I
S
T
M
316
Travel Characteristics and Risk-Taking Attitudes in Youths Traveling
to Nonindustrialized Countries
Pauline Han, MA, Victor Balaban, PhD, and Cinzia Marano, PhD
Travelers’ Health Branch, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta,
GA 30333, USA
DOI: 10.1111/j.1708-8305.2010.00444.x
Background. International travel to developing countries is increasing with rising levels of disposable income; this trend is seen
in both adults and children. Risk-taking attitude is fundamental to research on the prevention of risky health behaviors, which can
be an indicator of the likelihood of experiencing illness or injury during travel. The aim of this study is to investigate whether
risk-taking attitudes of youths are associated with travel characteristics and likelihood of experiencing illness or injury while
traveling to nonindustrialized countries.
Methods. Data were analyzed from the 2008 YouthStyles survey, an annual mail survey gathering demographics and health
knowledge, attitudes, and practices of individuals from 9 through 18 years of age. Travelers were defined as respondents who
reported traveling in the last 12 months to a destination other than the United States, Canada, Europe, Japan, Australia, or New
Zealand. Risk-taking attitude was measured by using a four-item Brief Sensation-Seeking Scale. All p values ≤0.05 were considered
significant.
Results. Of 1,704 respondents, 131 (7.7%) traveled in the last 12 months. Females and those with higher household income were
more likely to travel (odds ratio = 1.6, 1.1). Of those who traveled, 16.7% reported seeking pretravel medical care, with most
visiting a family doctor for that care (84.0%). However, one-fifth of respondents reported illness and injury during travel; of these,
83.3% traveled with their parents. Males and older youths had higher mean sensation-seeking scores. Further, travelers had a
higher mean sensation-seeking score than nontravelers. Those who did not seek pretravel medical care also had higher mean
sensation-seeking scores (p = 0.1, not significant).
Conclusions. Our results show an association between risk-taking attitudes and youth travel behavior. However, adult supervision
during travel and parental directives prior to travel should be taken into consideration. Communication messages should emphasize
the importance of pretravel advice, target parents of children who are traveling, and be communicated through family doctors.
T
he arrivals of international tourists grew from 25
to 903 million worldwide between 1950 to 2007,
and are expected by 2010 to reach 1 billion.1 In 2007,
approximately 31 million US residents traveled to an
overseas destination for different travel reasons.2 This
trend is not only seen in adults, but also in youths as
well. American students are increasingly participating in
study-abroad programs to unconventional destinations,
with strong increases in students going to China, India,
South Africa, Argentina, and Ecuador.3
Though still largely occurring in industrialized countries, international travel has shown fast growth in
developing economies in Asia, Central and Eastern
Corresponding Author: Pauline Han, MA, Centers for
Disease Control and Prevention, 1600 Clifton Rd., MS-E03,
Atlanta, GA 30333, USA. E-mail: [email protected]
© 2010 International Society of Travel Medicine, 1195-1982
Journal of Travel Medicine 2010; Volume 17 (Issue 5): 316–321
Europe, Middle East, Southern Africa, and South
America.1 Travel to developing destinations presents
different health risks and is found to be associated with
the likelihood of diagnoses of certain diseases.4 In a
study of those who traveled to a developing destination,
64% reported an illness after returning.5
Recommendations for staying healthy during travel
include learning about the destination, seeking pretravel
medical care, and obtaining the appropriate medications and vaccinations.6 In addition, risk perception is
increasingly being recognized as an important factor
in disease prevention due to its relationship to willingness to take preventive measures.7 Prior research on
risk-taking behaviors has been conducted via studies of
sensation seeking, a personality trait believed to have
a biological basis that is expressed as a need for physiological arousal, novel experience, and a willingness
to take social, physical, and financial risks to obtain
317
Findings From the 2008 YouthStyles Survey
such stimulation.8 Sensation seeking is fundamental to
research on the prevention of risky health behaviors and
has been shown to be associated with a variety of behaviors, including taking physical risks, illegal drug use, and
reckless driving.8,9 Risk-taking attitudes and risk perceptions of travel-related illnesses and injuries can be
indicators of the likelihood of engaging in risk behaviors
and subsequently the likelihood of experiencing illness
during or after travel.
The few studies that have examined the relationship
between risk-taking attitudes and travel have focused
primarily on risk perceptions of older age groups. In
a study of Hong Kong Chinese, younger travelers
(15–24 y) who regarded their future trips to be at low
risk were relatively more likely to have developed health
problems.10 In addition, Aro and colleagues found that
during the avian influenza outbreak younger Finnish
travelers (<40 y) and those on holidays were willing
to take more travel-related health risks than those who
were older and on business trips.11 The aim of this
study is to investigate whether risk-taking attitudes of
youths (9–18 y) are associated with travel characteristics and likelihood of experiencing illness or injury while
traveling to nonindustrialized countries.
Methods
Data were analyzed from the 2008 YouthStyles survey,
an annual mail survey gathering health knowledge,
attitudes, and practices of persons 9 through 18 years
of age. These are based on the results of a series of
consumer mail panel surveys administered in several
waves. The mail panel consists of approximately
340,000 potential respondents who are recruited to
join through a four-page questionnaire. Stratified
random sampling of the mail panel was used to
generate a list of 20,000 potential respondents for
the ConsumerStyles survey, which was the first wave
and was stratified on region, household income,
population density, age, and household size to create
a nationally representative sample. Additionally, a lowincome/minority supplement (N = 3, 000) was used
to ensure adequate representation of those groups,
and households-with-children supplement (N = 6, 000)
was used to ensure adequate numbers of potential
respondents for the second wave, YouthStyles. In
2008, the ConsumerStyles survey was completed by
10,108 people, yielding a response rate of 50.5%. The
YouthStyles survey was a follow-up survey sent to
households that returned the ConsumerStyles survey,
and was intended for the parents, children, and
adolescents in each household. It was mailed to 2,605
households; 1,704 responses were received, yielding a
65.4% response rate. A small incentive (monetary value
less than $5) was given if the survey was completed and
returned by August 2008.
Youthstyles data were weighted to reflect age and
sex of child, household size, household income, head
of household age, and race/ethnicity of adult of the
US population, as determined by the 2007 Census estimates taken from the Current Population Survey. A
traveler to a nonindustrialized country (from now on
referred to as ‘‘traveler’’) was defined as a respondent
who reported traveling in the last 12 months to a destination other than the United States, Canada, Europe,
Japan, Australia, or New Zealand.
Risk-taking Attitudes Measure
Risk-taking attitude was measured by using a four-item
Brief Sensation-Seeking Scale (BSSS-4) derived from
the BSSS.8 The four items of the BSSS-4 are designed
to assess four previously identified factors that comprise
the construct of sensation seeking: experience seeking,
disinhibition, thrill and adventure seeking, and boredom
susceptibility. The four items (questions 8–11, Table 1)
of the BSSS-4 were scored continuously (1–4), providing a total sensation-seeking score ranging from 4 to 16.
Statistical Analyses
Descriptive statistics of frequencies and percentages
were analyzed. Fisher’s exact test was used for categorical variables, while Wilcoxon rank-sum test was used for
continuous variables. p Values ≤0.05 were considered
significant. Bivariate and multivariate logistic regressions were done to calculate odds ratios and 95% confidence intervals for demographic characteristics, with the
final multivariate model determined using backwards
elimination at a 5% significance level for variable selection. Cronbach’s coefficient alpha was used to determine
internal consistency reliability for the four subscale survey questions. All analyses were done by using SAS
software (Version 9.2; SAS Institute, Cary, NC, USA).
Results
Demographics and Travel Characteristics
Of the 1,704 respondents, 131 (7.7%) had traveled in the
previous 12 months to a nonindustrialized country. The
mean age of travelers was 14 years old, and 59% of those
who traveled were female (Table 2). Females were more
likely to travel than males (p = 0.01). Compared with
other variables, travel was also more positively associated
with increasing household income (p < 0.0001), marital
status of parents (p = 0.007), and increasing household size (p = 0.03). The multivariate model showed
that the only significant factors associated with travel
were sex (p = 0.01) and household income (p < 0.0001)
(Table 2).
The regions most often visited were Mexico (44.3%),
the Caribbean (42.4%), and Central/South America
(12%). The majority traveled for vacation (81.0%),
followed by visiting friends or relatives (21.7%) and
research/student (5.8%). Nearly one fifth of youth travelers (18.0%) traveled without their parents (Table 3).
Those who traveled without parents were more likely
to be older than respondents who traveled with their
J Travel Med 2010; 17: 316–321
318
Han et al.
Table 1
YouthStyles, 2008, survey questions analyzed
Question
1
2∗
3∗
4∗
Response
In the last 12 months, have you traveled outside the United States
on a trip lasting more than 1 d to anywhere other than Canada,
Europe, Japan, Australia, or New Zealand?
Where did you go?
Yes, no
Before you traveled to these countries, did you go to any of the
following places for pretravel medical care?
Before you traveled to these countries, did you receive any of the
following?
5
6∗
Did you travel to any of these countries without your parents?
Why did you (your parents) travel to these countries?
7∗
8
9
10
11
Did any of the following things happen to you or your parents while
you were traveling to these countries?
I like doing scary things.
I like new and exciting experiences, even if I have to break the rules.
I would like to explore strange places.
I prefer friends who are exciting and unpredictable.
∗ Multiple
responses possible.
Mexico, Africa, Caribbean, Middle East, Central/South
America, Oceania/Pacific Islands, India, other countries in
Asia
Family doctor, pharmacist, health department, travel clinic,
other, none
Hepatitis A vaccine, antimalaria pills, yellow fever vaccine,
antidiarrhea pills, typhoid vaccine, meningitis vaccine, none,
don’t know
Yes, no
Vacation, medical care, visiting friends or relatives, parent’s
business trip, research/student, volunteer/missionary,
adoption, other
Diarrhea, fever, injury due to motorized vehicle accident,
cough/cold/pneumonia, other injury, other illness, none
Really disagree, sort of disagree, sort of agree, really agree
Really disagree, sort of disagree, sort of agree, really agree
Really disagree, sort of disagree, sort of agree, really agree
Really disagree, sort of disagree, sort of agree, really agree
Table 2 Frequency of demographic characteristics of traveler∗ versus nontraveler among 9- to 18-year olds, United States,
2008, YouthStyles (N = 1, 704)
Sex
Male†
Female
Age‡
Mean
9–13 y
14–18 y
Marital status of parents
Married†
Other
Household size‡
2 to 4
5 or more
Household income‡
Under $60,000
$60,000 or more
Traveler
(n = 131)
n (%)
Nontraveler
(n = 1573)
n (%)
53 (41)
78 (59)
808 (52)
741 (48)
14.0
56 (43)
75 (57)
13.5
762 (49)
786 (51)
114 (87)
17 (13)
1182 (76)
366 (24)
0.49 (0.29–0.82)
87 (67)
44 (33)
1,065 (69)
483 (31)
1.16 (1.01–1.32)
47 (36)
84 (64)
766 (49)
782 (51)
1.09 (1.05–1.14)
Bivariate logistic
regression OR (95% CI)
Multivariate logistic
regression OR (95% CI)
1.59 (1.11–2.28)
1.61 (1.12–2.32)
1.05 (0.99–1.12)
1.10 (1.05–1.15)
∗ All
travel refers to nonindustrialized countries.
group.
‡
Ordinal variable.
† Reference
parents (p = 0.001), with the mean age of those who
traveled alone being 15.5 and those who traveled
with parents being 13.5 years. Among respondents who
traveled without their parents, vacation (62%) and
research/student (20%) were the most frequent travel
reasons.
Pretravel Medical Care
Of the respondents who traveled, only 19.0% reported
seeking pretravel medical care from at least one of
J Travel Med 2010; 17: 316–321
the following: family doctor, pharmacist, health department, travel clinic, or other. Of those who sought
pretravel medical care, the family doctor was the most
common source of receiving that care (84.0%). Approximately two thirds (63.7%) reported not receiving any
of the following: hepatitis A vaccine, antimalaria prophylaxis, yellow fever vaccine, antidiarrhea prophylaxis,
typhoid vaccine, or meningitis vaccine. Approximately
one fifth of respondents (21.9%) did not know whether
they had received any pretravel vaccines (Table 3).
319
Findings From the 2008 YouthStyles Survey
Table 3 Frequency of reported travel∗ characteristics
among 9- to 18-year olds, United States, 2008, YouthStyles
(N = 131)
Table 4 Total sensation-seeking score (4–16) comparisons
between groups among 9- to 18-year olds, United States,
2008, YouthStyles (N = 1, 704)
n (%)
Destination region (n = 145† )
Mexico
Caribbean
Central/South America
Other
Travel reason (n = 161† )
Vacation
Visiting friends and relatives
Research/student
Other
Pretravel medical care‡ (n = 131)
Medicine/vaccine usage (n = 139† )
None
Don’t know
Received one or more§ prior to trip
Traveled without parents (n = 131)
Illness/injury during travel (n = 131)
58 (44)
56 (42)
12 (9)
19 (15)
106 (81)
28 (22)
8 (6)
19 (15)
25 (19)
83 (64)
29 (22)
27 (21)
24 (18)
26 (20)
∗ All
travel refers to nonindustrialized countries.
responses possible.
pretravel medical care from at least one of these: family doctor,
pharmacist, health department, travel clinic (see question 3, Table 1).
§
Hepatitis A vaccine, antimalaria pills, yellow fever vaccine, antidiarrhea pills,
typhoid vaccine, meningitis vaccine (see question 4, Table 1).
Experienced at least one of these: diarrhea, fever, injury due to motorized
vehicle accident, cough/cold/pneumonia, other injury, other illness (see
question 7, Table 1).
† Multiple
‡ Received
Illness or Injury During Travel
One fifth of the respondents (20%) reported experiencing one of the following during travel: diarrhea, fever, injury due to motorized vehicle accident,
cough/cold/pneumonia, other injury, or other illness
(Table 3). Almost all (83.3%) of the respondents who
reported illness or injury during travel had traveled with
their parents.
Risk-Taking Attitudes
The four items of the BSSS-4 showed acceptable internal consistency and reliability (Cronbach’s alpha = 0.7).
Males had higher sensation-seeking scores than females
(p = 0.0008), and older youths had higher sensationseeking scores than younger youths (p < 0.0001)
(Table 4).
Respondents who traveled had a higher mean
sensation-seeking score than those who did not travel
(p = 0.02). Although not significant, respondents who
did not seek pretravel medical care had higher sensationseeking scores than respondents who did (p = 0.1).
Furthermore, among respondents who traveled, we
found no significant associations between the individual sensation-seeking factors and whether they traveled
without their parents or experienced illness or injury
during travel (Table 4).
Discussion
The most frequent travel destinations among youth
travelers in the YouthStyles survey were locations closest
Sex
Male
Female
Marital status of parents
Married
Other
Household size
2–4
5 or more
Household income
Under $60,000
$60,000 or more
Age
9–13 y
14–18 y
Pretravel care
Yes
No
Traveled
Yes
No
Traveled without parents
Yes
No
Illness/injury during travel
Yes
No
Wilcoxon Rank Sum
p value
n
Mean
861
819
10.14
9.73
1296
383
9.95
9.85
0.95
1152
527
10.02
9.71
0.06
813
866
9.76
10.07
0.05
818
861
9.58
10.25
<0.0001
25
106
9.87
10.78
0.1
131
1573
10.58
9.87
0.02
24
107
10.99
10.50
0.4
26
105
10.53
10.84
0.4
0.0008
to the United States, which is consistent with the top
regions of destination (excluding Europe) for US resident adult travelers in 2007.2
Those who were older were more likely to travel
without their parents, as older age tends to be associated
with less parental supervision and a higher likelihood
of traveling for reasons such as study or research. Of
those who traveled alone, 20% traveled for student and
research opportunities. Higher household income was
also associated with travel to nonindustrialized destinations, possibly because travel is more accessible if there
is the income to afford it.1
Only 19.0% of respondents in this study traveled
reported-seeking pretravel medical care, with the majority seeing a family doctor to receive that care. In contrast,
36% of adult travelers from the United States sought
travel health advice.12 These data corroborate a previous
finding that children were less likely than adults to have
received pretravel medical advice.13 Before traveling,
approximately two thirds of travelers (63.7%) reported
not receiving any of the listed medications or vaccinations. Failing to obtain pretravel vaccinations could be
influenced by a variety of factors related to the knowledge, attitudes, and beliefs of the traveler regarding
travel vaccines and vaccine-preventable diseases,14 but
because the destination information in this study was
J Travel Med 2010; 17: 316–321
320
by region and not by a specific city or country, it was
difficult to determine whether medication or vaccination was appropriately received. Approximately one fifth
(21.9%) of youth travelers did not know whether they
had received any of the listed vaccines or medications.
These findings are consistent with the results reported
by Hartjes and colleagues15 that 58% of study abroad
students reported not receiving travel vaccinations.
Risk-Taking Attitudes
In this study, we found that youths who traveled to
nonindustrialized destinations had higher sensationseeking scores than those who did not. Additional
evidence for the validity of the BSSS-4 was provided by
the fact that, consistent with earlier studies of sensation
seeking,8,16 males had higher sensation-seeking scores
than females, and older youths had higher sensationseeking scores than younger youths. Those with a
household income of $60,000 or more also had a higher
mean sensation-seeking score.
Although not significantly different, the finding that
youth travelers who did not seek pretravel medical care
had higher mean sensation-seeking scores than those
travelers who did is suggestive. This difference could
possibly be significant if this study were replicated in
a larger sample. However, young travelers’ decisions
whether to seek pretravel medical care are likely
to be determined by multiple factors such as their
parents’ directive (or program directive, in the case
of study and/or research), and not solely a result
of their sensation-seeking score. Similarly, youths’
decision to travel is also often dependent upon parental
travel plans and permission. Furthermore, those who
reported illness/injury during travel had a lower mean
sensation-seeking score than those who did not report
illness/injury, though also not significantly different.
This could be a result of the survey question, which
asked about illness/injury occurring to either the child
or the parent, whereas the sensation-seeking score was
solely based on the child’s response.
In addition, approximately 7% of US adult residents
indicated they traveled with children in 2007, with an
average travel party size of 1.5.2 A study of 15–18 year
olds indicated that illness and injury are common in
those traveling to nonindustrialized countries, even
under adult supervision.17 Other studies have also shown
that travelers visiting friends and relatives (VFRs) are
more likely to travel with children, staying in places with
suboptimal sanitation and greater malaria risk, and more
likely to make last-minute travel plans, allowing little
time to receive pretravel medical care.18 With over 80%
of our study population traveling with their parents to
nonindustrialized countries and 20% reporting having
experienced illness or injury during travel, it seems of
interest to study the adults who travel with children and
whether their risk-taking attitudes are associated with
seeking pretravel advice prior to their trip and how that
affects the younger children who travel with them.
J Travel Med 2010; 17: 316–321
Han et al.
Limitations
There are several limitations to this study. First, the size
of the studied sample did not allow for in-depth investigation into further associations between travel reasons,
travel without parents, illness/injury experienced during travel, travel vaccines/medicines, and destination
region in relation to risk-taking attitudes. Second,
because the vaccination data are self-reported information, accuracy cannot be confirmed. However, some
studies have suggested that as many as 25% of patients
who report receiving immunizations may actually not
have received them.19 Finally, participation in the survey was voluntary and was not mailed more than once
to increase the response rate nor the results previously
validated, indicating that respondents might have different demographic characteristics and travel behavior
from nonrespondents, and might not be representative
of the general US population. Recall bias and sensitivity
to some items may also be reflected in the responses.
Conclusions
This study provides exploratory findings in areas where
little research has been conducted. Females and those
who have a higher household income were more
likely to travel, and one fifth of respondents reported
experiencing illness or injury during travel. Those who
traveled to a nonindustrialized country had a higher
mean sensation-seeking score than those who did not,
and although not significantly different, those who did
not seek pretravel medical care also had a higher
mean sensation-seeking score, showing a suggestive
link regarding youth travel behavior that should be
further explored in a larger study to confirm our
findings. Adult supervision during travel and parental
plans and directives prior to travel should be taken
into consideration. Knowing that pretravel advice is a
precautionary measure taken to keep travelers healthy,
communication messages should be directed toward
parents of children who are traveling and the importance
of pretravel advice to prevent health problems. These
messages should be communicated through family
doctors, as they are one of the main sources where
travelers seek pretravel medical care. The area of youth
travel, specifically those under age 18, needs to be
explored more, especially when linked with travel with
or without adult supervision.
Acknowledgments
The authors thank Nina Marano, Emad Yanni, and
Amanda Whatley for their assistance in survey question
development, and William Pollard for his assistance
with the YouthStyles database.
Declaration of Interests
The authors state they have no conflicts of interest to
declare.
Findings From the 2008 YouthStyles Survey
Disclaimer
The findings and conclusions expressed by authors
contributing to this journal do not necessarily reflect
the views of the Centers for Disease Control and
Prevention.
References
1. United Nations World Tourism Organization. Tourism
highlights. Last updated 2008. Available at: http://www.
unwto.org/facts/eng/highlights.htm. (Accessed 2009 Sep
16).
2. International Trade Administration, office of tourism and
travel industries. United States resident travel abroad.
Last updated 2007. Available at: http://tinet.ita.doc.gov/
outreachpages/download data table/2007 Outbound
Profile.pdf. (Accessed 2009 Sep 16).
3. Gardner D. Open Doors 2008: U.S. students studying
abroad. Last updated Nov 2008. Available at: http:// opendoors.iienetwork.org/?p=131592. (Accessed 2009 Sep 16).
4. Freedman DO. Spectrum of disease and relation to place
of exposure among ill returned travelers. N Engl J Med
2006; 352:119–131.
5. Hill D. Health problems in a large cohort of Americans
traveling to developing countries. J Travel Med 2000;
7:259–266.
6. Centers for Disease Control and Prevention. CDC Health
information for international travel 2010. Atlanta: U.S.
Department of Health and Human Services, Public Health
Service, 2009.
7. Zwart O. Perceived threat, risk perception, and efficacy
beliefs related to SARS and other (emerging) infectious
diseases: results of an international survey. Int J Behavioral
Med 2009; 16:30–40.
8. Stephenson M. Brief measures of sensation seeking for
screening and large-scale surveys. Drug Alcohol Depend
2003; 72:279–286.
321
9. Roberti J. Further psychometric support for the Sensation
Seeking Scale—Form V. J Pers Assess 2003; 81:
291–292.
10. Abdullah ASM. Health risks during travel: a populationbased study amongst the Hong Kong Chinese. Trop Med
Parasitol 2001; 95:105–110.
11. Aro AR. Willingness to take travel-related health risks—a
study among Finnish tourists in Asia during the Avian
Influenza outbreak. Int J Behav Med 2009; 16:68–73.
12. Hamer DH, Conner BA. Travel health knowledge,
attitudes and practices among United States travelers.
J Travel Med 2004; 11:23–26.
13. Hagmann S. Illness in children after international travel:
analysis from the GeoSentinel Surveillance Network.
Pediatrics. Pediatrics 2010; 125:1072–1080.
14. Crockett M, Keystone J. ‘‘I hate needles’’ and other factors
impacting on travel vaccine uptake. J Travel Med 2005;
12(Suppl 1): S41–S46.
15. Hartjes LB, Baumann LC, Henriques JB. Travel health
risk perceptions and prevention behaviors of US study
abroad students. J Travel Med 2009; 16:338–343.
16. Steinberg L. Age differences in sensation seeking and
impulsivity as indexed by behavior and self-report:
evidence for dual systems model. Devel Psychol 2008;
44:1764–1778.
17. Sadnicka A. Morbidity and determinants of health on
youth expeditions. Wilderness Environ Med 2004; 15:
181–187.
18. Bacaner N, Stauffer B, Boulware D, et al. Travel Medicine
Considerations for North American Immigrants Visiting
Friends and Relatives. JAMA 2004; 291:2856–2864.
19. Shenson D, Dimartino D, Bolen J, et al. Validation of
self-reported pneumococcal vaccination in behavioral risk
factor surveillance surveys: experience from the sickness
prevention achieved through regional collaboration
(SPARC) program. Vaccine 2005; 23:1015–1020.
J Travel Med 2010; 17: 316–321