Citation | Sample population | Sample size | Study design | Adherence rate to chemoprophylaxisa | Predictors of adherence (factors highlighted in italics indicate a significant result) | Self-reported reasons for adherence | Quality |
---|---|---|---|---|---|---|---|
Phillips-Howard et al. [15] | British travellers | 326 | Cohort study | 48% | Â | Complex information and receiving conflicting advice when they contacted other advisory services were recorded as reasons for non-adherence, with only 257 travellers felt to have fully understood the information. Forgetting, considering prophylaxis to be unnecessary, advised to stop (by local people or members of their peer group), side-effects and illness, and travelling at short notice so no tablets available | Low |
Lobel et al. [16] | US citizens travelling to Haiti or Africa | 4042 | Cross-sectional survey | 42.4% | Prophylaxis use was associated with receiving pretravel advice (p < 0.001) (forewarning risk of malaria, chemoprophylaxis recommendation, medical consultation). The source that provided the information was not an influence on chemoprophylaxis use |  | High |
Hilton et al. [17] | US travellers | 214 | Retrospective telephone interview | 81% in patients older than 40, 59% of patients younger than 40 | A greater number of travellers older than 40 were fully adherent compared with those under 40 (significance not reported) | Â | Low |
Lobel et al. [18] | European and North American travellers to Kenya | 5489 | Longitudinal study | 52% (of 3469 travellers who used chemoprophylaxis) | Business travellers (compared with tourists) were significantly more likely to be non-adherent (26%, p < 0.001), as were those visiting friends and relatives (32%, p < 0.001) compared with tourists. Logistic regression analysis showed that adherence was particularly poor among people who visited friends and relatives (37%), travelled for more than three weeks (39%), experienced adverse reactions (40%), used proguanil (31%), and among young travellers from the UK (43%) (P < 0.001) |  | High |
Steffen et al. [19] | European travellers | 42,202 | Cross-sectional survey | 55.4% (mean) | Weekly medication (p < 0.001) was significantly associated with increased adherence when compared with daily, twice weekly and thrice weekly medications. Those who stayed abroad over 3 months (p < 0.001) compared with those travelling for less than 3 months were significantly more likely to be non-adherent as were those who had had several previous journeys compared to those on their first journey to the tropics (p < 0.001). Severe adverse drug reactions were experienced by 1.5–4.4% of travellers and caused at least 200 of them to prematurely stop their chemoprophylaxis |  | High |
Held et al. [20] | European or North American travellers returning to Berlin | 507 | Retrospective study | 38% (195/507) | Significantly higher adherence was noted amongst: patients using only one information source compared to those who used no information source (p = 0.0026); shorter travel duration (37.2 ± 38.5 days (mean ± SD) in contrast to 69.8 ± 93.5 days in the group of patients with no adherence p = 0.00001); older patients compared to those aged under 55 (20/27 adherent > 54 compared with 175/476 < 55, p = 0.0001); travel destination with Southern and East African destinations showing highest levels of adherence (p = 0.0054); package tours (p = 0.0001) compared with those who had organised the travel themselves |  | Medium |
Cobelens et al. [21] | Dutch travellers | 547 | Cross-sectional survey | 60% | Adherence was significantly affected by geographical areas travelled to (p < 0.001)—for example adherence was 45% in South America compared with 78% in East Africa, those aged under 29 (p = 0.027) were significantly more likely to be non-adherent compared with those aged over 29, those who had previous travel experience (p = 0.031) were significantly more likely to be non-adherent and those with adventurous travel style (p < 0.001)—such as backpacking—were also more likely to be non-adherent compared with their non-adventurous counterparts Gender, education and travel purpose were not significantly associated with adherence in a logistic regression model | Self-reported reasons for early discontinuation included believing it unnecessary to continue prophylaxis during part of the journey due to the perceived low risk (43.9%), stopped on advice by others (12.2%), experiencing adverse reactions (11.6%), negligence (17.1%). Other reasons mentioned (all less than 5%) included: lack of awareness of the need to continue, loss of tablets, bad taste of the tablets, insufficient amounts prescribed, fear of developing adverse effects and (possible) pregnancy | Medium |
Chatterjee [22] | Travellers to India | 452 | Cross-sectional survey | 71% (320/452) | Females appeared more likely to be non-adherent than males (significance not reported), along with travellers under 30Â years old (significance not reported). Travellers on visits lasting longer than 3Â weeks tended to be less adherent (significance not reported) | Reasons for poor adherence included: inadequate dose or incorrect drug (21%); pretravel information deficit (45%); active decision (33%); side-effects (25%) | Low |
Banerjee et al. [23] | UK GPs travelling to South Asia | 145 | Telephone survey | 46% | Â | Some self-reported reasons for poor adherence included: thinking the area was free from malaria (34%); not wishing to take prophylaxis (18%); experiencing previous side-effects (10%); believing they had long-term immunity (10%); had no time to obtain prophylaxis (4%); costs (2%) and thinking it was easier to cure than to take the medication (2%); travelled for a short period and took the risk (2%) | Low |
Lobel et al. [24] | North American and European travellers to East Africa | 6633 | Cross-sectional study | 61.7% | Adherence was lowest in those who used a daily drug as opposed to a weekly schedule (OR = 4.03; 95% CI 3.32–4.89), attributed an adverse event (OR = 2.23; 95% CI 1.80–2.76) to the prophylaxis, stayed more than a month (OR = 3.32; 95% CI 2.64–4.18), those who were non-tourism travellers (OR = 3.04; 95% CI 2.42–3.82), those aged under 40 (OR = 2.19; 95% CI 1.76–2.71) |  | High |
Farquharson et al. [25] | Travellers attending a travel medicine clinic | 130 | Prospective study using regression analysis | 62% full adherence and 25% partial adherence | There were no significant differences across the adherence groups for age, gender, ethnicity, nationality, education, previous travel or previous experience of anti-malarial medication Multiple logistic regression showed that poor adherence (compared to full adherence) was associated with greater amounts of health professional discussion about adherence in the medical consultation (OR = 0.7, 95% CI 0.6–0.9). Increased likelihood of full adherence (compared to partial adherence) was associated with perceived benefits of taking prophylaxis (OR = 1.4, 95% CI 1.1–1.9), going for a longer trip (OR = 3.6, 95% CI 1.5–8.7), and greater amounts of traveller information and questions in the consultation (OR = 1.0, 95% CI 0.0–1.1). Poor adherence (compared to partial adherence) was associated with going for a longer trip (OR = 0.2, 95% CI 0.1–0.6) and greater amounts of traveller information and questions (OR = 1.0, 95% CI 0.9–1.0) |  | Medium |
Jute et al. [26] | Expatriates working on a Mali mine | 90 | Cross-sectional survey | 72% | Â | Some self-reported reasons for poor adherence included concerns over adverse side-effects, presumed immunity from long-term residence in Africa and a high standard of on-site care | Low |
Hamer et al. [27] | Expatriate corporate workers in Ghana | 42 | Cross-sectional survey | 0% amongst those based over a year 81% of those based three months or less | Duration of stay (p < 0.01) was significantly associated with lowered adherence – for example none of those based over a year were still taking their chemoprophylaxis compared with 81% of those based three months or less | Common reasons for discontinuing malaria prophylaxis include medication side-effects, low perceived malaria risk and suggestions from colleagues on the job site | Medium |
Ropers et al. [28] | German travellers to Kenya, Senegal and Thailand | 1001 | Cross-sectional survey | 69% in Kenya 53% in Senegal 6% Thailand | Travel to Kenya compared to Senegal resulted in a significantly higher adherence rate to chemoprophylaxis (p = 0.021), Receiving advice (from either a medical or non-medical professional) significantly increased adherence when compared with those who received no advice (p < 0.001), Correct risk perception (p < 0.001) was associated with a significant increase in prophylaxis adherence. Increased length of travel (for example comparing those travelling less than 14 days to those travelling 15–21 days) was associated with increased adherence (p < 0.001) | Reasons for poor adherence included absence of mosquitoes (53%) and ‘adverse effects’ with their medication (22%) | High |
Roukens et al. [6] | Non-immune expatriate business travellers | 2350 | Cross-sectional, web-based study | 45% | Malaria awareness and CMK training (RR = 2.2; 95% CI 1.6–3.2); long-term travellers less likely to be adherent compared to rotators or visitors (p < 0.001) |  | High |
Baggett et al. [29] | US residents travelling to India | 1302 | Cross-sectional study | VFRs (visiting friends and relatives) 16.3%; non-VFRs 39.4% | Factors significantly associated with lower adherence to chemoprophylaxis included travelling to India in the previous 5 years (POR = 0.46; 95% CI 0.31–0.67) and travelling with the purpose of VFRs (visiting friends and relatives) (p < 0.001). Taking chemoprophylaxis was also more common among US citizens (POR = 2.71; 95% CI 1.91–3.85) |  | High |
Alon et al. [30] | Israeli travel clinic | 394 | Telephone interview | 60.7% in over 60 age group 33.8% in 20–30 age group | Elderly travellers (p < 0.01)—those aged 60 and over—were significantly more likely to be adherent than those in the 20–30 age group |  | Medium |
Depetrillo et al. [31] | Travellers from the United States | 104 | Prospective, non-blinded study | 89% | Factors associated with increased adherence included travel destination, with those travelling to regions such as Sub-Saharan Africa having significantly higher adherence levels (p = 0.0063) compared with those travelling for example to Central America. Other significant predictors of non-adherence included previous travel to a malarious region (p = 0.0411) compared with those who had never travelled to a malarious region before | Travellers’ self-reported perception of need was felt to be a key influencer in adherence. 7/12 felt it was not necessary, 2/12 were told by their tour guides they did not need to take it and 3/12 reported adverse side-effects | Medium |
Dia et al. [32] | French travellers to Senegal | 358 | Prospective cohort study | 71.8% | Factors significantly associated with non-adherence included reporting at least one gastrointestinal symptom (p = 0.07) and non-reporting arthropod bite (p = 0.04) | The main reasons for not taking medications were: finding it useless (47.1%) and fearing side effects (44.1%) | Medium |
Joshi et al. [33] | UK South Asians | 400 | Cross-sectional survey | 49% (1994) and 32% (2004) | Factors associated with an increased adherence with prophylaxis included a basic knowledge of malaria (p = 0.003), perceiving malaria as a critical illness (p = 0.004) and defining trip as a holiday (as opposed, for example, to a ‘visit to friends and family’) (p = 0.043) Age, gender and occupational status did not relate to adherence in either year; years of post-16 education did not relate to adherence in the 2004 sample (not asked in the 1994 survey) Adherence was not related to experience of malaria or having been born in a malarial zone | Reasons given for non-adherence given by partial and zero adherers included: belief in personal immunity (47% in 1994, 43% in 2004); perceived low risk of getting malaria (42% in 1994, 26% in 2004); never heard of tablets (25% in 1994, 27% in 2004; forgot to take/get tablets (21% in 1994, 15% in 2004); dislike taking tablets (14% in 1994, 29% in 2004); believing malaria is easily treatable (9% in 1994, 22% in 2004); local norms (5% in 1994, 17% in 2004) | Medium |
Pistone et al. [34] | French adult travellers | 13,017 (3066 travellers to malaria-endemic countries) | Retrospective questionnaire study | 47.6% in high-risk areas 9.5% in low-risk areas | Factors significantly associated with increased adherence with malaria chemoprophylaxis included awareness malaria was serious (OR = 2.03, p = 0.033) and receiving information from a physician (OR = 3.01, p = 0.042). When the analysis was reiterated for travellers to low and high-risk areas separately, older travellers were less likely to be adherent for the high-risk travellers only (OR = 0.95 for each incremental year of age p = 0.018) |  | High |
Belderok et al. [35] | Dutch short-term travellers | 620 | Prospective cohort study | 75% (466/620) took 100% of recommended tablets | Significant factors associated with adherence included: travelling to Africa (OR = 3.5; 95% CI 1.9–6.5) instead of Asia or Latin America; taking mefloquine (OR = 5.3; 95% CI 1.2–23.1) compared to atovaquone–proguanil or proguanil; spending 14–29 days in endemic areas (OR = 2.2; 95% CI 1.2–3.8) instead of ≤ 13 days or ≥ 29 days in endemic areas; concurrent use of DEET for more than 50% of days in high-endemic areas (OR = 2.6; 95% CI 1.4–4.8) |  | Medium |
Caillet-Gossot et al. [36] | Children under 16 visiting travel medicine centre in Marseille, France | 167 | Prospective study | 66% | Adherence was significantly higher in those visiting African destinations (p < 0.02) compared with those taking a trip to Asia or Indian Ocean Being aged < 5 (p < 0.03) was also found to be a predictor of non-adherence as was being from a mono-parental family (p < 0.04) Adherence was identical between VFR and tourist children, irrespective of trip duration |  | Medium |
Muller et al. [37] | Adults consulting at a Medical Department for International Travellers’ | 287 | Cross-sectional survey and telephone interview | 76.3% | Travelling to areas of mass tourism (such as Kenya and Senegal) (p = 0.005) was found to be a predictor of adherence—it was noted that these travellers were also less likely to be seasoned travellers (compared with, for example, long-stay business travellers); trips shorter than 15 days were associated with better adherence (p = 0.001) | Side-effects (20.6%), forgetting (17.6%), too many pills—because of other treatments (17.6%), no mosquitoes seen (13.3%), tiredness (11.8%), did not like taking medication (10.3%), price (2.9%), lack of pills (1.5%) | Medium |
Wieten et al. [38] | Travellers to Ghana from the Netherlands | 154 | Questionnaire survey | 53.9% (had started chemoprophylaxis) | Attending pretravel clinic and receiving pre-travel advice was related to a greater likelihood of starting chemoprophylaxis (p < 0.01); if a participant incorrectly thought they had been vaccinated (p = 0.009) they were also more likely to use chemoprophylaxis Higher age (p = 0.004) and travelling for family purposes (p = 0.022) rather than business were positively associated with starting chemoprophylaxis. Having had malaria (p = 0.028) and spending more than 6 weeks in West Africa (p = 0.001) were negatively associated with starting and buying chemoprophylaxis Those who thought curing malaria was easier than taking preventative tablets (p = 0.046) were more likely to be non-adherent—it was felt that subjectively held information is more important than accurate information Previous use of chemoprophylaxis was not found to influence current preventive behaviour |  | Medium |
Cunningham et al. [12] | Foreign and Commonwealth Office employees on long-term placement in endemic areas | 327 | Questionnaire survey | 25.1% had adherence > 95% of prescribed pills 54.4% had adherence < 25% of prescribed pills | Increasing age was shown to be significantly associated with improved adherence (Chi squared p < 0.00), living in an endemic area for more than a year was significantly correlated with adherence less than 95%, pregnancy was associated with lower adherence (87.5% of pregnant women took no prophylaxis) Significant side-effects were reported by 39.5% of respondents and there was a trend between reported side-effects and self-reported adherence < 95% (p = 0.087) | Concerns with long term safety was cited by more than half of individuals with adherence < 25% | Medium |
Goldstein et al. [39] | Israelis attending Haifa travel clinics | 307 | Questionnaire survey | 34.7% | Shorter travel (p < 0.001), with those who adhered having a travel duration on average 2.6 times shorter than those who did not; travel to urban areas (p < 0.01) showed higher adherence; travellers older than 23 (p = 0.021) showed higher adherence, backpackers showed lower levels of adherence (p < 0.01) compared to other travellers |  | Medium |
Landman et al. [40] | Peace Corps volunteers in the Africa region in 2013 | 781 | Questionnaire survey | 73% | Factors significantly associated with non-adherence included: being prescribed mefloquine (OR = 5.4; 95% CI 3.2–9.0) as opposed to doxycycline or atovaquone–proguanil; if they were in the peace corps for over a year (OR = 1.8; 95% CI 1.2–2.8); being under 26 years old (OR = 1.7; 95% CI 1.1–2.6); not worrying about malaria (n = 214; OR = 2.6; 95% CI 1.6–4.1); fears long-term adverse effects (OR = 1.6; 95% CI 1.1–2.4) | The most common reasons for non-adherence included: forgetting (n = 530, 90%), fear of long-term adverse effects (n = 316, 54%) and experiencing adverse events that volunteers attributed to prophylaxis (n = 297, 51%) | Medium |
Shady [41] | Visitors to traveller’s health clinic to obtain malaria prophylaxis | 928 | Prospective comparative study | 81.6% with mefloquine and 79.5% with doxycycline | University education (p = 0.005) was a predictor of non-adherence, travel organized through an agent showed increased adherence (p = 0.0001) whereas independently organized travel (p = 0.0001) was a predictor of non-adherence, blue-collar workers (p = 0.0001) showed higher non-adherence compared to white-collar workers Predictors of good adherence for mefloquine group included travel to an African destination (p < 0.001), education above a secondary level (p < 0.001), organized travel (p < 0.05), travelling for leisure (p < 0.05) and Kuwaiti nationality (p < 0.001) Predictors of good adherence in the doxycycline group included higher than a secondary level of education (p < 0.001), organized travel (p < 0.001), travel for leisure (p < 0.05), travel to an African destination (p = 0.05) and Kuwaiti nationality (p < 0.001) |  | Medium |
Stoney et al. [42] | US travellers | 370 | Cohort study | 71.6% | No significant difference for sex (p = 0.74), location of birth (p = 0.49), endemicity of country of birth (p > 0.99), daily vs weekly chemoprophylaxis (p = 0.19), visiting friends or relatives as a reason for travel (p = 0.44), destination as partially or entirely endemic (p = 0.89), or travelling for more or less than 2 weeks (p = 0.19) | Reasons for declining entirely: advised by peers not to take chemoprophylaxis (32%), low perceived risk in area (28%), no mosquitoes present during trip (16%), fear of side effects (16%), cost (8%), had a side effect (4%), unable to fill prescription before trip (4%), other (8%) Reasons for not taking full course: Forgetting (cited by 50% of participants nonadherent during travel), side-effects (31%), not seeing mosquitoes (11%), low perceived risk in area (8%), lost medication (6%), other reason (6%). Data from a post-travel survey, completed by a smaller proportion of participants, are not reported here | Medium |
Rolling et al. [43] | German travellers | 928 | Questionnaire survey | 19% carried anti-malarial medication | Neither duration of travel or previous travel experience significantly differed between those carrying anti-malarial medication and those who did not A medical consultation prior to travelling was associated with significantly higher odds of carrying anti-malarial medication after adjusting for age, with the highest odds in those having had their consultation at a travel medicine specialist (OR 7.83 compared to no consultation) | Â | Medium |
Pagès et al. [44] | Malaria cases in Réunion Island (a previously malaria-endemic island; the last indigenous cases were reported in 1967, but international travel has reintroduced the illness) | 89 | Epidemiological surveillance data; data from Regional Health Agency investigations | 29 patients were prescribed chemoprophylaxis: 10 did not buy it, 13 stopped taking it early, 3 took it irregularly, and 5 reported proper adherence. Of the 56 patients not prescribed anti-malarial medication, 24 were not aware they should have consulted a doctor, 21 chose not to, and 11 were not prescribed a medication after their consultation | An absence of chemoprophylaxis or poor adherence was found in the majority of malaria cases (96%) regardless of the reason for travel (visiting friends and family vs. other reasons) |  | Low |