limitations. First, the questionnaire was conducted in Taiwan International Travel Fair in north Taiwan and might result in sampling bias. Most of the respondents were younger, with high education levels, with less experience of travel-associated illness, and with less pre-existing diseases; thus, our findings might not be applicable to all travelers. Nevertheless, few studies have investigated travelers’ attitude, willingness, and awareness about travel health insurance. We believe that this study will give an insight into pre-travel health consultation in the future.

Conclusions

Between a third and half of the travelers understand the content of health insurance, almost all recognize its importance, and more than two-thirds were willing to buy a health insurance when traveling. However, just buying insurance does not equal to being well-prepared. Understanding local epidemic and implement personal protective measures is still important. Most travelers thought that healthcare workers are the most reliable source of travel insurance. Therefore, health professionals should be encouraged to acquire health insurance knowledge and transmitted it on during pre-travel consultations before the countries reopen for tourism.

Supporting information

S1 File. Minimal data set.

(XLSX)

Click here for additional data file.^{(153.5KB, xlsx)}

Acknowledgments

We would like to thank Miss Chia-Chi Yu for her assistance in this study.

Data Availability

All relevant data are within the paper and its Supporting information files.

Funding Statement

This study has been partially sponsored by the Centers for Disease Control, Taiwan (JK108026). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0281199.r001

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29 Jun 2022

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Traveler’s Knowledge, Attitude, and Awareness about Travel Health Insurance during the COVID-19 Pandemic

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We will update your Data Availability statement to reflect the information you provide in your cover letter.

Additional Editor Comments:

We noticed that your manuscript title and abstract specifically mentions COVID-19. However, the survey was conducted in March 2019, just at the beginning of the global COVID-19 pandemic, and we assessed that the article was written to represent a much broader subject of international travel unrelated to COVID-19. We would therefore suggest removing the mention of COVID-19 from the title and abstract.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: A few things to consider in revisions:

1. This study is a knowledge, attitudes, and awareness study, but I am curious as to why "practices" was not included? To me, awareness is the same as knowledge, so I think this important component was left out of the questionnaire.

2. I am not sure what is meant by "important travel insurances." Typically travel insurance has multiple facets, and one needs to look to see what coverage is.

3. Remove the study from the 1980s from the intro. It is old and not relevant.

4. International SOS is not mentioned at all in the manuscript. As the largest provider of insurance and evacuation services globally they should be mentioned. They have also published findings they do not seem to be included.

5. Were respondents consented? If yes or no, this should be mentioned in the methods.

6. One third of people had a chronic illness, which likely greatly impacted their responses. This should be discussed thoroughly in the discussion.

7. All tables should be in descending numerical order. (example: purpose of trip is not in any sort of format). Right now each variable is not in descending order.

8. The discussion should start with a paragraph on what makes this analysis important and unique.

9. I am unclear what this means in the context of the discussion: "An increasing trend for international travel has been observed." Remove.

10. Conclusions should not have any data. They should reiterate the take home points without data. I also think the conclusions need to be strengthened. What is the public health and clinical importance of the findings?

11. Each paragraph of the discussion should be expanded on. Paragraphs should start with a strong introductory sentence, available evidence, and then followed by a strong closing.

12. I do not think that Figure 1 adds much. Remove.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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PLoS One. 2023 Feb 9;18(2):e0281199. doi: 10.1371/journal.pone.0281199.r002

Author response to Decision Letter 0

2 Aug 2022

Replay to Edits (2022/8/2)

We've checked your submission and before we can proceed, we need you to address the following issues:

1. Please provide additional details regarding participant consent. In the Methods section, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

Response: Thanks for your recommendation. We stated that the purpose of this study was to understand travelers’ knowledge, attitudes, and practice at the beginning of the questionnaire. And all respondents gave verbal consent before they fulfilled the questionnaire. We have also shown “The study was approved by the Institutional Review Board at National Taiwan University Hospital in Taiwan (201902070W) before the study was conducted.” on page 7. The questionnaire was administered anonymously in public. We cannot recognize the personal identification after completion of the questionnaire. The Institutional Review Board at National Taiwan University Hospital in Taiwan agreed that the study could be conducted with oral informed consent.

Reply to Editor

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.

Response: Thanks for your recommendation. We’ve checked and amended our manuscript to meet PLOS ONE's style requirements.

2. Thank you for stating the following financial disclosure:

“This study has been partially sponsored by the Centers for Disease Control, Taiwan (JK108026).”Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

Response: Thanks for your recommendation. We’ve added "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." in cover letter.

Response: Thanks for the instructions. We’ve uploaded minimal underlying data set as Supporting Information files, S1 File Minimal data set.

Additional Editor Comments:

Response: We appreciate your comment. We’d like to adjust the title to “Traveler’s Knowledge, Attitude, and Practice about Travel Health Insurance”. We also removed the mention of COVID-19 from the abstract and keywords.

Reply to Reviewer

Reviewer #1

Reviewer #1: A few things to consider in revisions:

Response: We appreciate your opinion. Actually, we included the travelers’ willingness toward visiting travel medicine clinics and buying travel health insurance, so we think that the revised title “Traveler’s Knowledge, Attitude, and Practice about Travel Health Insurance” is more appropriate.

2. I am not sure what is meant by "important travel insurances." Typically travel insurance has multiple facets, and one needs to look to see what coverage is.

Response: Thanks for your comments. We feel the same way, the importance of the travel health insurance depends on the coverage and the demand of the traveler. Because we want to clarify the attitude and the willingness of the travelers, we asked the travelers how do they think about different kind of insurance and will they buy that. The result was according to their reply.

3. Remove the study from the 1980s from the intro. It is old and not relevant.

Response: Thanks for your suggestion. We’ve removed the reference.

Response: Thanks for your suggestion. We agreed and used their statistics to show the need of 24-hour emergency assistance is quit a lot, so we added “According to the statistics of International SOS Group of Companies, they received 4 million assistance calls until 2022 [18]. The demand of 24-hour emergency assistance is quite a lot.” in discussion section, Line 226-227, Page 17.

5. Were respondents consented? If yes or no, this should be mentioned in the methods.

Response: Thanks for your reminder. Yes. All respondents consented. We added that” All respondents gave verbal consent before they fulfilled the questionnaire.” in the Design paragraph, Line 109-110, Page 7.

6. One third of people had a chronic illness, which likely greatly impacted their responses. This should be discussed thoroughly in the discussion.

Response: Thanks for your recommendation. There was no significant association between chronic illness and the willingness to buy travel health insurance, thus we did not expound it (Table 2). However, we found that the knowledge of travel-related infection, vaccine, and diseases was significantly associated with medical history (Table 3).

We stated “In addition, travelers with older age, medical histories, and travel-associated illnesses were significantly associated with a higher knowledge of travel medicine. In other words, those travelers who have the willingness to buy travel health insurance may not have a good knowledge of travel medicine.” in discussion section, Line 233-237, Page 17.

Table 2 Association between various characteristics and the willingness to buy different travel insurances.

Table 3 Comparison of mean scores of knowledge of travel medicine with socio-demographic variables.

7. All tables should be in descending numerical order. (example: purpose of trip is not in any sort of format). Right now each variable is not in descending order.

Response: Thanks for your recommendation. We’ve revised all tables, Table 1, 2 and 3.

8. The discussion should start with a paragraph on what makes this analysis important and unique.

Response: We appreciate for your recommendation. We’ve now revised the first paragraph of Discussion section and focused on the unique of this study.” In our main findings, we clearly demonstrated that the top three important travel health insurances were accidental death and disablement insurance (92%), accidental medical reimbursement (90.4%), and 24-hour emergency assistance (89%). Furthermore, we found that the education level, travel-associated illness, and special activities during travel were significant parameters to influence the willingness to buy various travel health insurances and willingness of pre-travel consultation.” (Line 199-204, page 16).

9. I am unclear what this means in the context of the discussion: "An increasing trend for international travel has been observed." Remove.

Response: Thanks for your suggestion. We’ve removed it.

Response: Thanks for your comments. We’ve revised the paragraphs of conclusion. Our study highlights the gap between travelers’ willingness to buy and to understand travel health insurance. Most travelers thought that healthcare workers are the most reliable source, so we should provide them more comprehensive advice, including travel health insurance.” Most travelers would buy travel health insurance, such as accidental death and disablement insurance and accidental medical reimbursement; however, a disproportionate percentage of the respondents understood the content very well. Just buying insurance does not equal to being well-prepared.” Line 261-264, Conclusions section, page 20.

11. Each paragraph of the discussion should be expanded on. Paragraphs should start with a strong introductory sentence, available evidence, and then followed by a strong closing.

Response: Thanks for your comments. We’ve revised every paragraph of discussion according to your suggestion. Discussion section, page 16-18.

12. I do not think that Figure 1 adds much. Remove.

Response: Thanks for your suggestion. We’ve removed it.

Attachment

Submitted filename: Response to Reviewers_20220802.docx

Click here for additional data file.^{(38.6KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0281199.r003

Decision Letter 1

Thomas Tischer

4 Oct 2022

PONE-D-21-34714R1Traveler’s Knowledge, Attitude, and Practice about Travel Health InsurancePLOS ONE

Dear Dr. Huang,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Your manuscript has been evaluated by 4 reviewers and their comments are attached below. They complement you for your effort with the revisions, but raised a couple more concerns about the study and presentation. They suggest to include more discussion about what can be done to increase knowledge about travel insurance and would like to see inclusion of a discussion about the results presented in the tables. They also have a couple grammatical suggestions and queries about clarifications.Would you be able to address all their concerns for a resubmission of the manuscript?

Please submit your revised manuscript by Nov 18 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Thomas Tischer

Staff Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

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6. Review Comments to the Author

Reviewer #1: (No Response)

Reviewer #2: I suggest you add the study’s design in the title and in the abstract.

In the abstract substitute:

Accident --> accidents

visitors of --> visitors to the

willingness --> the willingness

the international --> international

In the introduction substitute:

Increased --> increasing

Tourisms --> tourism

Responsibilities --> responsibility

Noncompliant --> non-compliant

1980s’ --> 1980s

Shown --> showed / has shown

Categories --> the categories

About --> of

Risk-coverage --> risk coverage

a travel --> travel

77 - 80 – you should clarify this sentence. First you say it is the health providers responsibility and then you say travellers did not follow the suggestions. Maybe the responsibility is shared?

93 - 95 – How the first part of the sentence justifies the second part?

In general, the introduction is not very clear and effective in demonstrating the importance of health insurance for travel and have several writing issues. I recommend that the text be proofread by a native English speaker.

111 – 114 - You should clarify this paragraph. It is not clear what is the study design, the instrument and the participants.

117 – 119 – This phrase does not belong in the subjects’ section.

In the subject’ section you should add from where and how the participants were selected.

Results

In the results’ section consider to include the number next to the percentage and also de p value next to the result presented.

The results presented in the tables should be better described in the text.

169 – selection --> selections

175 – illness --> illnesses

176 – self-guide --> self-guided

187 – 189 – In this sentence what means “top three ones”?. I suggest: Travellers when asked about the most important insurances or to rate the insurances, 92% answered..

Discussion

216 – illness --> illnesses

220 – from --> of

222 – for --> in

228-229 – I suggest you write it this way: The low percentage of travellers willing to seek pre-travel advice described in the literature contrasts with the percentage (percentage) of those motivated to buy travel health insurance in this study.

239 – 240 – You should clarify this sentence. According to what you described in 238-239, this sentence should be the cost of travel health insurance for the traveller or you are describing how much it cost without insurance?.

241 - 243 – I suggest: Overseas sickness coverage and medical evacuation are crucial while traveling during the Covid-19 pandemic since local healthcare capacity can be overwhelmed.

244 – remove “Besides” and “also”

245 – about --> of

249 – of --> to

255 – toward --> of

256 – remove “is”

257 – one third --> one-third

267 - 60% general --> 60% of general; give advice --> advise; insurances --> insurance

269 – the travelers --> travelers; insurances --> insurance

271 – insurances --> insurance; a new --> new

272 – airline --> airlines

Conclusion

The conclusion should include something about knowledge related to infections, vaccines, and illnesses while traveling.

289 – 291 I suggest: between a third and half of the travelers understand the content of health insurance, almost all recognize its importance, and more than two-thirds were willing to buy a health insurance when traveling.

293 – 294 I suggest: Therefore, health professionals should be encouraged to acquire health insurance knowledge and transmitted it on during pre-travel consultation..

295 – consultation --> consultations

Figure 1 must be redone, it is not possible to see due to lack of quality.

Reviewer #3: I would like to thanks the editors for giving me the opportunity to review the manuscript "Traveler’s Knowledge, Attitude, and Practice about Travel Health Insurance” which was submitted to ‘PLOS ONE'. I found the manuscript intriguing and informative. However, in my opinion, this manuscript cannot be published in its current form, certain corrections should be made. Therefore, based on my observations, I am making the following suggestions to improve the quality of the current work.

Comment one:

First and foremost, I'd like to thank to all of the authors for their strong effort. However, I found the manuscript's 'research gap and research objective' is not clear. The research gap should be clearly mentioned in the introduction part so that we can get a clear idea. For example, the following statements in the 'introduction section' is not clear and should be rewritten.

Introduction (lines no. 96 to 99):

'In addition, the travelers' awareness---------have not been well investigated'.

Comment two:

It is unclear Why the authors collected data on "willingness toward visiting travel medicine clinics". They emphasized on "travel insurance purchase behavior" rather than "willingness travel medicine clinics visit" in their research objectives. This should be included in your research objective or left out of the manuscript.

Questionnaire section (line no 119)

Comment three:

The authors mentioned about the pretest of the questionnaires, in the questionnaire section,which is commendable. However, the measurement scales of (lines 129 to 147) 'knowledge', 'attitude' and 'purchase behavior' are well established in the fields of marketing and management. It is unclear why the author did not adapted those scale to conduct the study. Moreover, a pretest alone is insufficient for developing a measurement scale, and it may cause concerns with the scale's validity and reliability. I believe that additional information in this area is required.

Comment four:

The findings of tables 1,2 and 3 should be properly discussed in the results section. The authors just mentioned a proportion of the table 1 and 2 and there was no interpretation for table 3. Please appropriately discuss the tables based on your research objective so that readers comprehend the research findings.

Moreover, no justification was provided for using one-way ANOVA and the t-test to analyse the data. Please provide justifications for using these statistical analysis to analyse the research data. Besides, the authors mentioned 'socio-demographic" variables in line 193 and 'socio-economic" variables inline 195 (under table 3). The terminology inconsistency should be addressed.

Comment five:

The data analysis from the discussion section can be transferred to the result section. It is better if the authors compare their findings to previous studies in this field and provide an explanation for any discrepancies in their findings based on prior research and theory. In the discussion section, they should also include the research contribution, which should address the research gap and objectives . Please revise the "Result" and "Discussion" sections.

Comment six:

It is mentioned that travelers rely more on "healthcare workers" (lines 241 to 246). However, the information about healthcare workers was not provided in any table.

Comment seven:

In the limitation section, the authors mentioned about non-response bias. This I believe is not a problem because 92.7% responses are already good enough. However, I am concerned that the the authors stated that they were unable to demonstrate a causal relationship due to the cross-sectional study (lines 254 to 256) !!!!! Cross-sectional studies are commonly used in social science studies to examine the causal relationship. There are numerous ways to addressing the bias of cross-sectional studies (e.g. marker variables). If the authors want, I believe they can use "Structural Equation Modeling" to provide greater understanding into the phenomenon. It is very important to understand the research objectives and what methodologies we are going to adopt to conduct the research.

Overall, I believe the manuscript can be accepted after addressing the above mentioned issues.

Thank you

Reviewer #4: The authors have addressed the reviewer's comments satisfactorily. An additional point should be mentioned in the discussion. How do the authors propose that travel medicine professionals educate themselves about the various types of travel insurance policies? This topic is rarely the exclusive topic of any conference session, although it is mentioned a lot in passing. Insurance medicine is itself a branch of medicine. Should there be greater cooperation between the two disciplines perhaps? Should we invite insurance physicians to attend our conferences or present at our webinars? A final point relates to the references. The authors correctly state that there has been limited previous work in this area. They may have overlooked the following article which is available as an open access source. There may be useful material that could strengthen your discussion. Source: Darrat M, Flaherty GT. An Exploratory Study of Medical Cover Policies Offered by the Travel Health Insurance Industry. International Journal of Medical Research & Health Sciences, 2019, 8(8): 1-8

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

**********

Attachment

Submitted filename: Reviewer attachment.pdf

Click here for additional data file.^{(121.8KB, pdf)}

PLoS One. 2023 Feb 9;18(2):e0281199. doi: 10.1371/journal.pone.0281199.r004

Author response to Decision Letter 1

7 Nov 2022

Reviewer #2:

1. I suggest you add the study’s design in the title and in the abstract.

Response: Thanks for your recommendation. We have added the study’s design in the title, “Traveler’s Knowledge, Attitude, and Practice about Travel Health Insurance: A Community-based Questionnaire Study.” We also added the design in the abstract. “Methods: This was a cross-sectional study. Anonymous structured questionnaires were distributed to 1000 visitors to the Taiwan International Travel Fair in May 2019.”

2. In the abstract substitute:

Accident --> accidents

Response: We have revised the word. (LINE 34)

visitors of --> visitors to the

Response: We have revised the word. (LINE 40)

willingness --> the willingness

Response: We have revised the word. (LINE 45)

the international --> international

Response: We have revised the word. (LINE 36)

In the introduction substitute:

Increased --> increasing

Response: We have revised the word. (LINE 70)

Tourisms --> tourism

Response: We have revised the word. (LINE 72)

Responsibilities --> responsibility

Response: We have revised the word. (LINE 76)

Noncompliant --> non-compliant

Response: We have revised the word. (LINE 77)

1980s’ --> 1980s

Response: We’ve removed this reference according to another reviewer’s suggestion.

Shown --> showed / has shown

Response: We have revised the word. (LINE 87)

Categories --> the categories

Response: We’ve removed this sentence according to another reviewer’s suggestion.

About --> of

Response: Thanks for your recommendation. We’ve removed this sentence according to another reviewer’s suggestion.

Risk-coverage --> risk coverage

Response: We’ve removed this sentence according to another reviewer’s suggestion.

a travel --> travel

Response: We’ve revised the word. (LINE 94)

3. 77 - 80 – you should clarify this sentence. First you say it is the health providers responsibility and then you say travelers did not follow the suggestions. Maybe the responsibility is shared?

Response: We have revised the sentence to avoid the misunderstanding. (LINE 75-76)

4. 93 - 95 – How the first part of the sentence justifies the second part?

Response: Thanks for your question. Initially, we wanted to emphasize that although there were many kinds of travel health insurance, few studies investigated travelers’ knowledge, attitude, and practice. Thus, we conducted this study. To make it clearer, we removed the redundant sentences. (LINE 92-99)

5. In general, the introduction is not very clear and effective in demonstrating the importance of health insurance for travel and have several writing issues. I recommend that the text be proofread by a native English speaker.

Response: The introduction section is revised carefully. We have also sent it to the English editing by a native English speaker.

6. 111 – 114 - You should clarify this paragraph. It is not clear what is the study design, the instrument and the participants.

Response: We’ve re-organized the paragraph of Design and Subjects to make them clearer. (LINE 104-112)

7. 117 – 119 – This phrase does not belong in the subjects’ section.

In the subject’ section you should add from where and how the participants were selected.

Response: We’ve re-organized the paragraph of Design and Subjects to make them clearer. (LINE 104-112)

8. Results

In the results’ section consider to include the number next to the percentage and also the p value next to the result presented.

The results presented in the tables should be better described in the text.

Response: Thanks for your recommendation. We’ve included the number and the p value next to the result presented. (Results paragraph)

9. Grammar correction

169 – selection --> selections

Response: We have revised the word. (LINE 162)

175 – illness --> illnesses

Response: We have revised the word. (LINE 167)

176 – self-guide --> self-guided

Response: We have revised the word. (LINE 169)

10. 187 – 189 – In this sentence what means “top three ones”? I suggest: Travelers when asked about the most important insurances or to rate the insurances, 92% answered.

Response: We appreciate your recommendation. Because another reviewer’s suggestion, we’ve adjusted this main finding to our discussion session. And we have revised the grammar according to your recommendation. (LINE 204-207)

11. Grammar correction

Discussion

216 – illness --> illnesses

Response: We’ve removed this sentence according to another reviewer’s suggestion.

220 – from --> of

Response: We’ve removed this sentence according to another reviewer’s suggestion.

222 – for --> in

Response: We’ve removed this sentence according to another reviewer’s suggestion.

12. 228-229 – I suggest you write it this way: The low percentage of travelers willing to seek pre-travel advice described in the literature contrasts with the percentage (percentage) of those motivated to buy travel health insurance in this study.

Response: We appreciate your recommendation. And we’ve revised the sentence according to your recommendation. (LINE 217-221)

13. 239 – 240 – You should clarify this sentence. According to what you described in 238-239, this sentence should be the cost of travel health insurance for the traveler or you are describing how much it cost without insurance?

Response: We apologize for confusing you. The cost is the emergency medical evacuation from a low-income nation. If the insurance coverage includes evacuation, then the traveler can pay less. We’ve revised this paragraph. We emphasized the respondents’ neglect of overseas sickness coverage and 24-hour emergency assistance first. Then, we showed that the fee of emergency medical evacuation is high. (LINE 231-234)

14. 241 - 243 – I suggest: Overseas sickness coverage and medical evacuation are crucial while traveling during the Covid-19 pandemic since local healthcare capacity can be overwhelmed.

Response: Thanks for your suggestion. We’ve revised according to your recommendation. (LINE 238-239)

15. Grammar correction

244 – remove “Besides” and “also”

Response: We’ve removed this sentence according to another reviewer’s suggestion.

245 – about --> of

Response: We’ve removed this sentence according to another reviewer’s suggestion.

249 – of --> to

Response: We’ve revised according to your recommendation. (LINE 240)

255 – toward --> of

Response: We’ve removed this sentence according to another reviewer’s suggestion.

256 – remove “is”

Response: We’ve removed this sentence according to another reviewer’s suggestion.

257 – one third --> one-third

Response: Thanks for your suggestion. We’ve revised the sentence to “Our study revealed only 31.5%–44.7% of respondents understood the content of travel insurance very well, whereas 9.5%–17.3% expressed their ignorance.” (LINE 222-223)

16. 267 - 60% general --> 60% of general; give advice --> advise; insurances --> insurance

Response: We’ve revised according to your recommendation. “ Recent studies have shown that approximately 60% of General Practitioners in New Zealand [7] and 39% of travel clinics worldwide [8] usually advise travelers to buy travel insurance.” (LINE 85-87)

17. 269 – the travelers --> travelers; insurances --> insurance

Response: We’ve revised the sentences after the last major revision. “Recent studies have shown that approximately 60% of General Practitioners in New Zealand [7] and 39% of travel clinics worldwide [8] usually advise travelers to buy travel insurance.” (LINE 85-87)

18. 271 – insurances --> insurance; a new --> new

Response: We’ve removed the sentences after the last major revision.

19. 272 – airline --> airlines

Response: Thanks for your suggestion. We’ve removed the sentences after the last major revision.

20. Conclusion

The conclusion should include something about knowledge related to infections, vaccines, and illnesses while traveling.

Response: We’ve added the sentence, “Understanding local epidemic and implement personal protective measures is still important.” in Conclusion paragraph. (LINE 272-273)

21. 289 – 291 I suggest: between a third and half of the travelers understand the content of health insurance, almost all recognize its importance, and more than two-thirds were willing to buy a health insurance when traveling.

Response: Thanks for your suggestion. We’ve revised the sentence according to your recommendation. (LINE 269-271)

22. 293 – 294 I suggest: Therefore, health professionals should be encouraged to acquire health insurance knowledge and transmitted it on during pre-travel consultation.

Response: We’ve revised the sentence according to your recommendation. (LINE 274-276)

23. 295 – consultation --> consultations

Response: We’ve revised the word according to your recommendation. (LINE 276)

24. Figure 1 must be redone, it is not possible to see due to lack of quality.

Response: Thanks for your suggestion. We’ve removed Figure 1 according to the last reviewer’s suggestion.

Reviewer #3:

I would like to thank the editors for giving me the opportunity to review the manuscript "Traveler’s Knowledge, Attitude, and Practice about Travel Health Insurance” which was submitted to ‘PLOS ONE'. I found the manuscript intriguing and informative. However, in my opinion, this manuscript cannot be published in its current form, certain corrections should be made. Therefore, based on my observations, I am making the following suggestions to improve the quality of the current work.

1. First and foremost, I'd like to thank to all of the authors for their strong effort. However, I found the manuscript's 'research gap and research objective' is not clear. The research gap should be clearly mentioned in the introduction part so that we can get a clear idea. For example, the following statements in the 'introduction section' is not clear and should be rewritten.

Introduction (lines no. 96 to 99):

'In addition, the travelers' awareness---------have not been well investigated'.

Response: Thanks for your comments. We’ve revised the paragraph of introduction according to your suggestion. (LINE 92-99)

2. It is unclear Why the authors collected data on "willingness toward visiting travel medicine clinics". They emphasized on "travel insurance purchase behavior" rather than "willingness travel medicine clinics visit" in their research objectives. This should be included in your research objective or left out of the manuscript.

Response: Thanks for your comments. Pretravel consultation is also important in addition to buying travel health insurance. In fact, pretravel consultation is our prime opportunity to educate travelers. Thus, we want to understand the correlation to clarify what else we could do. So, we include the willingness to seek pre-travel consultation in our research objective. (LINE 94-95)

Questionnaire section (line no 119)

3. The authors mentioned about the pretest of the questionnaires, in the questionnaire section, which is commendable. However, the measurement scales of (lines 129 to 147) 'knowledge', 'attitude' and 'purchase behavior' are well established in the fields of marketing and management. It is unclear why the author did not adapt those scale to conduct the study. Moreover, a pretest alone is insufficient for developing a measurement scale, and it may cause concerns with the scale's validity and reliability. I believe that additional information in this area is required.

Response: Thanks for your comments. Reviewing the literatures, most studies focus on health insurance rather than travel health insurance [1-3]. Our last study focused on emergency medical assistance services [4]. Because this time we wanted to know travelers’ knowledge, attitude, and purchase behavior of different kinds of travel insurance, we used our questionnaire which designed by ourselves. The Cronbach’s Alpha is 0.927, which represents good reliability. About validity, ten physicians with clinical experienced in travel medicine conducted face validity. So, we believe our questionnaire is qualified.

Reference:

1. Sheryl AR, Margarete E, Charles EI. Adolescents’ knowledge of their health insurance coverage. J Adolesc Health. 1998;22:293-299

2. Dhungana BR, Giri SS, Kushwaha SP, Khanal DK, Yadav BK. Awareness and Perception Regarding Health Insurance Among Community People in a Municipality: A Cross Sectional Study. MedS J Med Sci. 2021;1:76-82.

3. Evita A, Enrico MB, Gian PS. Understanding Insurance Knowledge: A Brief 7-Item Measure. Int J Bus Manag. 2021,16 (2), 65-74.

4. Lee YH, Lu CW, Wu PZ, Huang HL, Wu YC, Huang KC. Attitudes and awareness of medical assistance while traveling abroad. Global Health. 2018;14(1):67. doi:10.1186/s12992-018-0382-5.

4.The findings of tables 1,2 and 3 should be properly discussed in the results section. The authors just mentioned a proportion of the table 1 and 2 and there was no interpretation for table 3. Please appropriately discuss the tables based on your research objective so that readers comprehend the research findings.

Response: Thanks for your comments. Table 2 is our main research objective, so we wrote more about table 2. We’ve revised the discussion paragraph according to your suggestion. Our interpretation for table 3 is on LINE 240-246. We emphasize travelers who have the willingness to buy travel health insurance may not have good knowledge of travel medicine.

5. No justification was provided for using one-way ANOVA and the t-test to analyze the data. Please provide justifications for using these statistical analyses to analyze the research data. Besides, the authors mentioned 'socio-demographic" variables in line 193 and 'socio-economic" variables inline 195 (under table 3). The terminology inconsistency should be addressed.

Response: Thanks for your recommendation. We’ve revised the terminology inconsistency. There were 10 questions to test travelers’ knowledge of travel medicine. Each question was scored 1 point for a correct response, with a total score of 10 points, so it was a continuous variable. The socio-demographic variables included age, medical history, travel-associated illness and planned special activities during travel. We divided the respondents into 2 and 5 groups, so we used one-way analysis of variance (5 groups) and independent t-test (2) groups to clarify the relation between the knowledge of travel medicine and socio-demographic variables.

6. The data analysis from the discussion section can be transferred to the result section. It is better if the authors compare their findings to previous studies in this field and provide an explanation for any discrepancies in their findings based on prior research and theory. In the discussion section, they should also include the research contribution, which should address the research gap and objectives. Please revise the "Result" and "Discussion" sections.

Response: Thanks for your recommendation. We’ve revised the Result and Discussion sections according to your suggestion.

6. It is mentioned that travelers rely more on "healthcare workers" (lines 241 to 246). However, the information about healthcare workers was not provided in any table.

Response: We’ve added Table 4 to show the source and subjective trust of travel health insurance information.

7. In the limitation section, the authors mentioned about non-response bias. This I believe is not a problem because 92.7% responses are already good enough. However, I am concerned that the authors stated that they were unable to demonstrate a causal relationship due to the cross-sectional study (lines 254 to 256) ! Cross-sectional studies are commonly used in social science studies to examine the causal relationship. There are numerous ways to addressing the bias of cross-sectional studies (e.g. marker variables). If the authors want, I believe they can use "Structural Equation Modeling" to provide greater understanding into the phenomenon. It is very important to understand the research objectives and what methodologies we are going to adopt to conduct the research.

Response: Thanks for your recommendation. We agreed! We’ve revised the Limitations section. This is the pilot study to understand the traveler’s knowledge, attitude, and practice about travel health insurance. We’ll analyze the factors which influence their behavior in the future.

Reviewer #4:

The authors have addressed the reviewer's comments satisfactorily. An additional point should be mentioned in the discussion. How do the authors propose that travel medicine professionals educate themselves about the various types of travel insurance policies? This topic is rarely the exclusive topic of any conference session, although it is mentioned a lot in passing. Insurance medicine is itself a branch of medicine. Should there be greater cooperation between the two disciplines perhaps? Should we invite insurance physicians to attend our conferences or present at our webinars? A final point relates to the references. The authors correctly state that there has been limited previous work in this area. They may have overlooked the following article which is available as an open access source. There may be useful material that could strengthen your discussion. Source: Darrat M, Flaherty GT. An Exploratory Study of Medical Cover Policies Offered by the Travel Health Insurance Industry. International Journal of Medical Research & Health Sciences, 2019, 8(8): 1-8

Response: We appreciate your recommendation. If there are more cooperation between the two disciplines, we believe that travelers can receive more comprehensive care. (LINE 219-221) We have also added this study finding into our discussion section. (LINE 224-226, 254-255) (Darrat M, Flaherty GT. An Exploratory Study of Medical Cover Policies Offered by the Travel Health Insurance Industry. International Journal of Medical Research & Health Sciences, 2019, 8(8): 1-8)

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PLoS One. doi: 10.1371/journal.pone.0281199.r005

Decision Letter 2

Andrea Cioffi

18 Jan 2023

Traveler's Knowledge, Attitude, and Practice about Travel Health Insurance: A Community-based Questionnaire Study.

PONE-D-21-34714R2

Dear Dr. Huang,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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PLoS One. doi: 10.1371/journal.pone.0281199.r006

Acceptance letter

Andrea Cioffi

31 Jan 2023

PONE-D-21-34714R2

Traveler’s Knowledge, Attitude, and Practice about Travel Health Insurance: A Community-based Questionnaire Study.

Dear Dr. Huang:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File. Minimal data set.

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Data Availability Statement

All relevant data are within the paper and its Supporting information files.

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PERMALINK

Traveler’s knowledge, attitude, and practice about travel health insurance: A community-based questionnaire study

Chia-Jung Yang

Chia-Wen Lu

Chien-Hsieh Chiang

Hao-Hsiang Chang

Chien-An Yao

Kuo-Chin Huang

Roles

Abstract

Background

Methods

Results

Conclusions

Introduction

Materials and methods

Design

Subjects

Questionnaire

Statistical analysis

Results

Table 1. Basic characteristics of survey respondents (N = 828).

Table 2. Association between various characteristics and the willingness to buy different travel insurances (N = 828).

Table 3. Comparison of mean scores of knowledge of travel medicine with socio-demographic variables.

Table 4. Source and subjective trust of travel health insurance information (N = 828).

Discussion

Limitations

Conclusions

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Miquel Vall-llosera Camps

Roles

Author response to Decision Letter 0

Decision Letter 1

Thomas Tischer

Roles

Author response to Decision Letter 1

Decision Letter 2

Andrea Cioffi

Roles

Acceptance letter

Andrea Cioffi

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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