Travel Medicine and Infectious Disease (2012) 10, 152e156

Available online at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals / tmid

CASE REPORT

A multidisciplinary approach to engage VFRmigrants in Madrid, Spain

Miriam Navarro*, Barbara Navaza, Anne Guionnet, Rogelio Lopez-Velez

Tropical Medicine and Clinical Parasitology, Infectious Diseases Department, Ramon y Cajal Hospital, Ctra. de Colmenar,km 9.1, 28034 Madrid, Spain

Received 17 December 2011; received in revised form 2 March 2012; accepted 5 March 2012Available online 15 May 2012

KEYWORDSVFR;Visiting friends andrelatives;Health education;Malaria

* Corresponding author. Tel.: þ34 9E-mail addresses: mnavarro.hrc@s

barbaranavaza@gmail.com (B. Navaza),(A. Guionnet), rlopezvelez.hrc@salud.m

1477-8939/$ - see front matter ª 201doi:10.1016/j.tmaid.2012.03.001

Summary VFRs are at a greater risk of contracting travel-related illnesses such as malaria,and their knowledge about travel health tends to be poor. Since 2009, community-based activ-ities targeting potential and impending VFRs were performed by a multidisciplinary team inMadrid, Spain. The design and distribution of multilingual and culturally-sensitive materialfollowing a qualitative research, and intercultural mediators were key tools of the healtheducation programme.ª 2012 Elsevier Ltd. All rights reserved.

Brief report

The term VFRs refers to those travellers visiting friends andrelatives, who tend to be migrants. This population is ata higher risk for contracting travel-related illnesses whencompared to other groups of travellers.1e3 The lack of riskperception by VFRs when travelling to their countries oforigin and the consequent poor seeking for pre-travelhealth advice play a main role on it. In addition, theirlevel of knowledge about travel health tends to bepoor.4 To devise novel and adapted methods targeting

1 3368108.alud.madrid.org (M. Navarro),saludinmigracion@gmail.comadrid.org (R. Lopez-Velez).

2 Elsevier Ltd. All rights reserved

impending and potential VFRs seems crucial in order toengage them, basically for two reasons: 1) most of thetravel-related diseases they may acquire are preventable,and 2) VFRs have specific characteristics (such as languageand culture) that have to be taken into account inpreventive activities.5

It has been demonstrated that innovative and specificmethods are required to increase awareness of the need forpre-travel health advice among VFR travellers.5,6 Never-theless there are rare community-based campaigns.Recently, Leder et al.7 presented innovative activities toengage VFRs in Australia, and they should be commended.

Spain received in the past ten years more migrants thanany other country in the world, after the US.8 Currently,more than 5.7 million people in Spain (12.2% of the pop-ulation) are foreigners, and in the region of Madrid thisfigure is even higher: 17%.9 Migrants who enter the countrywith no resident permit cannot get a round trip to their

.

An approach to engage VFR migrants in Madrid 153

countries of origin to visit family and friends. Nonetheless,after living in Spain for some years, migrants have theopportunity to get this document. Thus, the number ofVFRs is expected to increase in the following years.

The Tropical Medicine Unit of the Ramon y Cajal Hospitalin Madrid, Spain, holds a pioneering health education pro-gramme adapted to migrants which also embraces activitiesaimed at VFRs. In this programme, called ‘New citizens,new patients’, activities are community-based andculturally-sensitive. It is aimed at migrants living in Spainand run by a multidisciplinary team of physicians, trans-lators, intercultural mediators and a psychologist. The mainactivities of this health education programme targetingVFRs take place in Madrid and are resumed in Fig. 1.

The programme was targeted at potential VFRs comingfrom Latin American and Sub Saharan African countries.We are specially focused on Sub Saharan African migrants.Although this population represents only 4.1% of docu-mented migrants emigrants with residence permite,9

they are more at risk for severe malaria while visitingtheir countries of origin. Several cases of complicatedmalaria among African VFRs (adults and their children)have been reported in Spain, mainly in patients fromthe Spanish ex-colony of Equatorial Guinea and otherWest Sub Saharan African countries such as Nigeria orCameroon.10,11

In an initial phase of the programme, we obtainedbackground information on migrants’ knowledge andbeliefs about travel-related health. First, from Septemberto November 2008, we carried out a qualitative researchconsisting of 15 in-depth interviews with migrants from SubSaharan African and Latin American countries who wereliving in Madrid. The results of the qualitative researchwere very helpful for the creation of appropriate educa-tional materials. It was observed that parents used to seekpre-travel advice for their children, so the importance ofprotecting children was highlighted in leaflets and postersand a mention to paediatricians was included. Other iden-tified item was the VFR migrants’ perception of Spanishmedical staff: They were seen as professionals with poor

Distribution of multilingual and culturally tailoredtravel health by trained intercultural mediators. Ma

* Waiting room of the Tropical Medicine consultatiawareness about risks while travelling and the people from Sub Saharan Africa informed anddevoted to African population: 120 people informe120 leaflets distributed (2011).

* Latin American migrants’ social event (National D

* Embassies and consulates, businesses, healthcpatients, NGOs and migrant’s associations campaigns (before summer and Christmas holida(2010 and 2011).

* Internet (www.saludentreculturas.es). Multilinguathis website. More than 245,000 visits (2010 and 2

Figure 1 VFR health education

capabilities to treat tropical diseases. Thus, materials alsoincluded information about specific and specialisedhealthcare resources for seeking medical advice before andafter their journey.

Once the qualitative research was concluded ein thefirst half of 2009e, we created multilingual, culturallytailored and fully illustrated leaflets and posters (Fig. 2).The materials were especially focused on Sub SaharanAfrican population, but they were also used among LatinAmerican migrants.

These materials were translated into French andEnglish, the most common vehicular languages of thetarget population. They contain information about healthrisks when travelling to the tropics, preventative measures(before, while and after travelling) and contact informa-tion for seeking pre-travel advice and post-travel assis-tance, emphasizing advises about malaria prevention andearly diagnosis. The materials were designed and adaptedby healthcare staff and intercultural mediators. Beforeprinting they had been tested with migrants coming fromSub Saharan and Latin American countries. This measurewas adopted in order to assure the materials were fullycomprehensible and will not hurt sensibilities. The mostremarkable contribution of the intercultural mediators atthis stage was in relation to the colours that should beused to represent the risk in the maps (warm colours asred or yellow). Mediators were also very helpful in thedesign of drawings as they explained which images couldbe mostly understood, disregarding the educational levelof readers.

From the second half of 2009 up to now, two volunteerintercultural mediators from Sub Saharan Africa specificallytrained for this purpose informed migrants individually andwithout giving any specific medical advice. In waiting roomof the Tropical Medicine consultation mediators informedSub Saharan African patients about travel-related health inand gave them the leaflets. Sixty-four impending andpotential VFRs (43 men, 21 women) were informed in theirown languages, in order to raise their awareness about theimportance of seeking pre-travel medical advice. They

leaflets and delivering of information about in scenarios:

on. Information was given individually to raise importance of seeking pre-travel advice: 64 64 leaflets distributed (2009-2011). NGO d about travel health and malaria prevention;

ay of Bolivia): 75 leaflets distributed (2009).

are centres with high percentage of migrant in Madrid. Two annual community-based ys): 1,260 leaflets and 60 posters distributed

l educational materials are freely available in 011).

programme’s main activities.

Figure 2 Culturally adapted poster about health and travel, extracted from the leaflet. English version. It also contains infor-mation about where to go for seeking medical advice in Madrid before and after travelling.

154 M. Navarro et al.

were coming from 16 Sub Saharan African countries, mainlyfrom Equatorial Guinea (16%), Republic of Guinea (14%) andSenegal (12%). The median of time living in Spain was 36months (range 1e240) and their main vehicular languageswere French (47%), Spanish (17%) and English (15%).

From August to December 2011, a trained interculturalmediator was based in a non-governmental organisation(NGO) targeted at Sub Saharan African population two daysa week. During this period, he informed 120 people aboutimportant preventative measures to be taken before,

An approach to engage VFR migrants in Madrid 155

during and after travelling to tropical countries withoutgiving any specific medical advice.

In August 2009, an informative stand with leaflets aboutChagas disease and travel health was set up in a venue inMadrid during the celebration of the National Day ofBolivia.12 Members of the multidisciplinary team engagedwith the crowd and distributed 75 leaflets about travelhealth while raising awareness of the importance of pre-travel medical advice.

In 2010, two community-based informative campaignstook place in Madrid (one before Christmas and one beforesummer holidays). Another campaign was carried outbefore the summer of 2011. A total of 1260 leaflets and 60posters (in English, French and Spanish) were distributed byintercultural mediators in primary healthcare centres,embassies and consulates, hairdressers, restaurants, callcentres, travel agencies, migrant’s associations and NGOsdevoted to migrants.

In January 2010, professionals from different fields(health sciences, computing, anthropology, psychology,intercultural mediation and translation) started to designa multilingual website (English, French and Spanish) inorder to improve the accessibility of health promotioninformation to VFRs. Targeted at migrants and professionalsin both health and social fields, this website gathersinformation about health and intercultural mediation, andhealth-related resources in Spain, being one of its sectionsabout travel health. Through this website, VFRs andprofessionals are able to access simple travel healthmessages and to consult and download the educationalmaterials.

We consider important to inform not only the impendingVFRs. Attitudes need time to be changed, therefore we alsoinform the potential VFRs even if they will not travelshortly. The more times the message reach them, the morechoices we have to succeed conveying the information in aneffective manner. That is why we chose the waiting room ofTropical Medicine consultation: there are many undocu-mented patients who attend and there is enough time toinvest while conveying the information. This is an idealscenario to identify the impending VFRs and to inform thepotential ones before they intend to travel, something thatmay be crucial for prevention. In addition, by givingmultilingual and culturally adapted materials we contributeto spread the message in their social circle. With theadapted material and the intercultural mediators weovercome many cultural and linguistic barriers. A formalevaluation of the impact of these interventions was notperformed. Some future strategies to measure theoutcomes could involve counting the number of appoint-ments for pre-travel consultation in this region or countingthe cases of imported malaria among VFRs. Yet it can takemany years before measurable changes are detected, and itwould be logistically difficult and costly. The aim of thisreport is to describe preventative activities and materialsthat have had a good acceptance and the methodsemployed to develop such tools.

Regarding the community-based campaigns targeted atimpending VFRs, the timing is very important. VFRs living inSpain use to travel during the summer and Christmas holi-days,13 therefore, the campaign will be more efficient iflaunched before these dates.

In order to understand the risk perception of VFRmigrants and their social, linguistic and cultural charac-teristics, it is essential to establish the best timing, locationand communication strategies for the preventative actions.Qualitative research, multidisciplinarity, community-basedactivities and intercultural mediators are key tools toconvey effective messages to VFRs. More initiatives areneeded to engage VFRs and we encourage other teamsworking in the same field to develop similar strategies andto share their methods and materials.

Conflict of interest

None declared.

Acknowledgements

VFRs’ activities are framed in the health education pro-gramme aimed at migrants in Spain (‘New citizens, newpatients’) and supported by sanofi-aventis.

Website’s design (www.saludentreculturas.es) was sup-ported by Vodafone Espana.

Authors’ affiliation centre belongs to the Red de Inves-tigacion Cooperativa en Enfermedades Tropicales (RICET).RED: RD06/0021/0020.

We thank Serigne Fall and Alban Kouakou, interculturalmediators, for their support. Both did convey the individualtravel-health messages in the waiting room of the TropicalMedicine consultation. Serigne Fall performed thecommunity-based activities and was based in the NGOKaribu for the individual counselling.

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