A Questionnaire Study of Voluntary Service Overseas (VSO) Volunteers: Health Risk and Problems Encountered

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1 I S T M 332 A Questionnaire Study of Voluntary Service Overseas (VSO) Volunteers: Health Risk and Problems Encountered Prakash Bhatta, MSc, Padam Simkhada, PhD, Edwin van Teijlingen, PhD, and Susanna Maybin, MFTM RCPS (Glas) Division of Applied Health Science, School of Medicine and Dentistry, University of Aberdeen, Scotland, UK; School of Health & Social Care, Bournemouth University, UK; Voluntary Service Overseas (VSO), Medical Unit, London, UK DOI: /j x Background. Every year several hundred Voluntary Service Overseas (VSO) volunteers are placed in developing countries where they live and work among the local population. This study analyzes the risk and problems encountered by VSO volunteers overseas. Methods. Information was collected from 219 returned VSO volunteers (out of 609; response rate 36%) recruited in the United Kingdom, using a self-administered questionnaire. During the period April 2006 to March 2007 volunteers were given a questionnaire by the VSO medical unit in London with a return envelope. Results. Diarrhea was the most prevalent problem (79.9%), especially for the younger volunteers. Skin and dental problems were next most prevalent. More than one in six had experienced accidents and nearly one-fourth acts of aggression (including verbal) or violence. Most (87.5%) lived in regions with mosquito-borne diseases, 11.6% of these had smear positive malaria. Of all volunteers, 11.0% had placed themselves at risk of HIV and sexually transmitted infections (STIs). Unprotected sexual intercourse (45.0%) and split condoms (30.0%) were the main sexual health risk factors. Just over one-fourth of volunteers reported ongoing medical/psychological problems on return, the most common being diarrhea (25.0%), skin disease (15.4%), gynecological problems (13.5%), and injuries (9.6%). Conclusion. Volunteers experience a range of health problems during and after their placement in the developing world. Our study shows the importance of (1) predeparture health preparation of volunteers and (2) medical care and advice for volunteers. This advice is also important for travelers in similar conditions such as those visiting relatives, long-term backpackers, and students working in or traveling to developing countries. Further research is needed to help explain some of the findings and study ways of preventing accidents and illness. Worldwide over 100,000 nongovernmental sponsored volunteers work in developing countries. 1 Since the inception of Voluntary Service Overseas (VSO) in 1958, approximately 30,000 volunteers have served in over 70 developing countries. 2 VSO has recruitment bases in the United Kingdom, the Netherlands, Canada, the Philippines, Kenya, and India. In 2006 VSO sent 1,748 volunteers to 35 of the world s poorest countries; 226 were youth volunteers working alongside partner organizations. 3 Travel brings new experiences, but it also brings potential health problems. VSO volunteers are placed mainly in countries of Africa and Asia where health facilities are under-resourced and illnesses such as diarrhea, malaria, hepatitis A, sexually transmitted Corresponding Author: Padam Simkhada, PhD, Section of Population Health, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD Scotland, UK. p.p.simkhada@abdn.ac.uk infection (STI), and HIV are highly prevalent. Therefore, health preparation of the volunteer predeparture and how medical support is to be accessed locally should be the significant aspects of all placements. Hence it is important to study the morbidity of volunteers whilst overseas and on return, so that appropriate advice and support can be given predeparture, overseas, and on return. The advantage of studying VSO volunteers rather than gap-year students, those visiting friends and relatives (VFRs), or long-term backpackers, is that VSO volunteers have a predeparture assessment, whilst other groups of long-term travelers to developing countries are far less easy to capture as research participants. However, the findings will be highly relevant to health care professionals giving advice to other groups of travelers living under similar basic conditions abroad and to these travelers themselves. All volunteers require to be medically cleared by the VSO medical advisor before going overseas. A medical check is carried out by the family doctor and the VSO medical advisor obtains additional information 2009 International Society of Travel Medicine, Journal of Travel Medicine 2009; Volume 16 (Issue 5):

2 Health Risk and Problems Encountered by VSO Volunteers 333 where relevant, matching this up with the conditions and medical facilities at the volunteer s placement. The medical unit is made up of a small team of medical and nursing advisors with administrative support. Medical clearance is only one of the functions of the medical unit; preparing volunteers before their departure and medical support to them whilst overseas are also key functions. Volunteers can be turned down on medical grounds, but much work is undertaken to try and find placements medically suitable and ways to support volunteers medically at these placements. Objectives The specific objectives were to establish the common health problems encountered by VSO volunteers (1) during their placement and (2) after returning home. Methods A confidential health questionnaire for returned volunteers (who came through the UK recruitment base) was drawn up by the VSO Medical Unit in London. The questionnaire was based on problems which staff at the Medical Unit had come across over the years as well as common problems amongst expatriates. 4 As part of a pilot study 5,6 40 UK-recruited returned volunteers were asked to complete a questionnaire, comment on its layout, any difficulties in completing and their general impressions of it. Minor changes were made to the questionnaire subsequently. This questionnaire was included with an information pack on resettlement routinely sent to all returning UK-recruited volunteers. A copy of the questionnaire is available from the authors. Volunteers were asked to complete this anonymously and return it by mail to the London-based VSO Medical Unit. A stamped preaddressed envelope was included. Returned questionnaires were checked for completeness; if volunteers had completed background/demographic information it was included regardless of the level of completion of the substantive health questions. Data from sufficiently completed questionnaire were entered to SPSS. Descriptive statistics and chi-square tests were used to analyze the data. Results A total of 609 UK-recruited returning volunteers (April 2006 to March 2007) were sent a questionnaire, 4 of whom 219 returned the completed questionnaire by post; response rate 36.0%. Of the 219 volunteers, 115 (52.5%) were aged between 26 and 45 years (median age group years) and most (69.4%) were female. More than three out of five volunteers had worked in urban or semi-urban areas (Table 1). Just over onethird of volunteers had worked as advisors, and most Table 1 Demographic characteristics of respondents Characteristics % N Gender (n = 219) Male Female Age group (n = 219) Below Older than Location of Urban placement Semi-urban (n = 219) Rural Occupation during Advisor placement Teaching (n = 217) Training Doctor/Nurse Community worker Engineering Area (n = 206) North Africa Sub-Saharan Africa Asia (South) Asia (East) Asia (North) Oceania South America Duration of service 12 months or less (n = 218) More than 12 months were teachers, health workers, and community workers. A small majority had been placed for more than 1 year. The duration of time on location varied from as short as a few weeks (for two people who returned early due to illness) to more than 5 years. For the purpose of analysis the findings are presented here around the volunteers preexisting health condition, illness overseas, and illness upon return from volunteering. Preexisting Health Conditions Approximately one in five volunteers (n = 42) were on regular medication before their placement; of these 31.0% were on asthma medication. Nearly half of all volunteers with preexisting medical conditions had fewer problems whilst at placement than before in the United Kingdom and only 10.0% had to take time off work because of a preexisting problem. Five (13.0% of those with preexisting medical conditions) had difficulty managing their health condition at their placement. Illness Overseas Many (175; 79.9%) suffered from diarrhea whilst on placement. Also 51.8% reported illnesses other than diarrhea; of these, skin problems (40.4%) and dental problems (22.8%) were the most common. Few volunteers suffered from multiple problems, such as a combination of skin/dental, dental/gynecological, and skin/chest problems.

3 334 Bhatta et al. Diarrhea The prevalence of diarrhea was more than four times higher than any other problem, but only 29.7% underwent stool testing. Giardia lamblia was detected in one in five volunteers tested. Seven of those tested (13.5%) had negative results. The remainder was diagnosed as food poisoning, dysentery, or worms. Seven volunteers were treated with antibiotics and the rest reported using other kinds of unspecified medication. More women reported diarrhea than men but the difference was not statistically significant (p = 0.086). Volunteers in the age group 46 and older were significantly less likely to report having experienced diarrhea (p = 0.016). There was no association between the reporting of diarrhea and length of time spent overseas. Approximately 40% of those suffering from diarrhea had more than four episodes (29.0% of total respondents) and 47.0% of volunteers with diarrhea experienced interference with work. Few (5.9% total respondents) missed more than a week of work due to diarrhea. Security and Accidents About one in six respondents (17.5%) was involved in or affected by an accident, mostly road traffic accidents (83%). Nearly one-fourth of respondents (42; 24.0%) reported exposure to an act of aggression (including verbal) or violence, 18 more than once. The main cause of violence was being mugged (18; 46.2%) and nine people (23.1%) experienced police violence and political unrest. Of those volunteers who experienced an act of aggression most (77.2%) informed the VSO. Malaria One in nine volunteers (22; 11.6%) living in an area of mosquito risk suffered from smear positive malaria, half of these more than once. Age and gender were not significantly associated with the chance of getting malaria; however volunteers who were younger, male, and placed in rural and semi-urban locations were more likely to report malaria than those who were older, female, and placed in urban areas. Most respondents, 189 of 216 (87.5%), were placed in areas with malaria and mosquito-borne diseases. Side effects were reported by 42.0% of volunteers taking prophylaxis, but most found these tolerable. Adverse effects included vivid dreams, headaches, hair loss, sleep problems, and nausea. Unfortunately we do not know from this study what type of chemoprophylactic agents were used at the time by these volunteers. Headaches, hair loss, sleep problems, and nausea were also reported. Most volunteers at risk of malaria (71.7%) slept under an impregnated mosquito net. Concern about side effects and long-term use were the most common reasons given by VSO volunteers for not taking appropriate malaria prophylaxis. Exposure to HIV and STIs A total of 215 volunteers answered HIV- and STIsrelated questions and 11.1% were concerned that they had placed themselves at risk. Unprotected sexual intercourse was the most commonly reported reason. Among these 24, most (81.8%) reported having sought advice. The main source of medical advice was a local medical advisor (58.8% of these cases), followed by the VSO Medical Unit and friends, after a high-risk contact while stationed overseas. Table 2 shows that there was no difference between those who were concerned that they had placed themselves at an increased risk of getting HIV or STIs in terms of gender, location, and duration of placement. However, there was an association between an increased likelihood of placing oneself at risk of HIV/STIs and age with the greatest risk in the age group years (p = 0.016). Illness upon Return from Volunteering Over one-fourth (27.0%) of volunteers reported ongoing or unresolved medical/psychological problems on return from their placements (Table 3). Diarrhea, skin disease, and gynecological problems were the most frequent medical problems reported. No association was found between medical problems on return with gender, age, or destination. The majority with ongoing problems (65.5%) had already seen a doctor and most of these volunteers (62.1%) had received medication. Discussion Diarrhea was the most prevalent health problem in our study; however older VSO volunteers were significantly Table 2 Risk of HIV/STIs stratified by demographic characteristics and destinations Variables Have risk P value Age (n = 215) Below 25 3 (10.0%) (16.1%) Above 46 2 (2.7%) Gender (n = 215) Male 7 (10.6%) Female 17 (11.4%) 1.00 Region (n = 202) North Africa 11 (11.7%) Sub-Saharan Africa 5 (26.3%) South Asia 1 (2.7%) East Asia 3 (12.0%) South America North Asia 2 (11.1%) Oceania Duration of placement (n = 214) 12 months or less 11 (11.2%) More than 12 months 11 (9.5%) 0.848

4 Health Risk and Problems Encountered by VSO Volunteers 335 Table 3 Returning respondents with unsolved health problems Problems (n = 52) N % Diarrhea (including those tested for Giardia lamblia) Skin problem Gynecological problems Injuries Malaria STIs (including HIV) Kidney pain Hypertension Dental Thyroid Respiratory/chest problem Depression Hernia Hepatitis C Inflammatory bowel syndrome (IBS) Total less likely to report having had diarrhea. A recent study of Scottish travelers also found that age was a highly significant risk factor for diarrhea. Younger travelers (age <20 years) were at a higher risk than older ones. 7 However, an earlier study found that people younger than 30 were not at a significantly increased risk of diarrheal infection. 8 Our study also found that time spent overseas seemed to be negatively correlated with risk although this finding was not statistically significant. The Peace Corps study also noted that the risk of diarrheal illness decreased in incidence as the length of stay increased. 8 Our study suggests that diarrheal problems could have some negative impact on the work performed by volunteers. This means VSO need to stress in its predeployment training the need to avoid consuming risky foods and beverages as well as the need to provide advice on food preparation during placement, including the use of good ingredients. The 1989 Peace Corps study found that 60% of volunteers and 50% of short-term travelers to developing countries suffered from diarrhea. 1 Amore recent Peace Corps study in Guatemala tested 1,168 specimens and found that 38% of volunteers was positive for at least one parasite. 9 The percentage of VSO volunteers who suffered from diarrhea was considerably higher than in the Peace Corps study, suggesting an increase in risk since the latter study was conducted and/or perhaps more accurate reporting by VSO volunteers. Compared to ordinary travelers and tourists, VSO and Peace Corps volunteers (1) stay longer in developing countries; (2) are more likely to live in rural areas; and (3) live under basic circumstances. Skin and dental problems were relatively common among VSO volunteers. The 1989 Peace Corps study found that 19% suffered from bacterial skin problems and 17% from dental problems. 1 VSO volunteers had a higher proportion of skin problems than the Peace Corps volunteers and a similar proportion of dental problems. Approximately one in six volunteers was involved in, or affected by, an accident during placement, mainly road traffic accidents. Traffic accidents are the most likely cause of morbidity and mortality in travelers. 10,11 A study with Peace Corps volunteers in Africa highlighted that motorcycle injuries accounted for 60% of road accidents. 1 Nearly half of the volunteers, who had been exposed to an act of aggression or violence, had been mugged. Worldwide violence is the leading cause of death for the age group Travelers may acquire malaria from mosquitoes in some 105 countries. 13 Most VSO volunteers were placed in areas where mosquito-borne diseases are prevalent; of these 18.0% had not taken malaria prophylaxis. This is low in comparison with previous related traveler research which indicated that 60% of travelers to malaria endemic areas did not carry malaria prophylaxis. 14 A previous study among returning British travelers found that approximately 40% taking antimalarial tablets reported adverse effects. 15 Approximately 71.7% of VSO volunteers at risk from malaria slept under an impregnated mosquito net but more than one in eight at risk did not. Some volunteers live in well-screened air-conditioned accommodation and therefore a net may not have been necessary in all cases; however, as the majority has fairly basic living conditions, this does suggest that a number of volunteers had put themselves unnecessarily at risk of malaria. It has been reported that malaria may be less of a risk in urban compared with rural areas. 16 Our study showed no statistical significance in smear positive malaria attacks between volunteers in rural and urban areas, although the relatively low numbers might help explain the absence of a rural urban difference. Poor accommodation and sanitary conditions may contribute to the risk of malaria for VSO volunteers in rural areas and clearly volunteers need to be reminded of the importance of malaria prevention. Some volunteers had placed themselves at risk of HIV and STIs mainly due to unprotected sex. The proportion was lower than two studies from the early 1990s when AIDS did not pose the same risk as it does for today s travelers. 17,18 Just over half of longterm Dutch expatriates posted to AIDS endemic areas (52.0%) reported having sex with local and expatriate partners, whilst 61% of Peace Corps volunteers had at least one sexual partner during their placement and 39% had sex with a host country national. Consistent condom use with a local partner was 69.0% among the Dutch expatriates, but only 39.0% among Peace Corps volunteers. Although 23.0% of the Dutch expatriates had unsafe sex in AIDS endemic areas, very few HIV

5 336 Bhatta et al. infections were found. VSO volunteers attend a health and security workshop predeparture run by the VSO Medical Unit and are given written material covering health risks at their placements. Volunteers receive further health briefing on arrival in their placement countries and condoms are provided freely. This may contribute to the lower level of HIV/STIs risk behavior among VSO volunteers. Use of condoms was not included in the VSO volunteer study. Of the VSO volunteers who had placed themselves at risk, the majority had sought advice and more than half received advice from local medical advisors. It is important that such advice is reliable and appropriate and it would be useful to look at ways to strengthen links between VSO and local medical advisors. Halioua and colleagues found that travelers of mean age 38 years were the most sexually active, 19 describing loneliness, monotony, and a sense of freedom as possible risk factors. This is consistent with the finding that VSO volunteers aged were more likely to be concerned that they had put themselves at risk of HIV/STIs than other age groups. Both this study and the Peace Corps study found that females were more likely to be involved in sex overseas. 18,19 Duration of placement could also be one of the contributing factors, but there were no significant findings in the VSO study related to this. More than one-fourth had returned home with a medical or psychological problem, most commonly diarrhea, skin, and gynecological problems. Although the proportion of returnees with gynecological problems seems high, the reader must bear in mind that a high proportion of volunteers were female and some problems were not particularly complicated, eg, women taking doxycycline are more prone to certain vaginal infections. VSO volunteers are given written health information on return on illnesses they may have been exposed to including asymptomatic infections such as bilharzia and advised to visit their general practitioner (GP) in the first instance. Brien and colleagues reported that 15 37% of short-term travelers experienced health problems after returning home, 20 highlighting the importance of ensuring that the traveler can easily access care on return home. Our findings are limited by the low response rate (36.0%) and that those who replied may have experienced recall bias. Moreover, it covered only one cohort of volunteers; larger studies such as the Peace Corp one 21 on tuberculosis which looked at their volunteers over a 10-year period, would give more reliable data. Finally, we could not find any literature on the preexisting health problems in international volunteers to relate our findings to. Conclusion Diarrhea was the most common medical disorder among VSO volunteers during their time overseas but fewer than half underwent stool analysis. More than half of the VSO volunteers suffered from health problems other than diarrhea, especially skin and dental problems. Moreover, over one-fourth of returnees suffered from (minor) health and psychological problems. Health preparation and medical support of volunteers while at their placement is a significant aspect of any overseas placement. This study shows that attention needs to be given, in particular, to the prevention of diarrhea, personal security, malaria, accidents, HIV, and STIs. Regarding the prevention of diarrhea VSO needs to make volunteers better aware of the risks and give advice which is easily implemented, eg, separate tables for the preparation of meat and vegetables, check hygiene levels of people involved in cooking, and washing hands before eating. It would also be useful to emphasize the importance of pretravel dental care as a strategy to limit the risk for urgent dental care at the international posting. This advice is not only important for volunteers, but also will be of use to health care providers who advise VFRs, long-term backpackers, and students working in or traveling to developing countries in a gap year (between high school and university). Any return has to be an integral part of the volunteering preparation. Planning for the phase after return should be an integral part of the preplanning for VSO volunteers. It is important to monitor the volunteers health status, not only to support individual volunteers who fall ill, but also to use obtained information to improve the necessary health preparation predeparture. With refinement our questionnaire could provide a useful monitoring tool for organizations such as VSO. Furthermore, a prospective case study of a sample of volunteers may help explain some of our findings and address ways of preventing accidents and illness. Declaration of Interests S.M. is a medical advisor to Voluntary Service Overseas. The other authors state they have no conflicts of interest to declare. References 1. Bernard K, Graitcer P, Vlugt T, et al. Epidemiological surveillance in peace corps volunteers: a model for monitoring health in temporary residents of developing countries. Int J Epidemiol 1989; 18: VSO. About VSO 2007, 2007; Available at: uk/about/ (Accessed 2007 October). 3. VSO. Annual Review 2005/2006, London, UK, 2006; Available at: (Accessed 2007 October). 4. Voluntary Service Overseas. UK Medical Unit Report 2005/2006, London, VSO, Van Teijlingen E, Hundley V. The importance of pilot studies. Soc Res Update 2001; 35, Department of Sociology, University of Surrey. Available at: ac.uk/sru/sru35.htm (Accessed 2009 January). 6. Simkhada P, Bhatta P, van Teijlingen E. Importance of piloting a questionnaire on sexual health research. Wilderness Environ Med 2006; 17:

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