Sample characteristics
Three hundred and eighty-five of 410 primary health care physicians completed the questionnaires (response rate of 94%).
Table 1 shows participants’ socio-demographic characteristics. More than half of the participants (56.4%) were females, and 47.3% of the participants were Saudi physicians. The participants were either general practitioners (54.5%) or family medicine physicians (45.5%). Most of the respondents were general practitioners and residents (54.5% and 27.8%, respectively), whereas registrars and consultants were less common (16.1% and 1.6%, respectively). Regarding work experience, the majority (39.7%) had 0-5 years of experience, and fewer participants had 6-10 years (19.5%), 11-15 years (20%), or >15 years (20.8%) of experience.
Table 1 Socio-demographic characteristics
Categorical variables
|
N
|
%
|
Age
|
≤35
|
207
|
53.8%
|
>35
|
178
|
46.2%
|
Sex
|
Female
|
217
|
56.4%
|
Male
|
168
|
43.6%
|
Nationality
|
Non-Saudi
|
203
|
52.7%
|
Saudi
|
182
|
47.3%
|
Specialty
|
Family Medicine
|
175
|
45.5%
|
General Practitioner
|
210
|
54.5%
|
Degree of Education
|
General Practitioner
|
210
|
54.5%
|
Resident
|
107
|
27.8%
|
Register
|
62
|
16.1%
|
Consultant
|
6
|
1.6%
|
Years of Practice
|
0-5
|
153
|
39.7%
|
6-10
|
75
|
19.5%
|
11-15
|
77
|
20.0%
|
>15
|
80
|
20.8%
|
Knowledge of diabetes and travel
The majority (96.4%) of PCPs had adequate knowledge that patients with diabetes should be advised to carry medicines and carbohydrate-rich snacks in easily accessible bags while travelling. In contrast, only two-thirds (60.8%) knew that insulin should not be stored in checked luggage. Moreover, more than half of physicians (56.9%) did not know that travelling across more than five time zones requires adjustment of insulin dose and frequency, while only approximately one third (32.2%) knew that travelling across more than five time zones does not require adjustment of oral anti-hypoglycaemic dose. Few PCPs knew that patients with diabetes travelling to the east region may need to increase their insulin dose, while those travelling to the west region may need to decrease their insulin dose (6.8% and 6.2%, respectively). A total of 212 (55.1%) physicians were aware of the effect of hot or cold climates on insulin and blood glucose monitoring while travelling. The majority (96.6%) recognized the importance of pre-travel vaccination, and all PCPs realized that patients with diabetes need to carry their diabetes ID while travelling abroad. Participants’ knowledge was deficient regarding the need to avoid injecting insulin while a plane is taking off (26.2%) (Table 2).
Table 2 Practitioners’ knowledge of pre-travel counselling (N= 385)
Question
|
N
|
%
|
1. Correctly answered that patients with diabetes should be advised to carry medicines and carbohydrate-rich snacks in easily accessible bags while travelling
|
371
|
96.4%
|
2. Correctly answered that insulin cannot be stored in checked luggage.
|
234
|
60.8%
|
3. Correctly answered that, during air travel, patients with diabetes are advised to not inject insulin at take-off.
|
101
|
26.2%
|
4. Correctly answered that travelling across more than five time zones requires adjustment of insulin dose and frequency.
|
166
|
43.1%
|
5. Correctly answered that travelling across more than five time zones does not require adjustment of oral anti-hypoglycaemic dose.
|
124
|
32.2%
|
6. Correctly answered that patients with diabetes who are travelling to the east region may need to increase their insulin dose
|
26
|
6.8%
|
7. Correctly answered that patients with diabetes who are travelling to the west region may need to decrease their insulin dose.
|
24
|
6.2%
|
8. Correctly answered that extremes of hot or cold climates can affect insulin and blood glucose monitoring in patients with diabetes while travelling.
|
212
|
55.1%
|
9. Correctly answered that pre-travel vaccination is important for patients with diabetes.
|
372
|
96.6%
|
10. Correctly answered that patients with diabetes need to carry ID that says that they have diabetes while travelling abroad.
|
385
|
100.0%
|
The total knowledge score ranged from 2-10, with a median of 5 (IQR=4-6). More than half (57.9%) of the participants had poor scores, and 3.6% had good scores. Table 3 demonstrates a statistically significant association between the total knowledge score and age, sex, nationality, level of education and years of experience. Significant associations were found (P<.05) between poor knowledge and the following participant characteristics: being younger than 35 years old, being male, being Saudi, being a general practitioner and having limited (0-5 years) experience.
Table 3 Association between knowledge score and socio-demographic data
|
Knowledge Score
|
|
|
Good
N=14 (3.6%)
|
Moderate
N=148 (38.4%)
|
Poor
N=223 (57.9%)
|
Total
N=385
|
Chi-Square
Test
|
|
N
|
%
|
N
|
%
|
N
|
%
|
N
|
%
|
P value
|
Age
|
≤35
|
2
|
14.3%
|
61
|
41.2%
|
144
|
64.6%
|
207
|
53.8%
|
<.001*
|
>35
|
12
|
85.7%
|
87
|
58.8%
|
79
|
35.4%
|
178
|
46.2%
|
Sex
|
Female
|
8
|
57.1%
|
99
|
66.9%
|
110
|
49.3%
|
217
|
56.4%
|
.004*
|
Male
|
6
|
42.9%
|
49
|
33.1%
|
113
|
50.7%
|
168
|
43.6%
|
Nationality
|
Non-Saudi
|
12
|
85.7%
|
98
|
66.2%
|
93
|
41.7%
|
203
|
52.7%
|
<.001*
|
Saudi
|
2
|
14.3%
|
50
|
33.8%
|
130
|
58.3%
|
182
|
47.3%
|
Specialty
|
Family Medicine
|
4
|
28.6%
|
59
|
39.9%
|
112
|
50.2%
|
175
|
45.5%
|
.063
|
General Practitioner
|
10
|
71.4%
|
89
|
60.1%
|
111
|
49.8%
|
210
|
54.5%
|
Education
Degree
|
General Practitioner
|
10
|
71.4%
|
89
|
60.1%
|
111
|
49.8%
|
210
|
54.5%
|
<.001*
|
Resident
|
2
|
14.3%
|
23
|
15.5%
|
82
|
36.8%
|
107
|
27.8%
|
Register
|
2
|
14.3%
|
34
|
23.0%
|
26
|
11.7%
|
62
|
16.1%
|
Consultant
|
0
|
0.0%
|
2
|
1.4%
|
4
|
1.8%
|
6
|
1.6%
|
Years of Practice
|
0-5
|
2
|
14.3%
|
42
|
28.4%
|
109
|
48.9%
|
153
|
39.7%
|
<.001*
|
6-10
|
0
|
0.0%
|
25
|
16.9%
|
50
|
22.4%
|
75
|
19.5%
|
11-15
|
4
|
28.6%
|
36
|
24.3%
|
37
|
16.6%
|
77
|
20.0%
|
>15
|
8
|
57.1%
|
45
|
30.4%
|
27
|
12.1%
|
80
|
20.8%
|
*significant at p<.05
Physicians’ attitudes towards pre-travel counselling and diabetes
The participants’ attitudes towards pre-travel counselling are illustrated in Table 4. Most of them strongly agreed with the following statements: pre-travel counselling for patients with diabetes is important; the availability of an Arabic resource to increase patients’ awareness of health practices before, during and after the trip is needed; and I would advise patients to visit such a resource (90.4%, 83.4%, and 83.9%, respectively). Moreover, the majority (77.7%) of PCPs strongly agreed that seeking medical advice before travelling would decrease patients’ chances of getting sick during their trip. Furthermore, more than half (57.1%) strongly agreed that Saudi Arabia lacks travel medicine practices, and two-thirds (60%) strongly agreed that our society lacks knowledge of the importance of travel medicine.
Table 4 Practitioners’ attitudes towards pre-travel counselling (N = 385)
Question
|
N
|
%
|
1. Pre-travel counselling for patients with diabetes is important.
|
Agree
|
37
|
9.6%
|
Strongly agree
|
348
|
90.4%
|
2. The availability of an Arabic resource to increase patients’ awareness of health practices before, during and after the trip is needed.
|
Agree
|
64
|
16.6%
|
Strongly agree
|
321
|
83.4%
|
3. If there is a trusted Arabic resource to increase patients’ awareness of health practices before, during and after the trip, I will advise my patient to visit it.
|
Agree
|
62
|
16.1%
|
Strongly agree
|
323
|
83.9%
|
4. Patients who seek medical advice before travelling will have lower chances of getting sick during their trip.
|
Agree
|
86
|
22.3%
|
Strongly agree
|
299
|
77.7%
|
5. In Saudi Arabia, we lack the practice of travel medicine.
|
Agree
|
159
|
41.3%
|
Strongly agree
|
220
|
57.1%
|
6. Our society lacks knowledge of the importance of travel medicine.
|
Agree
|
146
|
37.9%
|
Strongly agree
|
231
|
60.0%
|
The total attitudes score ranged from 0-6 with a median of 5 (IQR =4-6). More than half (52.5%) of the participants had strong agreement attitudes, while 183 (47.5%) showed disagreement attitudes towards the importance of pre-travel counselling among patients with diabetes. Table 5 shows that significantly higher percentages of physicians with disagreement attitudes were older than 35 years, whereas most participants who showed agreement were younger (p=.003). In addition, years of experience were significantly higher among physicians with disagreement attitudes (p=.006).
Table 5 Association between attitudes score and socio-demographic data
|
Attitudes score
|
|
|
Disagree
N=183 (47.5%)
|
Agree
N= 202 (52.5%)
|
Total
N=385
|
|
N
|
%
|
N
|
%
|
N
|
%
|
P value
|
Age
|
≤35
|
84
|
45.9%
|
123
|
60.9%
|
207
|
53.8%
|
.003*
|
>35
|
99
|
54.1%
|
79
|
39.1%
|
178
|
46.2%
|
Sex
|
Female
|
103
|
56.3%
|
114
|
56.4%
|
217
|
56.4%
|
.98
|
Male
|
80
|
43.7%
|
88
|
43.6%
|
168
|
43.6%
|
Nationality
|
Non-Saudi
|
103
|
56.3%
|
100
|
49.5%
|
203
|
52.7%
|
.183
|
Saudi
|
80
|
43.7%
|
102
|
50.5%
|
182
|
47.3%
|
Specialty
|
Family Medicine
|
83
|
45.4%
|
92
|
45.5%
|
175
|
45.5%
|
.97
|
General Practitioner
|
100
|
54.6%
|
110
|
54.5%
|
210
|
54.5%
|
Education
Degree
|
General Practitioner
|
100
|
54.6%
|
110
|
54.5%
|
210
|
54.5%
|
.12
|
Resident
|
46
|
25.1%
|
61
|
30.2%
|
107
|
27.8%
|
Register
|
36
|
19.7%
|
26
|
12.9%
|
62
|
16.1%
|
Consultant
|
1
|
0.5%
|
5
|
2.5%
|
6
|
1.6%
|
Years of Practice
|
0-5
|
61
|
33.3%
|
92
|
45.5%
|
153
|
39.7%
|
.006*
|
6-10
|
33
|
18.0%
|
42
|
20.8%
|
75
|
19.5%
|
11-15
|
38
|
20.8%
|
39
|
19.3%
|
77
|
20.0%
|
>15
|
51
|
27.9%
|
29
|
14.4%
|
80
|
20.8%
|
*significant at p<.05
Management practices
The relationship between physicians’ practices towards pre-travel counselling and their degree of education is illustrated in Tables 6. The majority (46.5%) of the participants reported that 20-40 patients with diabetes visit the clinic weekly for any reason. However, approximately 53% reported that only 1-10 patients per month ask for advice before travelling; this number was significantly increased among general practitioners (p<.001). Two hundred and thirty (59.7%) participants reported that pre-travel counselling would take 5-15 minutes. A significantly higher percentage of these physicians were consultants (p<.001). Additionally, the majority (84.2%) of respondents reported that they would advise and counsel patients with diabetes regarding the importance of recommended vaccines before they travelled. More than half (59.0%) were aware of travel safety recommendations for patients with diabetes. A significantly higher percentage of these physicians were general practitioners (p<.001). Approximately two-thirds (67.8%) reported that they did not feel confident about how to adjust insulin doses for patients travelling across several time zones. A significantly higher percentage of these physicians were general practitioners (p<001). A total of 219 (56.9%) participants stated that patients mostly asked about diabetes IDs, vaccinations, prescriptions, and medication adjustments.
Table 6 Practitioners’ practices towards pre-travel counselling and their relation to their degree of education
|
Education degree
|
GP
|
Resident
|
Register
|
Consultant
|
Total
|
N (%)
|
N (%)
|
N (%)
|
N (%)
|
N (%)
|
P value
|
1- Estimated number of patients with diabetes that visit clinic per week for any reason 20-40
|
100
( 47.6%)
|
47
(43.9)
|
28
(45.2%)
|
4
(66.7%)
|
179
(46.5%)
|
.77
|
2- Estimated number of patients with diabetes that ask for advice before his/her trip per month 1- 10
|
128
(61.0%)
|
34
(31.8%)
|
38
(61.3%)
|
5
(83.3%)
|
205
(53.2%)
|
<.001*
|
3- Counseled a patient with diabetes before traveling, it take about 5-15 minutes
|
145
(69.0%)
|
46
(43.0%)
|
34
(54.8%)
|
5
(83.3%)
|
230
(59.7%)
|
<.001*
|
4- I advise and counsel patient with diabetes regarding the importance of vaccines before travel
|
174
(82.9%)
|
86
(80.4%)
|
58
(93.5%)
|
6
(100%)
|
324
(84.2%)
|
.08
|
5- I face patients with diabetes who are trying to avoid travel because of their illness
|
50
(23.8%)
|
22
(20.6%)
|
14
(22.6%)
|
2
(33.3%)
|
88
(22.9%)
|
.85
|
6- I am aware of travel safety recommendations for patients with diabetes
|
143
(68.1%)
|
34
(31.8%)
|
46
(74.2%)
|
4
(66.7%)
|
227
(59.0%)
|
<.001*
|
7- I don’t feel confident about how to adjust insulin dose for patients who travel across several time zones
|
123
( 58.6%)
|
97
(90.7%)
|
38
(61.3%)
|
3
(50.0%)
|
261
(67.8%)
|
<.001*
|
*significant at p<.05
The mean ranks of knowledge scores were significantly higher among physicians who were older than 35 years of age, were female, were non-Saudi, were general practitioners, and were at the registrar rank (p<.05). Similarly, the practice score was significantly higher among physicians who were older than 35 years, were female, were non-Saudi, were general practitioners, and were consultants. However, the mean rank of the attitudes score was significantly higher among physicians aged 35 or younger (p=.038), as demonstrated in Table 7.
Table 7 Comparison of demographic characteristics and KAP scores
|
Knowledge score
|
Attitudes score
|
Practice score
|
Mean rank
|
P value
|
Mean rank
|
P value
|
Mean rank
|
P value
|
Age
|
<=35
|
166.56
|
<.001*
|
203.45
|
.038*
|
160.61
|
<.001*
|
>35
|
223.75
|
180.84
|
230.67
|
Sex
|
Female
|
208.59
|
.001*
|
|
.074
|
215.51
|
<.001*
|
Male
|
172.86
|
163.92
|
Nationality
|
Non-Saudi
|
220.55
|
<.001*
|
.67
|
224.40
|
<.001*
|
Saudi
|
162.27
|
157.98
|
Specialty
|
Family Medicine
|
175.16
|
.003*
|
.71
|
166.03
|
<.001*
|
General Practitioner
|
207.87
|
215.48
|
Degree of Education
|
General Practitioner
|
|
207.87
|
<.001*
|
.28
|
215.48
|
<.001*
|
Resident
|
|
147.45
|
134.77
|
Register
|
|
223.16
|
212.34
|
Consultant
|
|
173.33
|
244.50
|
*significant at p<.05
The comparison of the three scores among the studied participants revealed a significantly higher knowledge score, followed by the attitudes score and the practice score (mean ranks were 2.54, 2.19 and 1.27, respectively), as shown in Table 8.
Table 8 Score summary of knowledge, attitudes, and practices among primary health care physicians towards pre-travel counselling
Scores
|
N
|
%
|
Minimum- Maximum
|
Median
|
IQR
|
Mean Ranks
|
Knowledge
|
Good
|
14
|
3.6%
|
2-10
|
5
|
4-6
|
2.54
|
Moderate
|
148
|
38.4%
|
Poor
|
223
|
57.9%
|
Attitude
|
Disagree
|
183
|
47.5%
|
0-6
|
5
|
4-6
|
2.19
|
Agree
|
202
|
52.5%
|
Practice
|
Good
|
144
|
37.4%
|
1-4
|
3
|
2-4
|
1.27
|
Poor
|
241
|
62.6%
|
Table 9 illustrates a significant association between knowledge and practice scores (p<.001), while the attitudes score did not show a significant relationship (p>.05).
Table 9 Association between knowledge and subjects’ attitudes and practices towards pre-travel counselling
|
Knowledge score
|
|
≤5
|
>5
|
Total
|
N
|
%
|
N
|
%
|
N
|
%
|
P value
|
Attitudes
|
Disagree
|
102
|
55.7%
|
81
|
44.3%
|
183
|
100.0%
|
.41
|
Agree
|
121
|
59.9%
|
81
|
40.1%
|
202
|
100.0%
|
Practices
|
Good
|
56
|
38.9%
|
88
|
61.1%
|
144
|
100.0%
|
<.001*
|
Poor
|
167
|
69.3%
|
74
|
30.7%
|
241
|
100.0%
|
*significant at p<.05