Safe Travel Practices and Awareness among Diabetic Patients

Objective To measure the knowledge of Saudi patients with diabetes in coping with their condition and to assess their practice of disease control during travels. Study Design. Cross-sectional study using a self-administered questionnaire. Method This study was conducted between September 2018 and May 2019 at a University hospital in Riyadh, Saudi Arabia. The questions were adopted from guidelines and advices provided by the CDC, American Diabetic Association, and other references. Bivariate and multivariate analyses were used to identify factors associated with diabetic control during travels. Results From the included 242 patients, 33.6% showed the good practice of diabetic control during travels. 23.7% of patients were communicated by their doctors about the importance of consultations before traveling and 20.7% encountered complications during travels. Factors associated with doctors' consultation before travel are patients' concerns about travel duration and possible risks during trip. (OR = 2.588, 95% CI = 5.308–1.261), (OR = 3.525, 95% CI = 8.152–1.525); respectively. Conclusion Patient awareness and education about the importance of proper diabetic self-monitoring and control during travels is crucial as the study showed suboptimal diabetes management practice. Practice Implications. Physicians should proactively educate patients about the importance of seeking advice before their travels.


Introduction
Modern technology has transformed travel from a need-based activity to a luxurious experience accessible to almost everyone, for business, medical, or personal purposes. In 2015, the tourism movement exceeded all expectations with 1.2 billion international tourist arrivals; this number is expected to rise to 2 billion by 2030 [1]. Meanwhile, the number of people in Saudi Arabia who traveled in 2011 was more than 4 million, increasing to approximately 6 million in 2015; this number is expected to rise further in the future [2].
Diabetes mellitus (DM) is a global health issue responsible for approximately 1.6 million deaths annually; [3] its prevalence has increased dramatically over the years [4]; in Saudi Arabia, it is 24%, with an estimated 7 million patients [5,6]. Furthermore, the growth pattern of this condition is alarming [7].
Tere is no evidence that diabetic patients are more likely to develop related complications such as vascular or renal disease while traveling than those who do not have DM [3]. However, a change in multiple factors such as diet, level of activity, and environment (temperature and altitude) while traveling can alter blood glucose levels, making it challenging to maintain them [8].
Te Centers for Disease Control and Prevention (CDC) provides general and specifc advice for diabetic patients looking to travel or traveling, including consulting a healthcare provider for insulin dose adjustment according to their destination, activities, and diet changes, as well as carrying a glucose monitor and insulin at all times [9,10].
Diabetic patients have the right to travel safely. Terefore, we conducted this study to assess the knowledge and practices of Saudi diabetic patients in terms of managing and coping with their condition while traveling. Te results of this study could be benefcial for healthcare services aimed at such travelers, for providing better care and preventing complications.

Methods
Tis was a cross-sectional study, conducted at King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia. Data were collected between September 2018 and May 2019 from Saudi diabetic patients aged above 18 and visiting KKUH's diabetic outpatient clinics who had traveled in the last 12 months. Patients with gestational diabetes were excluded.
Te sample size was calculated using the standard formula for cross-sectional studies, considering a signifcance level of 5%, a precession of 7%, and a prevalence of good DM management while traveling of 38% [10]. While the initial sample size required for this study was 185, after adding 10% for the nonresponse rate, it was 205.
Saudi diabetic patients visiting KKUH were recruited from 3 clinics, specialized diabetes clinics that serve the general population in 2 diferent locations, the family medicine department and internal medicine department, in addition to primary care clinics that serve the university faculty and their dependents.
Using a simple random sampling method, participants were approached from each of the mentioned clinics from diferent sessions and days of the week in order to give patients an equal chance to be included.
Patients were approached in clinic's waiting area by explaining the need for diabetic patients who had traveled in the last 12 months as study participants; it was also clarifed to them that their decision to participate would not afect their consultation with the physician. Data were collected through a self-administered questionnaire containing questions on demographics including age, gender, education level, and occupation; diabetes and other comorbidities; and travel history, knowledge, and practices. Te questions were adopted from the guidelines and advice provided by the CDC and American Diabetic Association, and a survey by Elkins et al. [9,11,12] Face and content validity of the questionnaire were assessed by two independent researchers (an epidemiologist and a diabetes consultant).
Te study was piloted on 20 patients with diabetes from the general population to test for clarity and applicability of questionnaire; the time needed to fll the questionnaire. Data obtained from the pilot study were not included in this study.
Data were analyzed using SPSS 24.0 version statistical software. Descriptive statistics (mean, standard deviation, frequencies, and percentages) were used to describe the quantitative and categorical variables. Te bivariate statistical analysis was carried out using appropriate (chi-square, student's t-test) statistical tests. A p-value of <0.05 and 95% confdence interval were used to report the results' statistical signifcance and precision.
A multivariate logistic regression was performed to adjust for confounding variables. Variables with a p-value of 0.2 or less in bivariate analysis were entered into the regression model using enter method.
Te main outcome was pretravel medical consultation as an indicator of good travel practices. Tis indicator was further analyzed to determine its efect on the other elements of DM management while traveling, including carrying identifcation (ID), snacks, medications, and a frst aid kit; destination choice, mode of transport; telling one's partner about the condition; self-monitoring; self-control; management issues; and complications.
Te consent form was included with each questionnaire copy distributed; it explained the study purpose and included an agreement to participate and the participant's right to withdraw at any time without any obligation.
Participants' autonomy was ensured as well as data confdentiality and anonymity by number coding them for the purpose of analysis.
Only 23.7% of the respondents' physicians had informed them about the importance of pretravel medical consultation, while 14.9% of the respondents had concerns related to traveling; of these, 82.9% said that consultation with their physician would have helped address their concerns (Table 1).
Regarding overseas travel, 55.5% believed that they could go to a general practitioner for receiving medical care, while 59.7% thought that they would be able to buy their medications at a nearby pharmacy ( Table 2).
Assessment of their practices revealed that 33.6% of the respondents had consulted their physician before traveling. Of the respondents who had traveled abroad, 52.5% had exhibited poor self-control. Furthermore, 20.7% had experienced complications while traveling, with 54% of them experiencing hypoglycemia.
A minority of the respondents (7.9%) had carried an item identifying their condition, such as a card, bracelet, or smartphone health app; 67.6% had carried snacks; an overwhelming number (95%) had carried their medications.
Regarding DM's impact on travel, the condition afected destination choice and mode of transport of 12.8% and 18.2% of the respondents respectively (Table 2).
Bivariate analysis showed that the mean age of the respondents who sought medical advice was 48.96 and of those who did not was 53.28, with a statistically signifcant difference (p � 0.009, 95% CI � 7.525-1.103).
When comparing the respondents' education, the results revealed that those educated tended to visit their physician before traveling more than their uneducated counterparts (OR � 2.190, 95% CI � 3.814-1.258, p � 0.005). Te longer the trip duration, the higher the likelihood of the respondents visiting their physician (OR � 2.253, 95% CI � 4.010-1.266, p � 0.005). Likewise, the respondents' concern about possible risks during the trip infuenced their decision to visit their physician before traveling (Table 3).
Te study also showed that the respondents who consulted their physician were more likely to inform their partner about their condition (OR � 2.850, 95% Journal of Environmental and Public Health CI � 7.782-1.004, p � 0.034), as well as carry ID and a frst aid kit (Table 3).
In multivariate analysis, the logistic regression model showed 4 factors signifcantly associated with DM management while traveling: carrying ID and a frst aid kit, and concerns about trip duration and possible risks during the trip. Te respondents carrying ID and a frst aid kit were more likely to have consulted their physician before

Discussion
Tis study was conducted to investigate the compliance of Saudi diabetic patients with safe travel guidelines and to investigate the factors afecting their behaviors. For this, pretravel medical consultation was used as an indicator of good compliance, observed in only one-third (33.6%) of the respondents. Factors afecting pretravel medical consultation were concerns about trip duration and potential risks and carrying ID and a frst aid kit. Tis study showed that the respondents who were concerned about trip duration or possible risks demonstrated a higher compliance with safety guidelines and a higher tendency to consult their physician before traveling; this is similar to a fnding of the study by Burnett who found that travelers tend to consult their physician before departure when their trip duration is long [13].
Carrying an ID and a frst aid kit are important recommendations by healthcare professionals to diabetic patients looking to travel or traveling [9]. Although in this study, the proportions of respondents carrying ID and a frst aid kit were low (7.9% and 42.3%), pretravel medical consultation had a signifcant impact on these behaviors. Tis showed that those who visited their physician before traveling were more knowledgeable and engaged in signifcantly better DM management practices as per the recommendations for safe travel.
Tis study revealed that the respondents' main reason for consulting a physician was to get advice on glucose monitoring during their trip. Tis result is similar to that of a previous study, which found glucose monitoring to be one of the main reasons the participants went for pretravel   Journal of Environmental and Public Health medical consultation, in addition to insulin dose adjustment as a majority of that study's participants were insulin users [12]. However, in the present study, the respondents did not know how to adjust their insulin dose, demonstrated by the low response rate to a question on insulin dose adjustment during time zone changes; this fnding has been previously observed in diferent populations, highlighting a general lack of knowledge of the practice of insulin dose adjustment [12,13]. More than half of the present study's respondents who had experienced complications during their trip had had at least one episode of hypoglycemia. Previous research has attributed this to delayed meal time or infectious diseases [13][14][15].
In the present study, the majority of the respondents said that they would visit a general practitioner for receiving medical care or go to a nearby pharmacy to buy their medications when abroad. However, American diabetic patients get their medications through the emergency department and ask the hotel staf about where they can go for receiving medical care [12].
Saudi Arabia has a high DM prevalence, which is expected to increase further in the coming years [6]. Among this growing population of patients, a large number may travel multiple times [2]. Tis study assessed the possible risks encountered by diabetic patients who had traveled and highlighted several areas of importance. It also provides an overview of the behaviors of Saudi diabetic patients who travel and the complications they might face.
Tis was a hospital-based study, and thus, the results cannot be generalized to the entire population of diabetic patients in Saudi Arabia; therefore, a community-based study including multiple centers from diferent cities would provide a wider range of responses that could be generalized. Tere was no validated scoring system measuring knowledge and practices; therefore, items included in assessing knowledge and practice were analyzed individually rather than as a group factor. Both type 1 and type 2 DM were included in this study; however, a community-based study focusing on insulin-using diabetic patients is recommended to investigate their specifc needs as they are more prone to risks while traveling.

Conclusion
In conclusion, the majority of the respondents in this study had not sought out medical advice before traveling; and it was also found that pretravel medical consultation was a good indicator of their overall practices.  Educating patients on ways to monitor their blood glucose levels, adjusting their medication doses, preparing for emergencies when abroad, and the importance of carrying a medical ID is crucial. Moreover, providing a list of healthcare centers approved by the health ministry and Saudi embassy in every country, as well as information on where to get medications and receive medical care during emergencies, is just as important.

Data Availability
Te data used to support the fndings of this study are available from the corresponding author upon request.

Disclosure
Te authors certify that none of the authors have any relevant fnancial and/or nonfnancial relationships to disclose.

Conflicts of Interest
Te authors declare that there are no conficts of interest.