Travellers' Risk Perceptions, Values and Preferences - Final report

Prepared for the Public Health Agency of Canada (PHAC)

Supplier name: Kantar
Contract number: 6D026-184081/001/CY
Contract value: $79,422.26 (including HST)
Award date: January 16, 2019
Delivery date: June 2019

Registration number: POR # 110-18

For more information on this report, please contact:
hc.cpab.por-rop.dgcap.sc@canada.ca

Ce rapport est aussi disponible en français.

Travellers' Risk Perceptions, Values and Preferences
Final Report

Prepared for Public Health Agency of Canada
Supplier name: Kantar
June 2019

The Public Health Agency of Canada (PHAC) commissioned Kantar to conduct a public opinion research survey assessing Canadian travellers' risk perceptions, values and preferences. This study was conducted online with 2000 Canadians who have travelled outside of Canada and/or the United States, including Alaska or Hawaii in the past twelve months or plan to travel outside of Canada and/or the United States, including Alaska or Hawaii in the next twelve months.

Cette publication est aussi disponible en français sous le titre: La perception du risque, les valeurs et les préférences des voyageurs

This publication may be reproduced for non-commercial purposes only. Prior written permission must be obtained from Health Canada. For more information on this report, please contact Health Canada at hc.cpab.por-rop.dgcap.sc@canada.ca or at:

Health Canada, CPAB
200 Eglantine Driveway, Tunney's Pasture
Jeanne Mance Building, AL 1915C
Ottawa, Ontario K1A 0K9

Catalogue Number:
H14-323/2019E-PDF

International Standard Book Number (ISBN):
978-0-660-30841-8

Related publications (registration number: POR # 110-18):
Catalogue Number: H14-323/2019F-PDF (Final Report, French)
ISBN: 978-0-660-30842-5

© Her Majesty the Queen in Right of Canada, as represented by the Minister of Health, 2019

Table of Contents

• 1. Executive Summary
  • 1.1. Research Purpose and Objectives
  • 1.2. Summary of Findings
    • 1.2.1. Canadian International Travellers' Travel Habits
    • 1.2.2. Attitudes Towards Travel Health Risks
    • 1.2.3. Researching Travel-Related Health Risks and Recommendations
    • 1.2.4. Risk Mitigation Behaviours
  • 1.3. Methodology
    • 1.3.1. Sub-group analyses, statistical significance and rounding
  • 1.4. Contract Value
  • 1.5. Statement of Political Neutrality
• 2. Detailed Findings
  • 2.1. Research Purpose and Objectives
  • 2.2. Canadian International Travellers' Travel Habits
    • 2.2.1. Frequency of International Travel
    • 2.2.2. Past and Future Travel Plans
    • 2.2.3. Booking International Travel
    • 2.2.4. Where International Travellers Look when Planning and Booking Travel
    • 2.2.5. Trip Purpose
    • 2.2.6. Travel Party
    • 2.2.7. Travel Accommodations
  • 2.3. Attitudes Towards Travel Health Risks
    • 2.3.1. International Travellers' Attitudes Towards Travel Health Risks
    • 2.3.2. International Travellers' Risk Perceptions
    • 2.3.3. Influence of Health Risk on Travel Destination Choice
  • 2.4. Researching Travel Related Health Risks and Recommendations
    • 2.4.1. When International Travellers Typically Look for Health Risks and Associated Travel Health Recommendations
    • 2.4.2. Circumstances for Looking at Travel Health Risks
    • 2.4.3. Importance of Knowing about Infectious Diseases and Vaccinations at Destination
    • 2.4.4. Trusted Sources for Travel Health Information
  • 2.5. Risk Mitigation Behaviours
    • 2.5.1. Perceived Importance of Risk Mitigation Behaviours
    • 2.5.2. Following Recommendations
    • 2.5.3. Risk Mitigation During Trip Planning
    • 2.5.4. Risk Mitigation During Travel
    • 2.5.5. Barriers to Following Health Recommendations
    • 2.5.6. Travelling to Receive Medical Services
• 3. Appendix A: Methodology
• 4. Appendix B: Survey Instrument

1. Executive Summary

1.1. Research Purpose and Objectives

Health risks associated with travel are a public health concern as travellers are at risk of contracting serious infectious diseases during their trip which they may then spread to other Canadians upon their return. The Public Health Agency of Canada (PHAC) has been working with key stakeholders to increase awareness of the health risks associated with travel and to develop informational products and reports for Canadians. A key challenge in doing so has been to effectively reach the travelling public with messages that influence them to take actions to protect their health.

As such, PHAC needed additional information on risk perception, attitudes and behaviours of Canadian travellers. In addition, the 2017-18 Departmental Plan indicates that "PHAC will improve and integrate its travel health programs to better prevent, respond to, and minimize the impact of travel-related public health risks such as malaria, the Zika virus and food and water-borne illnesses". The integrated programming will focus on the traveller, respond to a range of travel-related public health risks, and identify priorities to enhance communication to Canadians about travel-related risks.

The information collected through this research will be used to support future messaging and enhance communications to Canadians about travel health. Additionally, it will support the Border and Travel Health communications strategy, a detailed and targeted marketing plan and the overarching approach for outreach to communicate with Canadians. Finally, the results from the survey will be used to support ongoing work with health care professionals when developing evidence-based recommendations related to travel health risk.

Research Objectives

The overall objective of this research was to better understand the knowledge, attitudes, and behaviours of Canadians regarding travel-related health risks.

Specific research objectives included:

• Understand Canadians' level of awareness in relation to travel health risks
• Understand the values and preferences of travellers related to when and how they choose to prepare for travel-related health risks with a health care professional
• Identify key messages that may influence the adherence to travel health recommendations
• Identify travel health subjects that are important to Canadians
• Identify what sources, tools or other resources Canadians currently use for travel health information and travel booking
• Understand the level of motivation among Canadian travellers to modify behaviour to reduce travel health risks
• Determine if attitudes, values, preferences and/or awareness differ among various demographic groups

1.2. Summary of Findings

To address the objectives of this research, certain groups of people were targeted for the survey. Specifically, these were Canadians who have travelled outside of Canada and the United States, including Alaska and Hawaii in the past 12 months or those who plan to travel outside of Canada and the United States, including Alaska and Hawaii in the next twelve months (hereinafter called "international travellers"). In total, surveys were conducted among 2,000 international travellers age 18 years and older. Quotas were placed to achieve 1,000 completions among international travellers who had travelled in the past 12 months; and 1,000 completions among those who plan to travel internationally in the next 12 months. Among the 2000 completes there was a good distribution for age, gender and region. Specifically, 27 percent were aged 18-34, 40 percent were aged 35-54 and 34 percent were aged 55 or older; 54 percent were female and 45 percent were male; and regionally, survey completions were distributed as per their quotas to ensure the ability to undertake analyses among regions of interest: Atlantic (13%), Quebec (25%), Ontario (35%), Prairies (10%) and BC/Territories (18%).

The following is a summary of the results, which at a high level, demonstrate that international travellers generally understand and agree that international travel can pose certain health risks to travellers. It also demonstrates that many international travellers would like to have health risk information and recommendations before travelling and are willing to follow the recommended advice. In fact, many international travellers undertake a variety of risk mitigation behaviours both before and during their trip to protect their health.

Although most international travellers are willing to follow recommendations, many don't believe it is important to see a health care professional or go to a travel health clinic prior to travelling. This is largely driven by the belief that they are already prepared for (e.g. have the necessary vaccinations) or are aware of the health risks associated with their travel.

Given that online resources for travel health information are most popular and the Government of Canada website is trusted by most international travellers, it becomes increasingly important to ensure travel health information is readily available, up-to-date, and easily accessible online so that international travellers can be informed and follow recommendations on actions to take to mitigate health risks that they may encounter at their destination.

1.2.1. Canadian International Travellers' Travel Habits

More than half of international travellers surveyed take at least one international trip per year (53%). In the past 12 (twelve) months, international trips were most often to Europe (27%), the Caribbean (18%), Central America and Mexico (15%), Asia (12%) and/or Territories of the United States (10%). Fewer trips were taken to South America (4%), the Middle East (3%), Africa (3%), Australia or New Zealand (2%), the Pacific Islands (1%) or elsewhere (3%).

Intended travel over the next 12 (twelve) months takes a similar pattern, with plans most likely to involve trips to Europe (36%), the Caribbean (28%), Central America and Mexico (19%), Territories of the United States (13%) and/or Asia (13%). Fewer plan to travel to South America (7%), Australia or New Zealand (5%), Africa (3%), the Middle East (3%), the Pacific Islands (2%) or elsewhere (4%).

Most (65%) international travellers typically book their travel arrangements two or more months in advance while the remainder (35%) book a month or less in advance. International travellers consult a variety of resources while planning and booking travel. Online sources are most popular and include general internet search engines (58%), travel websites (49%), online booking sites (44%) and government websites (42%). Just over one-third use travel providers such as airlines, tour companies, etc. (36%) and/or travel agents (35%).

1.2.2. Attitudes Towards Travel Health Risks

Three-quarters (75%) of international travellers surveyed agree that travelling internationally poses health risks that are not present in Canada. Fewer however, believe all international travellers should see a health care professional before they travel (64%) or, that an appointment should be booked with a health care professional at least six weeks before an international trip (62%).

For the most part, most international travellers (72-82%) assess the level of health risk to be either low or medium for most types of travel. Travel for volunteer/humanitarian work and adventure travel are considered "high" risk by more international travellers than other types of travel (55% and 45% respectively).

Furthermore, a small but sizeable proportion of international travellers find travelling to a familiar destination (18%) and/or travelling to visit friends and family (16%) to have no risk to their health.

For most international travellers, health risk plays a role in destination choice. Few international travellers (8%) indicate that health risks do not influence their choice of travel destination. Nearly one-quarter (24%) indicate health risk influences destination choice to a small extent, while the remainder (66%) indicate health risks influence their destination choice to a moderate (36%) or great extent (30%).

1.2.3. Researching Travel-Related Health Risks and Recommendations

The vast majority (89%) of international travellers look for health risks and associated travel health recommendations prior to travel. Many (40%) look for health risks more than six weeks before their trip, while nearly half (49%) look in the six weeks leading up to their trip.

The circumstances under which international travellers look for health risks varies, with less than half (45%) looking every time they travel to an international destination. Close to one-third (31%) look when they are travelling to places that they believe have health risks and one-fifth (21%) look when they are travelling to a destination for the first time and/or when they hear about health risks in the news or on social media.

Interestingly, while less than half (45%) of international travellers look at health risks every time they travel to an international destination, approximately three-quarters of international travellers consider it very important to know about:

• Vaccinations required to enter the country (79%);
• Infectious diseases or illness they can get from food and/or water at the destination (78%);
• Vaccinations recommended to prevent diseases that occur at the destination (74%);
• Infectious diseases or illness they can get from other people at the destination (71%); and/or
• Infectious diseases or illness they can get from insects at the destination (70%).

International travellers trust a variety of sources for accurate information about travel health. Government of Canada websites are trusted by nearly two-thirds (63%) of international travellers, followed by health care professionals (56%), international agencies (41%) and travel health clinics (40%).

1.2.4. Risk Mitigation Behaviours

When asked about the importance of a variety of risk mitigation behaviors, approximately seven-out-of-ten international travelers believe that it is very important to:

• Purchase or have existing travel health insurance (72%);
• Obtain the recommended vaccinations for their travel destination (72%);
• Ensure their routine vaccinations are up-to-date (71%);
• Follow travel health recommendations on how to protect themselves against health risks at their destination (70%); and/or
• Look for health risks that are present at their destination (65%).

Despite this, fewer believe that it is very important see a health care professional (49%), visit a travel health clinic (38%) and/or consult a pharmacist (29%).

Only one percent of international travellers will not follow travel health recommendations when travelling to a destination with a known infectious disease. Nearly all international travellers intend to undertake a variety of risk mitigation activities prior to embarking on (94%) or during (98%) a trip.

Common risk mitigation activities while preparing for a trip include:

• Purchasing or having existing travel health insurance (58%);
• Researching health risks present at their destination (50%);
• Obtaining vaccinations required to enter the country (49%);
• Ensuring their routine vaccinations are up-to-date (48%);
• Getting the recommended vaccinations for their destination (46%);
• Getting advice on how to protect themselves against health risks at their destination (42%); and/or
• Seeing a health care professional (40%).

As expected, given the lower perceived importance placed on travel health clinics and pharmacists, few will visit a travel health clinic (22%) or consult a pharmacist (20%) prior to travel.

Common risk mitigation activities while travelling include:

• Cleaning hands regularly (78%);
• Practicing safe eating and drinking habits (75%);
• Avoiding close contact with sick individuals (67%);
• Protecting oneself from insect bites (65%);
• Practicing proper coughing and sneezing etiquette (57%);
• Avoiding close contact with wild (56%) or domesticated (43%) animals; and/or
• Protecting oneself from sexually transmitted infections (44%).

A variety of factors influence whether international travellers follow recommendations to protect themselves from getting sick on an international trip. These factors are:

• The likelihood of spreading illnesses to loved ones and others upon return (68%);
• How well the recommended actions will work (55%);
• The possible side effects of the recommended actions (49%);
• The type of activities the traveller is planning (47%);
• The familiarity with or frequency of travel to the destination (46%);
• The cost of the recommended actions (40%); and/or
• The purpose of travel (38%).

Among those who do not typically visit a health care professional or go to a travel health clinic prior to travel (50%), a variety of reasons were provided. Many of these relate to being prepared for or aware of the risks associated with their travel such as:

• Being up-to-date on all vaccines (35%);
• A perception that there are no health risks associated with their travel plans (31%);
• Travelling to the same place(s) often (30%);
• A perception of low or no health risks because they are generally healthy (29%); and/or
• A belief that they are already aware of the health risks associated with their travel plans (26%).

Few cite costs (8%), lack of time (7%) or lack of available appointments (7%) as reasons for not visiting a health care professional or travel health clinic.

Several barriers exist that prevent international travellers from following travel health recommendations. In fact, nearly half (53%) of international travellers cited at least one reason that prevented them from following travel health recommendations in the past. Reasons tend to be quite varied, with no single reason preventing a large portion of international travellers from following travel health recommendations. These include:

• Believing the risk was too low to warrant taking the advice (15%);
• Being unaware of the recommendation(s) (14%);
• Being worried about the side effects (10%);
• Not realizing their vaccination(s) expired (8%); and/or
• Not having enough time for the recommended vaccines or medications to take effect before their trip (8%), to get the recommended vaccinations or medications (8%) or to see a health care professional or go to a travel health clinic (7%).

Few (10%) reported cost-related barriers such as believing the cost was too high compared to the risk and/or that they could not afford the cost of the recommendations (6%). Lastly, a small number (6%) reported vaccine/medications not being available.

When it comes to international travellers, not all have similar attitudes and behaviours towards travel risk. Several factors seem to play a role and should be considered when targeting particular types of travellers or when conveying specific messages. Age, gender, being born outside of Canada and the purpose of the trip all seem to play a role in attitudes and associated behaviours related to travel health.

Age

Destination choice as well as attitudes and behaviours surrounding travel health risk vary by age. Younger international travellers (18-34) are more likely to have travelled to Asia (18% vs 7-12%), South America (8% vs 1-4%) and/or Territories of the United States (13% vs 6-10%) than their older counterparts (35+) and they are more likely to have plans to travel to Asia (20% vs 6-12%). They are also more likelythan their older counterparts to book travel closer to their departure date (three weeks or less) (24% vs 5-16%).

Younger (18-34) and middle aged (35-54) international travellers also have a different perception of risk than older travellers (55+). Those 18-54are more likely to rate familiar destinations (12-13% vs 2-5%), destinations they travel to frequently (10-13% vs 2-5%) and visits to family and friends (12-14% vs 5%) as high risk compared to older international travellers (55+).

Younger (18-34) and senior (71+) international travellers are less likely than those 35-69 to research travel health risks every time they travel (40-41% vs 47%). Further, when younger and middle aged (18-54) travellers do look for travel-related health risks, they do so closer to their departure date (3 weeks or less before their trip) (26-39% vs 14-15%). Interestingly however, younger and middle aged international travellers are less likely than their older counterparts (55+) to believeit is very important to:

• Obtain the recommended vaccinations for their travel destination (64-68% vs 81-90%);
• Ensure their routine vaccinations are up-to-date (61-67% vs 81-94%);
• Purchase or have existing travel health insurance (58-69% vs 84-93%);
• Follow travel health recommendations on how to protect themselves against health risks at their destination (58-67% vs 80-94%); and/or
• Look for health risks that are present their destination (56-63% vs 75%).

As well, those aged 18-54 are less likely than their older counterparts to undertake most risk mitigation activities prior to and during travel, except for visiting a travel health clinic, consulting a pharmacist, signing up with ROCA and/or downloading the Travel Smart app where incidence is similar regardless of age. Furthermore, younger international travellers (18-34) are more likely to report protect themselves from sexually transmitted infections than their older counterparts (54% vs 34-43%) when travelling.

Younger international travellers (18-34) also tend to report higher incidences of all barriers to following travel health recommendations compared to their older counterparts. As the international traveller ages, they are more likely to report experiencing no barriers (70% for those 18-34 vs 25% for those 71+).

Gender

There are several gender-based differences when it comes to travel health risk perception and actions taken to mitigate risk. In particular, women are more likely than men to research health risks present at their destination (53% vs 45%), look at travel health risks every time they travel (43% vs 48%) and to seek advice on how to protect themselves against health risks at their destination (44% vs 39%). Men are more likely to book trips closer to their departure date (3 weeks or less before their trip) than women (22% vs 10%).

Compared to men, women are more likely to consider it very important to know about all aspects of destination-specific infectious diseases and vaccinations; and more likely to believe it is very important to:

• Purchase or have existing travel health insurance (75% vs 67%);
• Obtain the recommended vaccinations for their travel destination (75% vs 68%);
• Follow travel health recommendations on how to protect themselves against health risks at their destination (74% vs 65%);
• Ensure their routine vaccinations are up-to-date (73% vs 67%); and/or
• Look for health risks that are present their destination (69% vs 61%).

In addition, women are also more likely than men to undertake all precautions while travelling, except for protecting themselves from sexually transmitted infections and avoiding contact with domesticated animals where both genders take similar precautions. Lastly, women report experiencing fewer barriers to following travel health recommendations than men (50% vs 56%).

Born Outside of Canada

As one might expect, international travellers who were born outside of Canada have slightly different habits, perspectives and behaviours related to travel health compared to those who were born in Canada. First, international travellers born outside of Canada are more likely than those born in Canada to have travelled in the past twelve months to Asia (26% vs 8%), the Middle East (5% vs 2%) and/or Africa (5% vs 2%). Those born outside of Canada are also more likely to have plans to travel to Asia (25% vs 9%) and/or the Middle East (5% vs 2%) in the next twelve months than those born in Canada. Those born outside of Canada are also more likely to book their travel at least four months in advance of their departure date. (31% vs 25%).

Not only do the travel habits of international travellers born outside of Canada differ, but also their attitudes and behaviours related to travel health risks differ. More specifically, international travellers born outside of Canada are less likely than those born in Canada to agree that travelling internationally poses health risks that are not present in Canada (67% vs 78%); are less likely to believe all international travellers should see a health care professional before they travel (55% vs 66%); and/or that an appointment should be booked with a health care professional at least 6 weeks before an international trip (56% vs 64%).

International travellers born outside of Canada are also less likely to look at travel health risks every time they travel (34% vs 48%) and when they do look for health risks, they are more likely to look closer to their trip date (3 weeks or less before their trip) (33% vs 22%). Compared to those born in Canada, international travellers born outside of Canada are less likely to believe it is very important to:

• Obtain the recommended vaccinations for their travel destination (67% vs. 74%);
• Follow travel health recommendations on how to protect themselves against health risks at their destination (65% vs 71%);
• Purchase or ensure they have existing travel health insurance (64% vs 74%);
• Ensure their routine vaccinations are up-to-date (64% vs. 73%); and/or
• See a health care professional (45% vs 51%).

Lastly, international travellers that were born outside of Canada are more likely to report barriers to following travel health recommendations than those who were born in Canada (59% vs 51%). Barriers are varied and can include but are not limited to lack of awareness, cost or time. They are also less likely to undertake risk mitigation activities including:

• Purchasing or ensuring they have existing travel health insurance (48% vs. 62%);
• Obtaining vaccines required to enter the country (36% vs. 53%);
• Researching health risks present at their destination (44% vs. 52%);
• Ensuring their routine vaccinations are up-to-date (40% vs. 51%);
• Obtaining the recommended vaccinations for their travel destination (36% vs. 49%);
• Seeking advice on how to protect themselves against health risks at their destination (36% vs. 43%); and/or
• Seeing a health care professional (30% vs. 43%).

Purpose of travel

Looking at travel habits, international travellers that are travelling for volunteer/humanitarian work, business, or education/research book closer to the departure date (three weeks or less) than those travelling for tourism/pleasure, to visit friends or family or for adventure (30-43% vs 11-20%).

Risk assessments also differ. International travellers that primarily travel for tourism/pleasure or to visit friends and family are less likely to rate all trip types (except volunteer/humanitarian and adventure travel) as high risk compared to those who travel for volunteer/humanitarian work, business, education/research or adventure. They are also less likely to typically look for health risks and associated travel health recommendations compared to those travelling for volunteer/humanitarian work, business, education/research and adventure (88-89% vs 94-97%).

Tourism/pleasure travellers who look for travel health recommendations tend to do so further in advance of their trips (more than six weeks before travel) (44%) compared to those who travel for other reasons (i.e., volunteer/humanitarian work, business, education/research and adventure (28-37%)) and are also more likely to undertake many of the recommended precautions during their trip and report fewer barriers to following travel health recommendations (49% vs 66-89%). They are also more likely to say they would definitely follow travel health recommendations (73% vs. 61-69%).

In summary, international travellers are usually interested in protecting their health while travelling and many actively seek out and follow travel health recommendations and advice. However, some disparities exist among the various types of travellers and the purpose of travel; therefore, targeted messaging or approaches to informing Canadians about travel health risk may be required for various groups.

1.3. Methodology

These findings are based on online surveys conducted from March 14 to March 26, 2019. Respondents were randomly selected from the Kantar online panel and invited via email to participate in the survey. In total, surveys were conducted among 2,000 Canadians age 18 years and older. Quotas were placed to achieve 1,000 completions among Canadians who have travelled outside of Canada and the United States, including Alaska and Hawaii, in the past 12 months; and 1,000 completions among those who plan to travel outside of Canada and the United States, including Alaska and Hawaii, in the next 12 months. A pre-test consisting of 10 completed English surveys and 10 completed French surveys was completed on March 13, 2019 before fielding the survey.

The results of panel surveys are considered a non-probability sample, meaning they are not a random selection from the general population of Canada, rather they are a subset of people who have signed up to participate in online surveys. As such, margin of error does not apply and conclusions from these results cannot be generalized to any population.

Surveying was conducted in the respondent's official language of choice and took an average of 15 minutes to complete. A detailed methodology can be found in Chapter 3.

1.3.1. Sub-group analyses, statistical significance and rounding

Analysis was undertaken to establish differences between the total population that was surveyed and a number of demographics within this group. More specifically analysis was undertaken to identify any differences based on age, gender, region, education, born in or outside of Canada, trip purpose, travel party composition, past or future 12-month traveller, accommodation typically booked, travel frequency, influence of health risk on travel destination and whether or not travellers look for health risks. Exact breaks can be found in the detailed tables. Only differences significant at the 95% confidence level are presented in this report. Any differences that are statistically significant (t-test) between these subgroups are indicated by denoting the column letter within the tables throughout the report. For example, in the table below younger (18-34) and middle-aged international travellers (35-54) are significantly more likely to rate travelling to a familiar destination as high risk compared to older international travellers (55+).

The numbers presented throughout this report are rounded to the closest full number. Due to this rounding, in some cases it may appear that ratings collapsed together are different by a percentage point from when they are presented individually, and totals may not add up to 100%.

1.4. Contract Value

The total contract value for the project was $79,422.26 including applicable taxes.

1.5. Statement of Political Neutrality

I hereby certify as a representative of Kantar TNS that the deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Directive on the Management of Communications and Procedures for Planning and Contracting Public Opinion Research. Specifically, the deliverables do not include information on electoral voting intentions, political party preferences, or standings with the electorate or ratings of the performance of a political party or its leaders.

Tanya Whitehead
Kantar
Senior Director, Public Practice Leader

2. Detailed Findings

2.1. Research Purpose and Objectives

Health risks associated with travel are a public health concern as travellers are at risk of contracting serious infectious diseases during their trip which they may then spread to other Canadians upon their return. The Public Health Agency of Canada (PHAC) has been working with key stakeholders to increase awareness of the health risks associated with travel and to develop informational products and reports for Canadians. A key challenge in doing so has been to effectively reach the travelling public with messages that influence them to take actions to protect their health.

As such, PHAC needed additional information on risk perception, attitudes and behaviours of Canadian travellers. In addition, the 2017-18 Departmental Plan indicates that "PHAC will improve and integrate its travel health programs to better prevent, respond to, and minimize the impact of travel-related public health risks such as malaria, the Zika virus and food and water-borne illnesses". The integrated programming will focus on the traveller, respond to a range of travel-related public health risks, and identify priorities to enhance communication to Canadians about travel-related risks.

The information collected through this research will be used to support future messaging and enhance communications to Canadians about travel health. Additionally, it will support the Border and Travel Health communications strategy, a detailed and targeted marketing plan and the overarching approach for outreach to communicate with Canadians. Finally, the results from the survey will be used to support ongoing work with health care professionals when developing evidence-based recommendations related to travel health risk.

Research Objectives

The overall objective of this research was to better understand the knowledge, attitudes, and behaviours of Canadians regarding travel-related health risks.

Specific research objectives included:

• Understand Canadians' level of awareness in relation to travel health risks
• Understand the values and preferences of travellers related to when and how they choose to prepare for travel-related health risks with a health care professional
• Identify key messages that may influence the adherence to travel health recommendations
• Identify travel health subjects that are important to Canadians
• Identify what sources, tools or other resources Canadians currently use for travel health information and travel booking
• Understand the level of motivation among Canadian travellers to modify behaviour to reduce travel health risks
• Determine if attitudes, values, preferences and/or awareness differ among various demographic groups

To address the objectives of this research, certain groups of people were intentionally targeted for the survey. More specifically, Canadians who have travelled outside of Canada and the United States, including Alaska and Hawaii in the past 12 months or who plan to travel outside of Canada and the United States, including Alaska and Hawaii in the next twelve months (hereinafter called "international travellers") were the target groups.

2.2. Canadian International Travellers' Travel Habits

2.2.1. Frequency of International Travel

Frequency of international travel varies among travellers. Almost half (46%) take less than 1 international trip per year. Nearly one-third (32%) of international travellers take approximately 1 international trip per year and another 15 percent take 2 international trips per year. Few (6%) international travellers take 3+ trips per year.

Q033. Approximately, how often do you take international trips — that is, trips outside of Canada and the United States, including Alaska and Hawaii?

2.2.2. Past and Future Travel Plans

The destinations that travellers choose also varies. International travellers are most likely to have travelled to Europe (27%), the Caribbean (18%), Central America and Mexico (15%), Asia (12%) and/or Territories of the United States (10%) in the past 12 months. Fewer travelled to South America (4%), the Middle East (3%), Africa (3%), Australia or New Zealand (2%), or the Pacific Islands (1%).

Thirty percent do not plan to travel in the next twelve months. Among those who reported travelling in the past twelve months, Europe (39%) was most popular followed by the Caribbean (26%), Central America and Mexico (21%), Asia (17%), Territories of the United States (14%), South America (6%), the Middle East (4%), Africa (4%), Australia or New Zealand (3%), and the Pacific Islands (1%).

Some demographic differences exist in relation to past travel:

• Younger international travellers (18-34) are more likely to have travelled to Asia (18% vs 7-13%), South America (8% vs 1-4%) and/or Territories of the United States (13% vs 6-10%) than their older counterparts (35+);
• International travellers living west of Quebec (Ontario, Prairies and BC) are more likely to have travelled to Asia (14-19% vs 7%); and
• International travellers born outside of Canada are more likely to have travelled to Asia (26% vs 8%), the Middle East (5% vs 2%) and/or Africa (5% vs 2%).

Q006. In the past 12 months, have you taken a trip outside of Canada and the United States, including Alaska and Hawaii, that lasted one or more nights to any of the following regions? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

* Less than 0.5%

Q006. In the past 12 months, have you taken a trip outside of Canada and the United States, including Alaska and Hawaii, that lasted one or more nights to any of the following regions? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

* Less than 0.5%

In the next 12 months, international travellers are most likely to plan on travelling to Europe (36%), the Caribbean (28%), Central America and Mexico (19%), Territories of the United States (13%) and/or Asia (13%). Fewer plan to travel to South America (7%), Australia or New Zealand (5%), Africa (3%), the Middle East (3%), or the Pacific Islands (2%).

Eight percent of international travellers do not plan to travel in the next twelve months. Among those who plan to travel in the past twelve months, Europe (39%) is most popular followed by the Caribbean (30%), Central America and Mexico (21%), Asia (14%), Territories of the United States (14%), South America (8%), Australia or New Zealand (5%), the Middle East (3%), Africa (3%), and the Pacific Islands (2%).

Some demographic differences also exist in relation to planned travel in the next 12 months:

• Younger international travellers (18-34) are more likely to plan to travel to Asia (20%) than their older counterparts (35+) (6-12%);
• Men are more likely to plan to travel to Asia than women (15% vs 11%); and
• International travellers born outside of Canada are more likely than those born in Canada to plan to travel to Asia (25% vs 9%) and/or the Middle East (5% vs 2%).

Q007. In the next 12 months, do you plan to take a trip outside of Canada and the United States, including Alaska and Hawaii, that will last one or more nights to any of the following regions? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

* Less than 0.5%

2.2.3. Booking International Travel

When it comes to booking international travel, nearly two-thirds of international travellers (65%) typically book their travel arrangements two or more months in advance of travelling. The remainder book a month or less in advance. More specifically, 20 percent book about a month before travelling, 12 percent book two to three weeks before travelling and few (4%) book a week or less before travelling.

Typical booking times vary based on several factors. More specifically:

• Younger international travellers (18-34) book travel closer to the departure date than older international travellers (35+). Younger international travellers are also more likely to book three weeks or less before travelling (24%) compared to their older counterparts (35+) (5-16%);
• Men book travel closer to the departure date than women. Men are more likely to book three weeks or less before travelling than women (22% vs 10%);
• International travellers born outside of Canada are more likely to book at least four months before travelling than those born in Canada (31% vs 25%); and
• International travellers that are travelling for volunteer/humanitarian work, business, or education/research book closer to the departure date (three weeks or less) than those travelling for tourism/pleasure, to visit friends or family or for adventure (30-43% vs 11-20%).

Q031. How far in advance do you typically book your travel arrangements for international trips?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

Q031. How far in advance do you typically book your travel arrangements for international trips?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

Q031. How far in advance do you typically book your travel arrangements for international trips?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

** Caution: Low base <30

2.2.4. Where International Travellers Look when Planning and Booking Travel

When looking for information to plan or book travel to an international destination, international travellers look in a variety of places. Online sources such as internet search engines (58%), travel websites (49%), online booking websites (44%) and government websites (42%) are most popular. Other sources include friends and family (41%), travel providers such as airlines, tour companies, etc. (36%), travel agents (35%), travel blogs (20%), travel magazines or books (16%) and other (2%).

Travel providers and travel agents are more popular among older international travellers (55+) (42-48% and 43-47% respectively) than their younger or middle-aged counterparts (30-33% and 28-33% respectively). Friends and family are more popular among younger (18-34) and middle aged (35-54) international travellers (42-49% vs 30-35%). Furthermore, government websites and travel agents are less popular among those born outside of Canada (36% and 28% respectively) compared to those born in Canada (44% and 37% respectively).

Q019. When you look for information to plan or book travel to an international destination, where do you look? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

* Less than 0.5%

2.2.5. Trip Purpose

Most travellers typically travel internationally for tourism or pleasure (82%), to visit friends or relatives (39%), and/or for adventure travel (25%). Fewer travel for business (12%), education or research (7%), or volunteer or humanitarian work (5%).

Older international travellers (55+) are more likely to travel for tourism or pleasure than their younger counterparts (89-90% vs. 76-80%); while younger travellers (18-34) are more likely than their older counterparts to travel for adventure (37% vs. 10-27%), business (19% vs. 3-12%), and/or education or research (13% vs. 2-6%).

Those born in Canada are more likely to travel for tourism/pleasure or for adventure (85% and 27% respectively) than their counterparts born outside of Canada (75% and 20% respectively) and are less likely to travel to visit friends or relatives (31% vs. 65%).

Q026. When travelling internationally, do you typically travel for…? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

* Less than 0.5%

2.2.6. Travel Party

More than half of international travellers (59%) typically travel internationally with their spouse or significant other. Close to a quarter travel with their friends (26%), other family members (23%) or alone (22%). Fewer travel with their children under 18 (17%), parents (13%), children over 18 (7%), co-workers (4%) or grandparents (1%).

Men are more likely to travel alone (26% vs. 19%) or with co-workers (5% vs. 3%), while women are more likely to travel with friends (28% vs. 23%), other family members (27% vs. 17%) and/or parents (14% vs. 10%).

Q029. Who typically travels with you when you travel internationally? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

* Less than 0.5%

2.2.7. Travel Accommodations

When travelling internationally, the majority of international travellers typically stay at a hotel (71%). Close to one-third typically stay at a resort (37%) and/or with family (30%). Less common accommodations include privately-owned homes or apartment rentals (19%), staying with friends (18%), hostels (9%), camping (6%) and/or cruises (1%).

Predictably, younger international travellers (18-34) indicated they are much more likely than their older counterparts (35+) to stay in less-expensive forms of accommodation, such as with family (39% vs. 20-31%), in privately-owned homes or apartment rentals (24% vs. 16-19%), with friends (23% vs. 14-17%) and/or in hostels (16% vs. 5-7%).

Q030. Where do you typically stay when you travel internationally? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

* Less than 0.5%

2.3. Attitudes Towards Travel Health Risks

2.3.1. International Travellers' Attitudes Towards Travel Health Risks

While many (75%) international travellers agree that travelling internationally poses health risks that are not present in Canada, fewer (64%) believe (completely/somewhat) that all international travellers should see a health care professional before they travel or that an appointment should be booked with a health care professional at least six weeks before going on an international trip (62%).

Most (82%) international travellers understand that when entering Canada, they must report to a Border Services Officer if they have, or suspect they have, an infectious disease or illness. Furthermore, most (89%) also understand that if they become ill after returning from an international trip, they should see a doctor and inform the doctor they have been travelling internationally.

A number of factors play a role related to international travellers' attitudes toward travel health risks:

• International travellers with a university education are less likely than their less educated counterparts to agree that:
  • Travelling internationally poses health risks that are not present in Canada (71% vs 77-81%);
  • International travellers should see a health care professional before they travel (59% vs 66-70%); and/or
  • An appointment should be booked with a health care professional at least six weeks before an international trip (57% vs 66-70%).
• International travellers born outside of Canada are also less likely than those born in Canada to agree that:
  • Travelling internationally poses health risks that are not present in Canada (67% vs 78%);
  • International travellers should see a health care professional before they travel (56% vs 64%); and/or
  • An appointment should be booked with a health care professional at least six weeks before an international trip (55% vs 66%).
• International travellers who plan to take an international trip in the next 12 months are more likely than those who travelled internationally in the past twelve-months to agree that:
  • Travelling internationally poses health risks that are not present in Canada (76% vs 73%);
  • International travellers should see a health care professional before they travel (65% vs 59%); and/or
  • An appointment should be booked with a health care professional at least six weeks before an international trip (64% vs 59%).
• Those who travel internationally less frequently (less than one trip per year) are more likely than those who travel more frequently (one or two trips per year) to agree that:
  • Travelling internationally poses health risks that are not present in Canada (77% vs 71-74%);
  • All international travellers should see a health care professional before they travel (70% vs 55-58%); and/or
  • An appointment should be booked with a health care professional at least six weeks before an international trip (68% vs 56-57%).

Interestingly, those who travel on three or more trips per year have similar attitudes to those who travel less than once per year.

Q009. Please indicate the extent to which you agree or disagree with the following statements.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

Q009. Please indicate the extent to which you agree or disagree with the following statements.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

2.3.2. International Travellers' Risk Perceptions

For the most part, international travellers assess the level of health risk to be either low or medium for most types of travel. Travel for volunteer/humanitarian work and adventure travel is considered "high" risk by more international travellers (55% and 45% respectively) compared to other types of travel. Furthermore, a small but noteworthy proportion of international travellers find travelling to a familiar destination (18%) and/or travelling to visit friends and family (16%) to have no risk to their health.

Q022. Please indicate the level of health risk you would generally associate with the following types of travel.

There are a variety of factors that impact international travellers' risk perceptions. Younger and middle aged international travellers (18-54) are more likely to rate familiar destinations, destinations they visit frequently, and visits to family and friends high risk compared to older international travellers (55+). International travellers that primarily travel for tourism/pleasure or to visit friends and family are less likely to rate all trip types (except volunteer/humanitarian or adventure travel) high risk compared to those who travel primarily for volunteer/humanitarian work, business, education/research or adventure.

As expected, international travellers who investigate travel health risks prior to travelling are more likely to rate all types of travel high risk compared to those who do not investigate health risks prior to travelling. As well, international travellers who book last minute travel (one week or less) are also more likely to consider most types of travel high risk except for volunteer/humanitarian and adventure travel. Perceived health risks associated with volunteer/humanitarian and adventure travel were viewed similarly regardless of when one typically books travel. Complete details can be found in the tables below.

Q022. Please indicate the level of health risk you would generally associate with the following types of travel.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

Q022. Please indicate the level of health risk you would generally associate with the following types of travel.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

** Caution: Low base <30

Q022. Please indicate the level of health risk you would generally associate with the following types of travel.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

2.3.3. Influence of Health Risk on Travel Destination Choice

For most international travellers, travel health risk plays a role when choosing a travel destination. Few (8%) international travellers indicate that health risks do not influence their choice of travel destination. Nearly one-quarter (24%) indicate travel related health risks influence their destination choice to a small extent, just over one-third (36%) indicate to a moderate extent and just under one-third (30%) indicate health risks influence their destination choice to a great extent.

Those who typically travel with children under the age of 18 were more likely to indicate health risks influence their destination choice to a great extent (36%) as compared to those travelling alone (27%) or with a spouse (30%). Moreover, those who typically travel alone were more likely than those who do not travel alone, to indicate health risks do not at all influence their choice of travel destination (12% vs 4-8%).

Furthermore, international travellers who book their trip one week or less in advance are more likely that those who book more than one week in advance to report that health risks do influence their destination choice to a great extent (62% vs 25-32%) while those who book their trip four or more months in advance compare to those who book less than four months in advance are more likely to indicate health risks influence their destination choice only to a small extent (30% vs 8-24%). Predictably, those who look for travel health risks are more likely to report health risk having a higher influence on their destination choice compared to those who do not look for travel health risks (32% vs 11% - to a great extent; 37% vs 20% - to a moderate extent).

Q012. To what extent do health risks influence your choice of travel destination?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

** Caution: Low base <30

Q012. To what extent do health risks influence your choice of travel destination?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

2.4. Researching Travel Related Health Risks and Recommendations

2.4.1. When International Travellers Typically Look for Health Risks and Associated Travel Health Recommendations

The vast majority (89%) of international travellers look for health risks and associated travel health recommendations prior to travel. Many (40%) look more than six weeks before their trip, while almost half (49%) look in the six weeks leading up to their trip. Specifically, close to one-quarter (24%) look 4-6 weeks before travel, one-fifth (20%) look 2-3 weeks before travel and only a small portion (5%) look the week before. More than one-in-ten (11%) international travellers do not look for health risks and associated travel health recommendations.

Several subgroups of international travellers are more likely to look for health risks and associated travel health recommendations closer to their trip date (3 weeks or less before their trip). Younger and middle aged international travellers (18-54) look for health risks and associated travel health recommendations closer to their trip date than their older counterparts (55-71) (26-39% vs 14-15%), as do those who were not born in Canada (33% vs 22%).

Tourism/pleasure travellers look for travel health recommendations further in advance of their trips (more than six weeks before travel) compared to those who travel for other reasons (i.e., visiting friends and family, volunteer/humanitarian work, business, education/research and adventure) (44% vs 28-37%).

As well, tourism/pleasure travellers and those visiting friends and family are more likely to report that they do not typically look for health risks and associated travel health recommendations compared to those travelling for volunteer/humanitarian work, business, education/research and adventure (11-12% vs 3-6%).

Q010. When deciding to travel to an international destination, when do you look for health risks and associated travel health recommendations (e.g. vaccines required, medications needed or preventative measures) related to the destination?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

Q010. When deciding to travel to an international destination, when do you look for health risks and associated travel health recommendations (e.g. vaccines required, medications needed or preventative measures) related to the destination?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

** Caution: Low base <30

2.4.2. Circumstances for Looking at Travel Health Risks

While the vast majority (89%) of international travellers look for health risks and associated travel health recommendations prior to travel, the circumstances under which they look vary. Less than half (45%) of all international travellers look at health risks every time they travel to an international destination. Close to one-third (31%) look when they are travelling to places that they believe have health risks and just over one fifth (21%) look when they are travelling to a destination for the first time and/or when they hear about them in the news or on social media. Fewer look at health risks when they hear about them from family or friends (14%), when they think of it (7%) or when they have enough time (4%).

Certain groups are more likely to look at travel health risks every time they travel and include:

• Men (48% vs 43%);
• International travellers with an education of high school or less (52% vs 42-44%);
• International travellers who were born in Canada (48% vs 34%); and
• Those who book their trips one week or less before travelling (71% vs 39-48%).

Q011. Under what circumstances would you look at the health risks before travelling to an international destination? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

*Less than 0.5%

Q011. Under what circumstances would you look at the health risks before travelling to an international destination? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

*Less than 0.5%

Q011. Under what circumstances would you look at the health risks before travelling to an international destination? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

*Less than 0.5%

2.4.3. Importance of Knowing about Infectious Diseases and Vaccinations at Destination

When asked about the importance of knowing about infectious diseases and associated vaccinations at their destination, approximately three-quarters of international travellers consider it very important to know about:

• Vaccinations required to enter the country (79%);
• Infectious diseases or illness you can get from food and water at the destination (78%);
• Vaccinations recommended to prevent diseases that occur at the destination (74%);
• Infectious diseases or illness they can get from other people at the destination (71%); and/or
• Infectious diseases or illness they can get from insects at the destination (70%).

Fewer international travellers, but still a majority, find it very important to know about infectious diseases or illness they can get from animals (58%).

Overall, older international travellers (55+) and women are more likely to consider it very important to know about all aspects of destination-specific infectious diseases and vaccinations. Complete details can be found in the table below.

International travellers who book their trip at the last minute (2-3 weeks before departure), are less likely than those who book further in advance, to think travel health risk information is very important. This is a surprising finding given they tend to report higher incidences of looking for travel health risk information, higher incidences of looking every time they travel and a greater influence of health risk on their travel destination choice.

Q015. When travelling to an international destination, how important is it to you to know about...?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

Q015. When travelling to an international destination, how important is it to you to know about...?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

*Less than 0.5%

2.4.4. Trusted Sources for Travel Health Information

International travellers trust a variety of sources for accurate information about travel health. Government of Canada websites are trusted by nearly two-thirds (63%) of international travellers followed by health care professionals (56%), international agencies (41%) and/or travel health clinics (40%). Fewer international travellers report trusting the following sources:

• Pharmacies or pharmacists (34%)
• Provincial government websites (29%)
• Internet search engines (26%)
• Travel websites (24%)
• Travel agents (22%)
• Friends and family (20%)
• United States government websites (20%)
• Other country government websites (20%)
• Travel magazines or books (8%)
• Travel apps (8%)
• Other (1%)

Q020. Which of the following sources do you trust to have accurate information about your health when travelling? Select all that apply.

2.5. Risk Mitigation Behaviours

2.5.1. Perceived Importance of Risk Mitigation Behaviours

International travellers were asked about the importance of a variety of risk mitigation behaviours. Many international travellers believe it is very important to:

• Purchase or have existing travel health insurance (72%);
• Obtain the recommended vaccinations for their travel destination (72%);
• Ensure their routine vaccinations are up-to-date (71%);
• Follow travel health recommendations on how to protect themselves against health risks at their destination (70%); and/or
• Look for health risks that are present at their destination (65%).

Despite this, fewer believe that it is very important to see a health care professional (49%), visit a travel health clinic (38%) and/or consult a pharmacist (29%).

A number of groups are more likely to believe the above noted risk mitigation behaviours are very important compared to their counterparts. These include:

• Older international travellers (55+);
• Women;
• Those with high school education or less;
• Those who were born in Canada; and/or;
• Those who look for travel-related health risks

Complete details can be found in the tables below.

Q016. When travelling to an international destination, how important do you think it is to do the following before you travel?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

Q016. When travelling to an international destination, how important do you think it is to do the following before you travel?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

Respondents who indicated that looking for health risks present at their destination was not important (1%) provided several reasons for that answer. These reasons included:

• Not being concerned or worried about health risks (23%);
• Being aware of the health risks already (12%);
• Having consulted their doctor already (8%);
• Being healthy or having a good immune system (8%);
• A belief that the health risks are propaganda from the government or big pharma (8%)
• Not having had an issue in the past (4%)
• Belief that their destination is risk-free (4%)
• General refusal to take vaccinations (4%)
• Misc. other/ don't know (23%)

2.5.2. Following Recommendations

Only 1% of international travellers indicated they would not follow travel health recommendations when travelling to a destination with a known infectious disease. The large majority indicated they would definitely (70%) or probably (22%) follow travel health recommendations if they were travelling to a destination where there is a known infectious disease or illness.

Interestingly, those who travel for volunteer or humanitarian work are much less likely than those who travel for most other reasons (i.e., pleasure/tourism, visiting friends and family, business, and/or adventure) to say they definitely or probably would follow recommendations (84% vs 93-95%), while international travellers who do not look for health risks are less likely to say they would definitely or probably follow the recommendations (86% vs 94%).

Q014. If you were travelling to a destination where there is a known infectious disease or illness, how likely are you to follow travel health recommendations?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B

* Less than 0.5% ** Caution: Low base <30.

Q014. If you were travelling to a destination where there is a known infectious disease or illness, how likely are you to follow travel health recommendations?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

* Less than 0.5%

A variety of factors influence whether international travellers follow recommendations to protect themselves from getting sick on an international trip. For more than half of international travellers, the likelihood of spreading illnesses to loved ones and others upon return (68%), and how well the recommended actions will work (55%) are very important when deciding to follow recommendations. Also very important when deciding to follow recommendations, are the possible side effects of the recommended actions (49%), the type of activities the traveller is planning on doing on the trip (47%), the familiarity with or frequency of travel to the destination (46%), the cost of the recommended actions (40%) and the purpose of travel (38%). Inconvenience, either before (29%) or during (32%) a trip, is considered very important by less international travellers when deciding to follow recommendations.

Women are more likely than men to think all are very important apart from inconvenience, purpose of travel and cost where views on importance are similar for both men and women. Complete details can be found in the table below.

Q018. Thinking about travel health recommendations to protect you from getting sick on an international trip (e.g. vaccines required, medications needed, or preventative measures like insect repellent), how important are the following when deciding to follow the recommendation?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

2.5.3. Risk Mitigation During Trip Planning

Nearly all (94%) international travellers report undertaking a variety of risk mitigation activities prior to embarking on a trip. Just over half (58%) purchase or have existing travel health insurance. Approximately half, research health risks present at their destination (50%), obtain vaccinations required to enter the country (49%), ensure their routine vaccinations are up-to-date (48%) and/or get the recommended vaccinations for their destination (46%). Fewer get advice on how to protect themselves against health risks at their destination (42%) or see a health care professional (40%), visit a travel health clinic (22%) or consult a pharmacist (20%). This is expected given the lower perceived importance placed on travel health clinics and pharmacists. Few international travellers sign up with the Registration of Canadians Abroad (ROCA) service (14%) or download the Travel Smart app (8%).

Older international travellers (55+) and those born in Canada are more likely than their younger or Canadian born counterparts to undertake most risk mitigation activities prior to travel. The exceptions being visiting a travel health clinic, consulting a pharmacist, signing up with ROCA and/or downloading the Travel Smart app where incidence is similar regardless of age or where they were born. Women are more likely than men to purchase or have existing travel health insurance (63% vs 53%), research health risks present at their destination (53% vs 45%) and get advice on how to protect themselves against health risks at their destination (44% vs 39%).

The further one plans their trip in advance, the more likely they are to undertake many risk mitigation activities. Those who look for heath risk information are also more likely to undertake all of the risk mitigation activities. Complete details can be found in the tables below.

Q023. When preparing for an international trip, which of the following do you typically do before you go? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

Q023. When preparing for an international trip, which of the following do you typically do before you go? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

Among those who do not typically visit a health care professional or go to a travel health clinic (50%), a variety of reasons were cited. Many of these include reasons or beliefs that focus on already being prepared for or aware of the risks associated with their travel such as:

• Being up-to-date on all vaccines (35%);
• A perception that there are no health risks associated with their travel plans (31%);
• Travelling to the same place(s) often (30%);
• A perception of low or no health risks because they are generally healthy (29%); and
• A belief that they are already aware of the health risks associated with their travel plans (26%).

Nearly one-in-five (19%) do not see a health care professional or travel health clinic prior to travel because they are not concerned about getting sick on their trip (19%), while fewer cite costs that they do not to want to pay for or cannot afford (9%), lack of time (7%) or lack of available appointments (7%). A small percentage (3%) cited other reasons, including that they did not think of it at the time, that they did not know they should be concerned, or that it depended on the country they were visiting.

Q024. Why don't you typically see a health care professional (doctor or nurse) or visit a travel health clinic before an international trip? Select all that apply.

* Less than 0.5%

2.5.4. Risk Mitigation During Travel

Virtually all international travellers (98%) reported undertaking at least some risk mitigation activities to protect their health during their trip. Approximately three-quarters clean their hands regularly (78%) and/or practice safe eating and drinking habits (76%). Two-thirds avoid close contact with sick individuals (67%) and/or protect themselves from insect bites (65%), while just over half practice proper coughing and sneezing etiquette (57%) and/or avoid close contact with wild animals (56%). Many also protect themselves from sexually transmitted infections (45%) and/or avoid close contact with domesticated animals (43%).

For the most part, older international travellers (55+) are more likely than their younger counterparts to undertake all of the above risk mitigation activities while travelling except for protecting themselves from sexually transmitted infections where younger international travellers (18-34) are more likely than their older counterparts to protect themselves from sexually transmitted infections (54% vs 35-43%) while travelling. Women are also more likely than men to undertake all of the identified risk mitigation activities while travelling, except for protecting themselves from sexually transmitted infections and avoiding contact with domesticated animals where men and women take these precautions at a similar rate.

Interestingly, those who typically undertake volunteer/humanitarian travel, business or education/research travel are less likely to undertake some of the risk mitigation activities listed compared to those who travel for tourism/pleasure or to visit friends and family. Additionally, the further in advance one books their travel, the more likely they are to practice all risk mitigation activities apart from protecting themselves from sexually transmitted infections where incidence is similar regardless of when they book their trip.

Those who look for travel health risks are more likely to undertake most risk mitigation activities while travelling compared to those who do not look for travel health risks.

Q025. When travelling internationally, which of the following do you typically do to protect your health during your trip? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

* Less than 0.5%

Q025. When travelling internationally, which of the following do you typically do to protect your health during your trip? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

* Less than 0.5%

** Caution: Low base <30

Q025. When travelling internationally, which of the following do you typically do to protect your health during your trip? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

2.5.5. Barriers to Following Health Recommendations

Several barriers exist that prevent international travellers from following travel health recommendations. In fact, more than half (53%) of international travellers cited at least one reason that prevented them from following travel health recommendations in the past. The reasons indicated for this vary, with no single reason preventing a large portion of international travellers. Some (15%) international travellers believe the risk was too low to warrant taking the advice or they did not agree with recommendations (5%). Others (14%) were unaware of the recommendation(s), were worried about the side effects (10%) or didn't realize their vaccination(s) expired (8%). A number of international travellers cited time-related barriers such as not having enough time for the recommended vaccines or medications to take effect before their trip (8%), not having enough time to get the recommended vaccinations or medications (8%), not having enough time to see a travel health care professional or go to a travel health clinic (7%) and/or that there were no available appointments prior to their travel (5%).

Some international travelers (10%) reported cost-related barriers such as believing the cost was too high compared to the risk and/or that they could not afford the cost of the recommendations (6%). Lastly, a small portion (6%) reported that the recommended vaccines/medications were not available.

Some groups are more likely to experience barriers to following travel health recommendations than others. More specifically:

• Younger international travellers (18-34) tend to report higher incidences of all barriers compared to their older counterparts. In fact, as the traveller ages they are more likely to report no barriers (30% for those 18-34 vs 75% for those 71+);
• Men are more likely to report barriers than women (56% vs 49%);
• International travellers who were not born in Canada report more barriers than those who were born in Canada (59% vs 50%);
• Travellers for volunteer/humanitarian work, business, education/research and adventure are more likely to experience barriers compared to travellers for tourism/pleasure and/or for visiting friends and family (63-79% vs 48-56%); and
• Those who book their trips closer to their departure date (3 weeks or less) are more likely to cite barriers compared to those who book it further out (79-86% vs 37-60%);

Q021. What, if anything, has prevented you from following travel health recommendations in the past? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

* Less than 0.5%

Q021. What, if anything, has prevented you from following travel health recommendations in the past? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

** Caution: Low base <30

Q021. What, if anything, has prevented you from following travel health recommendations in the past? Select all that apply.

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

* Less than 0.5%

2.5.6. Travelling to Receive Medical Services

Just over one-in-ten (13%) international travellers have travelled internationally to receive medical services, including consultations, treatment and care, or surgery. Several types of international travellers are more likely to have travelled for medical services including:

• Younger international travellers (18-34) (25%) vs their older counterparts (5-12%);
• Men (16%) vs women (11%);
• International travellers who were born outside of Canada (17%) vs those born in Canada (12%);
• Those who travel for volunteer/humanitarian work, business, education/research and/or adventure compared to those who primarily travel for tourism/pleasure or to visit friends and family (20-43% vs 10-14%).

Forty-one percent of those who have travelled internationally for medical services did so following consultations from their physician in Canada, while a similar proportion did so based on their own research or advice from a friend or relative (40% each). A small portion (4%) cited other reasons.

Q027. Have you ever travelled outside of Canada and the United States, including Alaska and Hawaii, to receive medical services, including consultations, treatment and care, or surgery?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

Q027. Have you ever travelled outside of Canada and the United States, including Alaska and Hawaii, to receive medical services, including consultations, treatment and care, or surgery?

Note: Capital letters denote statistically significant difference. For example, if there is a B then the result is significantly higher than the corresponding result in column B.

** Caution: Low base <30

Q028. How did you decide to receive medical services, including consultations, treatment and care, or surgery? Select all that apply.

3. Appendix A: Methodology

Survey Administration

The online survey was conducted using computer assisted web interviewing (CAWI) technology. CAWI ensures the interview flows as it should with pre-programmed skip patterns. It also controls responses to ensure appropriate ranges and data validity. Surveys were conducted in English or French as chosen by the respondent. All participants were informed of the general purpose of the research, the sponsor, the supplier and that all of their responses would be confidential.

The online survey was conducted from March 14 to March 26, 2019. In total 2,000 surveys were completed. The average survey length was 15 minutes.

Pre-test

A pre-test was undertaken on March 13, 2019 obtaining 10 English and 10 French completions, including probing questions. The results were reviewed to ensure the survey was working as expected and that the questions were being interpreted as expected. Based on the results of the pre-test, no changes were required and as such the results of the 20 completes were included in the final data set.

Sample Design and Selection

A regionally disproportionate sample of Canadians was drawn from the Kantar proprietary panel to achieve 2,000 completed surveys among the target groups. The sample was stratified to ensure regional quotas were met. As stated previously, we obtained 1,000 completions among past 12-month travellers outside of Canada and the United States, including Alaska and Hawaii and 1,000 completions among those who plan to travel outside of Canada and the United States, including Alaska and Hawaii in the next 12 months. It was possible for respondents to fall into both categories of travellers, however, there was a minimum of 1,000 past travellers and 1,000 future travellers for a total of 2,000 completions overall.

Margin of Error

As mentioned previously, panel sample was used for this survey. Panel surveys are considered a non-probability sample and as such margin of error does not apply and conclusions from these results cannot be generalized to any population.

Data Analysis

Analysis was undertaken to establish differences between the total population that was surveyed and a number of demographics within this group. More specifically analysis was undertaken to identify any differences based on age, gender, region, education, born in or outside of Canada, trip purpose, travel party composition, past or future 12-month traveller, accommodation typically booked, travel frequency, influence of health risk on travel destination and whether or not travellers look for health risks. Exact breaks can be found in the detailed tables. Only differences significant at the 95% confidence level are presented in this report. Any differences that are statistically significant (t-test) between these subgroups are indicated by denoting the column letter within the tables throughout the report.

Weighting

Weighting adjustments were not made within this survey due to the fact that no national data is currently available on Canadian international travellers.

Online Completion Rate

A total of 47,537 invitations were sent to panelists, of which n=2,000 completed the survey. The overall completion rate achieved for the online study was 4%. The following table outlines the sample disposition and response rate as per the former MRIA guidelines².

Tabulated Data

Detailed tables are included under a separate cover.

Appendix B: Survey Instrument

Introduction

Thank you for agreeing to take part in our survey. Kantar TNS is currently conducting a survey on behalf of the Government of Canada about travel health. The information collected will be used to inform and develop public policy.

Your participation in this survey is voluntary and your responses will be kept anonymous. Your decision on whether to participate will not affect any dealings you may have with the Government of Canada. The survey will take about 15 minutes to complete.

Should you wish to verify the legitimacy of this survey you may contact Patrick Kasparian at Patrick.Kasparian@kantar.com.

What about your personal information?

The personal information you provide to the Public Health Agency of Canada is governed in accordance with the Privacy Act and is being collected under the authority of Section 4 of the Department of Health Act in accordance with the Treasury Board Directive on Privacy Practices. We only collect the information we need to conduct the research project.

Purpose of collection: We require your personal information such as demographic information to better understand the topic of the research. However, your responses are always combined with the responses of others for analysis and reporting; you will never be identified.

For more information: This personal information collection is described in the standard personal information bank Public Communications – PSU 914, in Info Source, available online at www.infosource.gc.ca.

Your rights under the Privacy Act: In addition to protecting your personal information, the Privacy Act gives you the right to request access to and correction of your personal information. For more information about these rights, or about our privacy practices, please contact Health Canada's Privacy Coordinator at 613-948-1219 or hc.privacy-vie.privee.sc@canada.ca. You also have the right to file a complaint with the Privacy Commissioner of Canada if you think your personal information has been handled improperly.

What happens after the online survey?

The final report, written by Kantar TNS, will be available to the public from Library and Archives Canada http://www.bac-lac.gc.ca/.

Your assistance is greatly appreciated, and we look forward to receiving your feedback.

[Embed at bottom Kantar TNS Privacy Policy: www.tnscanada.ca/privacy-policy.html]

Screener

Language

Preferred language:
Langue préférée :

• English/Anglais
• Francais/French

Gender

1. Are you…

• Male gender
• Female gender
• Gender diverse
• Prefer not to say

Age

2. In what year were you born?

[PROGRAMMING INSTRUCTION: TERMINATE IF GREATER THAN 2001]

Province or Territory

3. In which province or territory do you live?

• Alberta
• British Columbia
• Manitoba
• Newfoundland and Labrador
• New Brunswick
• Northwest Territories
• Nova Scotia
• Nunavut
• Ontario
• Prince Edward Island
• Quebec
• Saskatchewan
• Yukon Territory
• Prefer not to say - Terminate

Trip in P12M

4. In the past 12 months, have you taken a trip outside of Canada and the United States, including Alaska and Hawaii, that lasted one or more nights to any of the following regions?

Select all that apply

• Territories of the United States (Puerto Rico, Guam, US Virgin Islands, etc.)
• Europe
• Central America and Mexico
• South America
• Caribbean
• Middle East
• Africa
• Asia
• Australia or New Zealand
• Other Pacific Islands (Fiji, Tahiti, Papua New Guinea, etc.)
• Elsewhere, please specify:
• I have not taken a trip outside of Canada and the United States in the past 12 months

Trip in N12M

5. In the next 12 months, do you plan to take a trip outside of Canada and the United States, including Alaska and Hawaii, that will last one or more nights to any of the following regions?

Select all that apply

• Territories of the United States (Puerto Rico, Guam, US Virgin Islands, etc.)
• Europe
• Central America and Mexico
• South America
• Caribbean
• Middle East
• Africa
• Asia
• Australia or New Zealand
• Other Pacific Islands (Fiji, Tahiti, Papua New Guinea, etc.)
• Elsewhere, please specify:
• I do not plan to take a trip outside of Canada and the United States in the next 12 months

[PROGRAMMING INSTRUCTION: TERMINATE IF DID NOT TRAVEL OUTSIDE OF CANADA AND THE UNITED STATES, INCLUDING ALASKA AND HAWAII IN Q4 AND Q5]

International traveller

Attitudes, awareness and behaviours

DISPLAY: The next few questions are about travel to international destinations — that is, travel outside of Canada and the United States, including Alaska and Hawaii.

Agreement attitudes

6. Please indicate the extent to which you agree or disagree with the following statements.

Scale:

• Completely agree
• Somewhat agree
• Neither agree nor disagree
• Somewhat disagree
• Completely disagree

Items:

[RANDOMIZED]

• All international travellers should see a health care professional (doctor or nurse) before they travel.
• An appointment should be booked with a health care professional at least 6 weeks before going on an international trip.
• Travelling internationally poses health risks that are not present in Canada.
• When entering Canada, you must report to a Customs or Border Services Officer if you have, or suspect you have, an infectious disease or illness or have been close to someone with an infectious disease or illness.
• If you become ill after returning home from an international trip, you should see your doctor as soon as possible and inform them that you have been travelling.

Scripter notes:

2 instances At Stub 4- make popup of "infectious disease or illness" with this text:

For the purpose of this survey, an infectious disease or illness is a disorder of the body caused by germs, such as bacteria, viruses, fungi or parasites. For example, the flu, Zika, malaria or measles.

Consideration of health risks

7. When deciding to travel to an international destination, when do you look for health risks and associated travel health recommendations (e.g., vaccines required, medications needed or preventative measures) related to the destination?

• The week before I travel
• 2-3 weeks before I travel
• 4-6 weeks before I travel
• More than 6 weeks before I travel
• I do not typically look for this information before travelling.

8. [PROGRAMMING INSTRUCTION: SKIP "IF I DO NOT TYPICALLY" IS CHOSEN IN Q7] Under what circumstances would you look at the health risks before travelling to an international destination?

[RANDOMIZED]

• I look every time I travel- [FIXED, EXCLUSIVE]
• When I am travelling to the destination for the first time
• When I hear about health risks in the news or on social media
• When I hear about health risks from family or friends
• When I am travelling to places that I believe have health risks
• When I think of it
• When I have enough time
• Other, please specify: [FIXED]

9. To what extent do health risks influence your choice of travel destination?

• To a great extent
• To a moderate extent
• To a small extent
• Not at all
• Don't know

DISPLAY: We would like to understand at what point you would change your travel destination or follow travel health recommendations based on a risk to your health.

10. If you were travelling to a destination where there is a known infectious disease or illness, how likely are you to follow travel health recommendations? For the purpose of this survey, an infectious disease or illness is a disorder of the body caused by germs, such as bacteria, viruses, fungi or parasites. For example, the flu, Zika, malaria or measles

Scale:

• I would definitely follow the recommendations
• I would probably follow the recommendations
• I may or may not follow the recommendations
• I would probably not follow the recommendations
• I would definitely not follow the recommendations

Level of importance of knowledge

11. When travelling to an international destination, how important is it to you to know about:

Scale:

• Very important
• Moderately important
• Slightly important
• Not at all important

Items:

[RANDOMIZED]

• Infectious diseases or illness you can get from other people
• Infectious diseases or illness you can get from food and water
• Infectious diseases or illness you can get from insects
• Infectious diseases or illness you can get from animals
• Vaccinations recommended to prevent diseases that occur at the destination
• Vaccinations required to enter the country

Scripter notes: Make popup of "infectious disease or illness" with this text:

For the purpose of this survey, an infectious disease or illness is a disorder of the body caused by germs, such as bacteria, viruses, fungi or parasites. For example, the flu, Zika, malaria or measles.

Level of importance of activity

12. When travelling to an international destination, how important do you think it is to do the following before you travel?

Scale:

• Very important
• Moderately important
• Slightly important
• Not at all important

Items:

[RANDOMIZED]

• Look for health risks that are present at your destination (e.g., infectious diseases or illness)
• Follow travel health recommendations on how to protect yourself against health risks that are present at your destination
• Purchase or have existing travel health insurance
• Visit a travel health clinic
• Make sure your routine vaccinations are up-to-date
• Obtain recommended vaccinations to prevent diseases that occur at the destination
• See a health care professional (doctor or nurse)
• Consult a pharmacist

Scripter notes: Make popup of "infectious disease or illness" with this text:

For the purpose of this survey, an infectious disease or illness is a disorder of the body caused by germs, such as bacteria, viruses, fungi or parasites. For example, the flu, Zika, malaria or measles.

Why travel health risk research is not important

13. [PROGRAMMING INSTRUCTION: ASK ONLY THOSE WHO SELECTED NOT IMPORTANT FOR "LOOKING FOR HEALTH RISKS…" IN Q12] You indicated that looking for health risks present at your destination was not important. Can you please tell us why this is not important to you?

OPEN

Level of importance of risk factors in following advice

14. Thinking about travel health recommendations to protect you from getting sick on an international trip (e.g., vaccines required, medications needed, or preventative measures like insect repellent), how important are the following when deciding to follow the recommendation?

Scale:

• Very important
• Moderately important
• Slightly important
• Not at all important

Items:

[RANDOMIZED]

• The likelihood of spreading illnesses to loved ones and others when I return
• How well the recommended actions will work
• Possible side effects of the recommended actions
• Cost of the recommended actions
• Inconvenience of taking the recommended actions before my trip
• Inconvenience of taking the recommended actions during my trip
• Familiarity with or frequency of travel to the destination
• Purpose of travel (e.g., pleasure or business trip)
• The type of activities I plan to do on my trip

Information research practices

15. When you look for information to plan or book travel to an international destination, where do you look?

Select all that apply

[RANDOMIZED]

• Internet search engines (e.g. Google)
• Travel websites (e.g. Trip Advisor, Lonely Planet, etc.)
• Travel blogs
• Online booking websites (e.g. Expedia, Trivago, Airbnb, etc.)
• Travel providers directly (e.g. airlines, tour companies, vacation packages, etc.)
• Travel agents
• Travel magazines or books
• Government websites
• Friends and family
• Other, please specify: [FIXED]

Sources of trusted information

16. Which of the following sources do you trust to have accurate information about your health when travelling?

Select all that apply

[RANDOMIZED]

• Internet search engines (e.g. Google)
• Travel websites
• Travel agents
• Travel magazines or books
• Government of Canada websites [PROGRAMMING NOTE: KEEP GOVERNMENT WEBSITES TOGETHER]
• Provincial government websites
• United States government websites
• Other country government websites
• Friends and family
• Travel health clinic
• Health care professional (doctor, nurse)
• Pharmacy or pharmacist
• Travel Apps
• International agencies (e.g. World Health Organization, Red Cross, etc.)
• Other, please specify: [FIXED]

Barriers

17. What, if anything, has prevented you from following travel health recommendations in the past?

Select all that apply

[RANDOMIZED]

• I was unaware of the recommendation(s) I should follow
• I didn't realize my vaccination(s) expired
• The recommended vaccines or medications were not available
• I was worried about the possible side effects of the recommended vaccines or medications
• I did not have the time needed to get the recommended vaccinations or medications
• There was not enough time for the recommended vaccines or medications to take effect before my trip
• I did not have the time to see a travel health care professional (doctor or nurse) or go to a travel health clinic
• There were no available appointments for me to see a travel health care professional.
• I felt the cost was too high compared to the risk
• I could not afford the cost of the recommendations
• I did not agree with the recommendations
• I felt the risk was too low to warrant taking the advice
• Other, please specify: [FIXED]
• Nothing has prevented me from following travel health recommendations in the past [FIXED UNIQUE CHOICE]

Risk perceptions

18. Please indicate the level of health risk you would generally associate with the following types of travel.

Scale:

• High
• Medium
• Low
• No risk

Items:

[RANDOMIZED]

• Travelling to a familiar destination (e.g. going back to where you were born)
• Travelling to a destination that you visit frequently
• Travelling to visit family or friends
• Travelling for tourism or pleasure
• Travelling for volunteer or humanitarian work
• Travelling for business
• Travelling for education or research
• Adventure travel

Trip preparation actions for travel in P12M

19. When preparing for an international trip, which of the following do you typically do before you go?

Select all that apply

[RANDOMIZED]

• Research health risks that are present at your destination (e.g., infectious diseases or illness)
• Get advice on how to protect yourself against health risks that are present at your destination
• Purchase or have existing travel health insurance
• Visit a travel health clinic
• Make sure your routine vaccinations are up-to-date
• Obtain recommended vaccinations to prevent diseases that occur at the destination
• Obtain vaccinations required to enter the country
• See a health care professional (doctor or nurse)
• Consult a pharmacist
• Download the Travel Smart app
• Sign up with the Registration of Canadians Abroad (ROCA) service
• None of the above [FIXED POSITION]

Scripter notes: At Stub 1- make popup of "infectious disease or illness" with this text:

For the purpose of this survey, an infectious disease or illness is a disorder of the body caused by germs, such as bacteria, viruses, fungi or parasites. For example, the flu, Zika, malaria or measles.

Why not seeing a health care professional

[PROGRAMMING INSTRUCTION: ONLY Ask Q20 if BOTH "See health care professional…" and "Visit a travel health clinic" are NOT SELECTED in Q19, otherwise skip q20]

20. Why don't you typically see a health care professional (doctor or nurse) or visit a travel health clinic before an international trip?

Select all that apply

[RANDOMIZED]

• I am not concerned about getting sick on my trip
• I am an overall healthy person
• I am up-to-date on all of my vaccines
• There are no health risks associated with my travel plans
• I travel often to the same place(s)
• I am aware of the health risks associated with my travel plans
• I do not have enough time to see a travel health care professional (doctor or nurse)
• There were no available appointments for me to see a travel health care professional
• There are costs associated with this that I do not want to pay for or cannot afford
• Other, please specify: [FIXED]

Actions during trip

21. When travelling internationally, which of the following do you typically do to protect your health during your trip?

Select all that apply

[RANDOMIZED]

• Protect myself from insect bites (e.g. insect repellent, use bed nets, etc.)
• Clean hands regularly (with soap and water or hand sanitizer)
• Practice proper coughing and sneezing etiquette
• Practice safe eating and drinking habits
• Avoid close contact with sick individuals
• Protect myself from sexually transmitted infections (e.g. use condoms consistently and correctly with new partners or avoid activities where body fluids are exchanged)
• Avoid close contact with domesticated animals (e.g. pets, farm animals)
• Avoid close contact with wild animals
• Other, please specify: [FIXED]
• None of the above

Trip purpose

22.When travelling internationally, do you typically travel for:

Select all that apply

Items:

[RANDOMIZED]

• Tourism or pleasure
• Visiting friends or relatives
• Volunteer or humanitarian work
• Business
• Education or research
• Adventure
• Other, please specify: [FIXED]

23. Have you ever travelled outside of Canada and the United States, including Alaska and Hawaii, to receive medical services, including consultations, treatment and care, or surgery?

• Yes
• No

If Q23= Yes

24. How did you decide to receive medical services, including consultations, treatment and care, or surgery?

Select all that apply

Randomize

• Following consultation with my physician in Canada
• Based on my own research
• Based on advice from a friend or relative
• Other (specify): *Open *Fixed

TRAVEL COMPOSITION

25. Who typically travels with you when you travel internationally?

Select all that apply

Items:

[RANDOMIZED]

• I travel alone
• Spouse or significant other
• Child (under 18 years old)
• Child (18 years old or older)
• Parent(s)
• Grandparent(s)
• Other family members
• Friend(s)
• Co-workers
• Other, please specify: [FIXED]

Where travellers stay

26. Where do you typically stay when you travel internationally?

Select all that apply

Items:

[RANDOMIZED]

• Resort
• Hotel
• Privately-owned house or apartment rental (e.g. vacation rental property)
• With friends
• With family
• Hostel
• Camping
• Other, please specify: [FIXED]

When trip planned

27. How far in advance do you typically book your travel arrangements for international trips?

• One week or less before travelling
• 2-3 weeks before travelling
• About a month before travelling
• 2-3 months before travelling
• 4 months or longer before travelling

Demographics

DISPLAY: The next few questions are for classification purposes only.

Frequency of Travel

28. Approximately, how often do you take international trips — that is, trips outside of Canada and the United States, including Alaska and Hawaii?

Items:

• Less than 1 trip every three years
• 1 trip every three years
• 1 trip every two years
• 1 trip per year
• 2 trips per year
• 3+ trips per year

Education

29. What is the highest level of formal education you have completed?

• Less than high school
• High school diploma or equivalent
• Registered Apprenticeship or other trades certification or diploma
• College, CEGEP or other non-university certificate or diploma
• University certificate or diploma below bachelor's level
• Bachelor's degree
• Post graduate degree above bachelor's level
• Prefer not to say

Born in Canada

30. Were you born in Canada?

• Yes
• No
• Prefer not to say

How long in Canada

[PROGRAMMING INSTRUCTION: ONLY ASK HOW LONG IN CANADA, IF NOT BORN IN CANADA]

31. How many years have you lived in Canada?

• Less than 5 years
• 5-9 years
• 10-19 years
• 20-29 years
• 30 or more years
• Prefer not to say