Anxiety and Health Problems Related to Air Travel
lain B. McIntosh, Vivien Swanson, Kevin G. Power, Fiona Raeside, and Craig Dempster
Background: A significant proportion of air travelers experience situational anxiety and physical health problems.Takeoff and landing are assumed to be stressful, but anxiety related to other aspects of the air travel process, anxiety coping
strategies, and in-flight health problems have not previously been investigated.
MethodsWe aimed t o investigate frequency of perceived anxiety at procedural stages of air travel, individual strategies
used to reduce such anxiety, and frequency of health problems on short-haul and long-haul flights. A questionnaire measuring the occurrence and frequency of the above was administered t o t w o samples of intending travelers during a 3
month period to: (a) 138 travel agency clients, and (b) 100 individuals attending a hospital travel clinic.
Results: Of the 238 respondents, t w o thirds were wornen.Take-off and landing were a perceived source of anxiety for
about 40% of respondents, flight delays for over 50%, and customs and baggage reclaim for a third of individuals. Most
frequent anxiety-reduction methods included alcohol and cigarette use, and distraction or relaxation techniques. Physical
health problems related to air travel were common, and there was a strong relationship between such problems and frequency of anxiety.Travel agency clients reported more anxiety but not more physical health symptoms overall than travel
clinic clients. Women reported greater air-travel anxiety, and more somatic symptoms than men.
Conclusions: Significant numbers of air travelers report perceived anxiety related to aspects of travel, and this is associated with health problems during flights. Airlines and travel companies could institute specific measures, including
improved information and communication, t o reassure clients and thereby diminish anxiety during stages of air-travel.
Medical practitioners and travel agencies should also be aware of the potential stresses of air travel and the need for
additional information and advice.
Travel associated anxieties and fears are common.’
Locke and Feinsod2 have suggested that enjoyment of
travel depends upon a predisposition to cope well with
a variety of physical and psychological stresses.
Relocation is a recognized stress09 as is the mode
of tran~portation.~
Although all modes of transport have
associated risks, flying is probably perceived by the general public as the most dangerous of current common
methods of travel. Apart from potential anxieties associated with flying itself (i.e., fear of heights, being in
enclosed spaces),air travelers are also particularly affected
by in-transit worries and fears heightened by episodes of
hijack, bomb explosions and aircraft crashes. Delays, airport congestion, airline and security procedures create
anxiety. Similarly being away from home and in what may
be an unfamiliar and uncontrollable environment means
that some travelers may be exposed to considerable stress
at a time of maximal ~ulnerability.~
lain B Mclntosh, MBChB, Vivien Swanson, PhD., and
Kevin G Power, Professor: Anxiety and Stress Research
Centre, Department of Psychology, University of Stirling,
Stirling; Fiona Raeside, RGN: Scottish Centre for Infection
and Environmental Health (SCIEH), Ruchill Hospital,
Glasgow; Craig Dempsfer: BellTravel Ltd., Bridge of Allan.
Reprint requests: Dr. VSwanson;Anxiety and Stress
Research Centre, Department of Psychology, University
of Stirling, Stirling, FK9 4LA.
JTravel Med 1998; 5398-204.
Fear and anxiety are normal phenomena of everyday living and as responses to real or imagined threats to
the person, are in minor degree a part of the cultural
norm. However, a continuum exists between mild and
intense fears with severe anxiety and phobias leading to
avoidance of travel or anticipatory dread of it. Clinicians
are often consulted by potential travelers seeking anxiolytics to dispel anxieties and fears related to a forthcoming trip and by those too fearful to travel. In the latter,
phobic reactions may actually prevent participation in air
travel due to a fear of flying, or prevent people traveling
by boat.‘
Preflight and in-transit stress may play an important
part in the cardiac problems which affect air travelers.
They account for 15%of in-flight emergencies but more
than half of in-flight deaths.’ However, airport physicians
believe that the airport segment ofair travel may be more
hazardous to the health of travelers than the in-flight segAent, with arriving passengers more at risk than departing ones.’ The Federal Aviation Administration in
America has recently noted that there are now 15 medical emergencies per day on US airlines compared with
3 per day in 1986.Some of these physical impairments
(illnesses) may be associated with the stresses resulting kern
luggage handling, flight delays, customs inspections and
security clearances, which are all inevitable parts of contemporary air travel.
In-transit travel stressors have been poorly researched
and travel agents and travel health clinic personnel give
scant attention to this element of travel’ which may
198
M c l n t o s h e t al., A n x i e t y a n d Health P r o b l e m s R e l a t e d t o A i r T r a v e l
199
produce sufficient psychological stress to precipitate cardiological or stress related ill health at a later stage in the
journey. Travel agents rarely address these issues with
clients." The travel health clinic has been shown to be
effective in diminishing ill health in travelers." The
travel industry's role in promoting good health in travelers is recognized and collaboration with the travel
medicine community has been recommended.'2 If both
parties drew attention to potential health disturbing features and offered appropriate advice on reducing disturbance, travel-related stress, phobias and cardiac problems
might be minimized.
Both need good data on which to base advice, but
the research base for in-transit health problems is limited. To address this problem we set up a collaborative
research venture with a travel agency network, using a
questionnaire in a pilot survey of in-transit anxieties and
stresses admitted by intending travelers at the point of
flight booking. The questionnaire was also administered
to a comparative population of intending travelers attending a hospital based travel clinic.
to have different degrees of situational anxiety and health
problems related to air travel.
The first sample comprised individuals who attended
travel agencies over a period of 1 month in early summer for the purpose of making travel arrangements, the
majority of such bookings being for holiday/leisure purposes. The agencies were six branches of one travel company, based in towns in Scotland or North East England.
Individuals at each of the study locations (1) who had
traveled by air in the past 3 years (2) were aged 16 or over
and (3) agreed to take part in the study were invited by
staff to complete a questionnaire.
The second sample comprised individuals who
attended a hospital travel clinic over a similar time period,
and also fulfilled the three criteria above. Attendance at
the clinic was either by medical- or self-referral. Individuals attendmg the clinic were business or independent
travelers, and included those who anticipated health difficulties while traveling (e.g., pregnant women), required
vaccinations, had complex travel plans, or were traveling
to high risk destinations.
Aims of the Study
Measures
The study aimed to describe levels of situational anxiety related to air travel at a series of points in-transit, from
journey to the airport at the start of a travel episode, to
baggage reclaim at the end. We aimed to describe methods frequently used to reduce such anxiety and what specific health problems were experienced, both on short
fights (less than 5 hours) and longer flights (more than 5
hours). Individuals attending travel agents were almost
entirely doing so to book private/holiday travel, since the
survey did not include ofices dealing with business travel
customers. These individuals were expected to have less
air travel experience than those attending the hospital
travel clinic. Approximately a quarter of individuals attending the hospital travel clinic were business travelers. OEthe
remainder, the majority comprised mainly independent
travelers (i.e., nonpackage holiday), with long-distance
travel plans, intending to visit h g h risk destinations, and
therefore likely to anticipate more travel related health problems. However, it was hypothesized that due to their
greater travel experience this latter group would be less
likely to experience flight related situational anxiety than
travel agency clients. As previous research has indicated,
women travelers were expected to experience more frequent travel-related situational anxiety, but not more
health problems than men.'."
A questionnaire was constructed for the study comprising the following:
Methods
This was a cross-sectional questionnaire survey oftwo
opportunistic samples of air travelers who were anticipated
a) Demographic information requested included gen-
der and the number of domestic and international
flights (total flights) over the previous 3 years.
Frequency of flight-related situational anxiety (defined
as, for example, "tension, nausea, panic") was rated on
a five point scale,scored from "never" (0) to "always"
(4). Anxiety was assessed in relation to the following
stages of air travel: Travel to airport; check-in, flight
delays; transfer between airport terminals; waiting in
departure lounge; boarding flight; take-ofi; during
flight; aircraft landing; customs; baggage reclaim.
Respondents were asked how frequently they used the
following methods to reduce air travel related anxiety, on a similar scale (0-4):Alcohol; cigarettes; relaxation techniques (e.g., breathing control); distraction
(taking your mind off it); prescribed medication; and
nonprescribed medication (over the counter).
Using an equivalent scale,respondents were asked how
frequently they experienced the following,* firstly
*It is acknowledged that the flight-related "symptoms" rated
by respondents could have either a physical or psychological
etiology. It was not possible t o describe the etiology of
symptoms in detail using the cross-sectional questionnaire
methodology adopted in this study.The wording of this
question was however deliberately left "open" so as not to
bias respondents' perceptions regarding the etiology of
symptoms.
J o u r n a l ofTravel Medicine, V o l u m e 5 , Number 4
200
during flights lasting less than 5 hours (short haul),
and secondly, during flights lasting more than 5 hours
(long haul): Breathlessness; diarrhea; dizziness; dry
eyes; earache; headaches; heart pounding (fast heart
beats); muscular pains; nausea (feeling of sickness);
stomach pains; stuffy nose; swollen ankles; urinary
problems. Respondents were also asked if they had
experienced any “health problenis” withn 1 hour following a flight lasting more than 5 hours.
Analysis
Preliminary examination of the data revealed one
univariate outlier (over 400 domestic flights in the past
3 years) which was excluded from analysis, reducing
skewness.Data for flight related situational anxiety methods used to reduce anxiety, and flight-related health
problems revealed a “floor effect” in responses,with a proportion of individuals reporting no anxiety and therefore “never” using methods to reduce anxiety, and
reporting few health problems. For analysis therefore, the
five-point response categories were collapsed into three
(i.e., “never,” “sometimes” and “often”). In order to
investigate the relationship between reporting of flightrelated anxiety, and health problems, total scores were calculated by adding together the item frequency ratings on
the recalculated three-point scales, firstly indicating the
overall fi-equency of anxiety, and secondly the overall frequency of health problems on both short-haul and longhaul flights. Reliability estimates were a = 0.86 (scale
mean 4.3) for the “anxiety” scale, a = .82 (scale mean
3.4) for the short-haul health problems scale, and (Y 0.79
(scale mean 3.7) for the long-haul health problems scale.
Since the data for situational anxiety, anxiety reduction strategies and both health problem scales, was nonnormally distributed and highly skewed with a high
degree of variance, nonparametric statistics (Chi square,
Mann-Whitney U, Wilcoxon Rank Sum Test, Spearman
correlations) were used for these variables throughout.
Results
A total of 238 individuals conipleted questionnaires:
138 (58%) attended the six travel agency branches, and
100 (42%) attended travel clinics. A similar proportion
of men and women responded at travel agencies (84 (61%)
women, 54 (39%) men) and travel clinics (66 (66%)
women and 34 (34%) men) (chi2 = 0.66, n.s.). Although
respondents fi-om the travel agencies were older than those
from the travel clinic (mean age 41.7(sd 15.8) compared
with mean age 26.6 (sd 9.6) (t = 8.4, df 234, p < .001)),
they had traveled by air a similar number of times in the
past 3 years (travel agents mean 9.3 (sd 10.8);travel clinics mean 10.5 (sd 12.4) (t = 0.79, df 234, n.s.).
Table 1 Reported Anxiety for Aspects of Air Travel
Often/
Item
Never
Sometimes Always
Agency“
and GendeP
Comparisons
Chi’(dj=Z)
Travel to
airport
Check-in
Flight Delays
Transfer
between
terminals
Waiting in
lounge
Boarding
flight
Take-off
During
flight
166 (70.3) 60 (25.4) 10 (4.2) 8.Y*
165 (69.9) 62 (26.3) 9 (3.8) 17.9“3
115 (49.6) 99 (42.7) 18 (7.8) 18.0”$
156 (67.2) 70 (30.2)
172 (72.9) 64 (27.1)
6 (2.6)
-
%la+
182 (77.1) 47 (19.9) 7 (3.0)
137 (57.8) 73 (30.8) 27 (11.4)
Landing
149 (63.4) 76 (32.3) 10 (4.3) 9.9b*
133 (56.6) 79 (33.6) 23 (9.8) 7.1b*
Baggage
reclaim
Customs
141 (60.0) 78 (33.2) 16 (6.8)
154 (65.3) 75 (31.8) 7 (3.0)
A preliminary investigation of the data revealed no
significant differences in responses between the six travel
agency branches. This data was combined for further
analyses.
Anxiety Related to Aspects of Air Travel
Table 1 indicates to what extent different aspects of
air travel caused respondents to feel anxious. Items are
sequentially ordered through the air travel process, from
travel to airport, to baggage reclaim.
All of the aspects of air travel in Table 1 were rated
to be a source of anxiety “sometimes” or “always,” with
individual aspects being perceived as a source of anxiety
by between 50% and 23% of travelers surveyed in this
study. Overall, flight delays were most frequently rated
,as a source of anxiety, with just over 50% of travelers
reporting anxiety for this item. Boarding the flight was
the least anxiety-provoking aspect of air travel. Although
“take off’ and “landing” were rated as being “often” or
“always” a source of anxiety by the largest percentage of
travelers (11% and 10% respectively), flight delays (8%)
and baggage reclaim (7%) were also found to be “often”
or “always” a source of flight related anxiety.
Travel agency clients and travel clinic clients were
compared in terms of the above aspects of flight-related
anxiety. Chi square analysis revealed that in each case,
“travel to airport” (p < .05),flight “check-in” (p < .001),
“waiting in lounge” (p < . O l ) , and “flight delays”
M c l n t o s h et a l . , A n x i e t y a n d Health P r o b l e m s Related t o Air Travel
Table 2 Frequency of Anxiety Reduction Methods for Air
Travel Anxiety
Item
Never
Often/
Sometimes Always
Agency‘
and GendeS
Comparisons
Chi2(dj=2)
146 (62.9)
197(84.5)
187 (81.0)
124(53.2)
67 (28.9)
16 (6.9)
38 (16.5)
90(38.6)
19 (8.2)
20(8.6)
6 (2.6)
19 (8.2)
31.3*
6.5*
0.9
0.8
4 (1.7)
1.4
1 (0.4)
4.2
~~
Alcohol
Cigarettes
Relaxation
Distraction
Nonpres-
cribed
medication 217 (93.5) 11 (4.7)
201
your mind off it), with 47% of respondents using this
method “sometimes” or “always.” Approximately 37%
reported using alcohol, and rather fewer used “relaxation
techniques” (19%) or cigarettes (16%) “sometimes” or
“always” as a means to reduce anxiety. A small proportion (5%) reported using prescribed or nonprescribed
medication to reduce flight-related anxiety.
Travel agency clients were significantly more likely
to report more frequently using alcohol (p < ,001) and
cigarettes (p < .05) than travel clinic clients. There were
no significant gender differences in frequency of use of
any of these methods.
Prescribed
medication 221 (95.7) 9 (3.9)
Health Problems Related to Air Travel
*p < .05; *p < ,001
(p < ,001) were more frequently reported to be a source
of anxiety by travel agency clients than travel clinic
clients, with no significant differences between these
groups of respondents for other items in this scale.
When men and women were compared, significant dfferences were found on only two items, with more
women than men reporting both “during flight” (p < .01)
and “landing” (p < .05)to be a source of anxiety.
When individual items were totalled, there was no
significant mean gender difference in situational anxiety
(male mean ~ 3 . 8sd, 4.0,female mean = 4.7,sd 4.1, n.s.).
However, travel agency clients recorded significantly
more frequent flight-related anxiety (mean 7.9, sd 7.2)
than travel clinic clients overall (mean 4.5, sd 5.1) (Mann
Whitney U, p < .001).
Methods Used to Reduce Air Travel Anxiety
As revealed in Table 2, the most common method
used to reduce air travel anxiety was “distraction” (taking
Table 3
Respondents were invited to record how frequently
they had experienced each of the flight-related health
problems detailed in Table 3, firstly on short-haul flights
(less than 5 hours) and secondly on long-haul flights
(longer than 5 hours).
Ear problems were the most common health difticulty, reported by over 55% of respondents on both
short-haul and long-haul fights. Headache (41%),swollen
ankles (31%) and stuffy nose (31%) were also frequently
reported. Potentially more severe problems, such as
breathlessness and urinary problems were reported by less
than 10% of respondents.
Most health problems reported were experienced
more frequently on long-haul than on short-haul flights.
Statistical comparisons (Wilcoxon Signed Ranks test)
revealed significant differences between frequency of
somatic symptoms on short-haul (SH) and long-haul &H)
flights for three items, with “swollen ankles” (SH mean
= .39, sd .62;LH mean = .58,sd .71; z = - 4 . 2 , ~< .001),
“stuffy nose” (SH mean = .40, sd .65; LH mean = .48,
sd .68;z = -2.9, p < .01),and ”muscular pain” (SH mean
= .18, sd .41; LH mean z.24, sd .47; z = -2.8, p < .()I),
Frequency of Physical Health Problems for Short-Haul (less than 5 hours) and Long Haul Flights (over 5 hours)
~~~~
_________
~
~~
__________
Flights < 5 Hours (n=230)
Ear problems
Headache
Swollen ankles
Stuffy nose
Dry eyes
Sickness
Heart poundmg
Muscular pain
Stomach pain
Dizziness
Diarrhea
Breathlessness
Urinary problems
~ _ _ _ _ _ _ _ _ _ ~
Flights
______
~~
5 Hours (n=153)
Never n (99)
Sometimes n (%)
Often n (?A)
Never n (%)
Sometimes n
103 (44.4)
134 (58.3)
158 (68.7)
159 (68.8)
164 (71.3)
177 (76.6)
188 (81.4)
192 (83.5)
201 (87.0)
205 (88.7)
209 (91.3)
211 (91.7)
214 (92.6)
93 (40.1)
88 (38.3)
54 (23.5)
51 (22.1)
48 (20.9)
46 (19.9)
34 (14.7)
35 (15.2)
27 (11.7)
25 (10.8)
18 (7.9)
18 (7.8)
16 (6.9)
36 (15.5)
8 (3.5)
18 (7.8)
21 (9.1)
18 (7.8)
8 (3.5)
9 (3.9)
3 (1.3)
3 (1.3)
1 (0.4)
2 (0.9)
1 (0.4)
1 (0.4)
67 (43.8)
85 (55.6)
85 (55.6)
96 (62.7)
99 (64.7)
117 (76.0)
130 (84.4)
118 (77.6)
131 (85.1)
135 (88.2)
138 (89.6)
143 (93.5)
142 (92.2)
67 (43.8)
65 (42.5)
48 (31.4)
41 (26.8)
37 (24.2)
32 (20.8)
21 (13.6)
31 (20.4)
20 (13.0)
17 (11.1)
14 (9.1)
9 (5.9)
12 (7.8)
(?A) Often II (%)
19 (12.4)
3 (2.0)
20 (13.1)
16 (10.5)
17 (7.1)
5 (3.2)
3 (1.9)
3 (2.0)
3 (1.9)
1 (0.7)
2 (1.3)
1 (0.7)
-
Journal of Travel M e d i c i n e , Volume 5 , N u m b e r 4
202
and long-haul flights (F mean 4.4, sd 3.6, M mean 2.6,
sd 3.3) (both Mann-Whitney U, p < ,001). There was
no significant difference between travel agency and travel
clinic clients in terms of total health problems on shorthaul or long-haul flights.
all being experienced more frequently on long-haul
than short-haul flights.
Comparisons between individuals attending travel
agents (TA) and travel clinics (TC) (Mann Whitney U
test) revealed significant differences only for short-haul
flights, with travel agent clients more frequently reporting swollen ankles (TA mean = .50, sd .70; TC mean =
> .24,sd .48,z=-2.8,p < .Ol),diarrhea (TAmean .13,
sd .55; TC mean .lo, sd .27; z = -2.0, p < .05),and muscular pain (TA mean = .23, sd .47; T C mean = .lo, sd
.31; z = -2.1, p < .05) on such flights.
Gender comparisons (Mann Whitney U test)
revealed differences both on long-haul and short-haul
flights. O n short-haul flights, women travelers more
frequently reported swollen ankles (Female (F) mean =
.50, sd .68; Male (M) mean =.20, sd .46; z = -3.4,
p < .001)), sore eyes (F mean = .43, sd .64, M mean =
.25, sd .57; z = -2.6, p < .01), s t u e nose (F mean =
.48, sd .66; M mean = .26, sd =.60; z = -3.0, p < .01)
and headache (F mean = .52, sd .56, M mean = .33, sd
.54; z = -2.65, p < .01). Similarly, on long-haul flights,
women reported significantly more swollen ankles (F
mean = .76, sd .75, M mean = .26, sd .51; z = -4.4,
p < .001), sore eyes (F mean = .61, sd .74, M mean =
.24, sd .54; z = -3.4, p < ,001) s t u e nose (F mean =
.56, sd .70, M mean = .34, sd .60; z = -2.5, p < .01) and
headache (F mean = .54, sd .52, M mean = .34, sd .54;
z = -2.1, p < .05) than men.
When items were totalled to obtain overall frequency of flight-related health problems, women recorded
problems more frequently than men, both on shorthaul flights (F mean = 3.8,sd 3.5; M mean = 2.6, sd 3.6)
Relationship between Situational Anxiety, Health
Problems and Anxiety Reduction Strategies
The relationship between total scale scores for
reported anxiety and health problems on short and longhaul flights, and reported ways of coping with anxiety
was investigated. As shown in Table 4, there was a strong
relationship between the overall frequency of anxiety and
frequency of health problems, both on short-haul
(p < ,001) and long-haul flights (p < ,001).
Greater anxiety was also positively associated with
greater frequency of use of anxiety reduction methods.
Participants recording higher levels of flight-related a m iety more frequently used distraction (p < ,001)and alcohol (p < .001) in particular to reduce anxiety. Similarly,
indwiduals who recorded more (short-haul and long-haul)
flight-related health problems more frequently used distraction (both p < ,001) and alcohol (both p < .001) as
a means of coping with anxiety.
There was also a significant positive correlation
between methods used to cope with anxiety, suggesting
individuals used multiple strategies. For example, individuals using alcohol were also likely to smoke cigarettes
(p < .001) and use distraction (p < ,001) to cope with
anxiety, and use of distraction and relaxation strategies
were highly correlated (p < ,001).
Table 4 Spearman Correlations Showing Relationship between Anxiety, Total Physical Health Problems on Short-Haul and
Long-Haul Flights, Anxiety Reduction Methods, Age and Number of Flights
1
Total Anxiety, Physical Health Problems
2
3
4
5
6
7
8
1
2
Anxiety
Health problems
-
(short-haul)
Health problems
(long-haul)
.51'
-
3
.52$
.87'
-
.35*
.26*
.23t
.46*
.35*
.18t
.21t
.42*
.32'
.21+
.19*
.38*
-
.37'
.04
.25*
-
.02
-
.ll
.41*
-
.21t
.12
.14
.ll
.ll
.14*
.22t
-
.17*
.22+
.02
.15*
.02
-.03
.10
-.01
-.02
.09
.13
.10
.13*
.06
.02
.16*
.02
-.04
.13*
.12
-.03
,430
.08
-.09
9
10
-.14*
.15*
Anxiety Reduction Methods
4
5
6
7
8
9
10
11
Alcohol
Cigarettes
Use relaxation
Use dlstraction
Nonprescribed
medication
Prescribed
medication
Age
No. of flights
M c l n t o s h et al., A n x i e t y a n d H e a l t h P r o b l e m s R e l a t e d t o A i r T r a v e l
Older participants were likely to record more travelrelated anxiety than younger travelers (p < .Ol), although
there was no significant relationshp between age and frequency of health problems, or use of specific methods
to reduce anxiety There was also a significant but weak,
association between the age of individuals and their total
number of flights over the past 3 years (p < .05).
Only a small proportion (7.7%) of individuals taking part in the study reported experiencing any health
difficulties within 1 hour of a long-haul flight. Those who
did experience such difficulties reported essentially minor
problems, including sickness, earache/deafness, urinary
problems, headache, diarrhea, and jet-lag.
Discussion
In a previous study’ we showed that flight related
worries are common, with 24% of travelers affected,
although the cohort in our previous study was drawn from
people attending general practice consultation and results
may not have been generalizable to the traveling public. One in four people in The Netherlands13 and in the
USA’4 are reported to be anxious about flying.These new
results show a similar prevalence ofworry relating to individual aspects of air transit.
Take-off and landing, realistically the most hazardous parts of the journey, provoke anxiety in passengers but flight delays and baggage reclaim, where there
is no health hazard, are also stressful. Flight delay created
anxiety in halfof the cohort, exacerbated perhaps by lack
of information, time loss, personal inconvenience and loss
of personal control of events occasioned by such transit
disturbance. The perceived meaning of the delay is crucial, and may be different for different people. Our own
survey was not able to determine the specific cognitions
which determined respondents’ perceived flight-related
anxiety. For example, delays may have been perceived as
due to aircraft faults, which heighten fears of crashing,
or anxiety about delays may have been related to late
arrival at the destination. For individuals experiencing
claustrophobia, delays may indicate “being trapped” for
longer. Baggage delays, whereby personal belongings
may be lost or stolen are also an understandable cause of
anxiety. Unfamiliarity with aspects of the travel process,
and a loss of personal control over the environment are
also potential sources of psychological hsturbance, as previously noted.3 Many of these situations offer opportunities for transit companies to intervene to make the
occasion less anxiety-provoking for the traveler. Further, detailed research aimed at addressing specific cognitions related to air-travel anxiety would allow
interventions to reduce such anxieties to be more specifically targeted.
203
A considerable number of travelers either anticipate
travel stress or respond to it, with one third ingesting alcohol and 5% resorting to doctor prescribed or over-thecounter medication. Twenty percent report using
relaxation and distraction techniques to combat perceived air travel anxiety. Use of anxiety reduction strategies were also intercorrelated, suggesting people use
multiple coping strategies. Health professionals might
encourage the alcohol and drug users in particular, in the
use of cognitive behavior therapy and hypnotherapeutic techniques to reduce their dependence upon chemicals which treat symptoms but are poor coping
mechanisms in deahng with travel related stress or^.^ Such’
cognitive behavioral methods might prove more effective than the apparent multiplicity of methods used by
the most travel anxiety prone.
The study compared levels of perceived air-travel
anxiety, ways of coping with such anxiety and physical
health problems in two groups of travelers with different levels of travel experience, and different motivations
for traveling. It was hypothesized that the travel clinic s m ple would report less anxiety than the travel agent sample due to their greater travel experience and the more
independent nature of their travel arrangements. This was
the case, with travel agency clients uniformly reporting
greater anxiety and more frequent flight related health
problems than travel clinic clients. It therefore seems
that despite the risky nature of their destinations, and
anticipation of travel-related health problems, the latter
group were more relaxed about the in-transit flight
process. However, much more information about individual characteristics and psychological differences in the
clientele of the travel clinics and travel agents would be
required to fully explain the differences between these
groups identified in this study. The individuals who
agreed to complete questionnaires at both the travel
agency and hospital clinic may not have been representative of all travelers, and more anxious individuals may
have declined to respond. Although staff at each center
were asked to keep a log of individuals who were invited,
but declined to complete questionnaires, administrative
flculties meant that it was not possible to maintain accurate records of nonresponders at either location.
The results also show that women are more apprehensive about flying, or more likely to admit to flying worries, than men. This finding is in keeping with our
previous work showing significantly more women than
men worry about flying and the severity of worry is
greater in women than men.’ Some of these severe worries may be in fact phobias about traveling by air. A phobia is considered to be an irrational fear disproportionate
to the trigger stimulus, which promotes intense anxiety
and avoidance behavior. In a random sample survey of
204
respondents over 16 years in a general practice population, we have also previously recorded that 16%reported
phobias related to travel, and 13%of this group had a fear
of flying with a female to male preponderance of 2: 1.l5
Women also appear to have slightly more health
problems related to air travel than men, although it
should be noted that women generally are more likely
than men to experience, and/or to report minor illness.16
In the present study there was a strong relationship
between overall anxiety and fi-equency of reported health
problems. Some of these symptoms reported were those
usually associated with stress or anxiety (e.g., breathlessness, headache, heart pounding). However, it was not possible to determine which of these symptoms were a
result of situational anxiety, and which may have been
caused by physical factors in the airport or aircraft environment (e.g., low humidity, poor air quality), or by
existing physical morbidity. Several of the health problems experienced more frequently in women, particularly swollen ankles, dry eyes and stu@ nose appear to
relate to the immobility, low partial oxygen pressures and
humidity, features of travel in an aircraft.
These results confirm previous reports that perceived air travel anxieties are common. Further research
could helpfully illuminate the specific cognitions travelers have which determine perceived anxieties, allowing airlines and travel agencies to institute measures to
reassure people more when there are onward travel
delays. Provision of additional information, improved
communication and better management might reduce
stress related to delay and baggage retrieval. Health professionals should question the prescription of medication
to combat flying anxieties and consider cognitive behavioral therapy instituted prior to travel. They should also
be aware that elderly people are likely to be more stressed
by air travel, precipitating in-transit morbidity. It may also
be useful in future studies to consider not only the
frequency, but also the severity of air travel-related
J o u r n a l o f T r a v e l M e d i c i n e , V o l u m e 5, N u m b e r 4
physical symptoms, to enable services to be targeted
towards those individuals experiencing particularly severe
symptoms of anxiety or physical morbidity. Therapy for
such individuals could be usefully offered at pretravel
health clinic consultations.
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