Knowledge and Use of Measures to Reduce Health Risks by Corporate Expatriate Employees in Western Ghana

Davidson H. Hamer MD, Ronald Ruffing MD, MPH, Michael V. Callahan MD, MSPH, DTM&H, Stephen H. Lyons RN, NREMT‐P, Abu Saleh M. Abdullah MBBS, MPH, PhD, FFPH
DOI: 237-242 First published online: 1 July 2008


Background Expatriate corporate workers stationed in remote regions of developing countries with limited health care resources are at substantial risk for a variety of infectious diseases.

Methods A survey was carried out among expatriates working at a large power plant construction site in western Ghana in 1998 to evaluate their use of pretravel medical services, current knowledge, and behavioral practices in relation to food‐ and waterborne disease prevention, diarrhea, malaria, respiratory infections, alcohol use, and high‐risk sexual activity. An anonymous, structured, and pretested questionnaire was used.

Results The response rate was 42 of 60 (70%). Most respondents were men (39 of 42, 93%) with previous international construction experience. Adherence to food and water safety recommendations decreased with time. Expatriates (15 of 23, 65%) from developed countries reported at least one episode of diarrhea, whereas no expatriates (0 of 9) from resource‐poor countries reported diarrhea (p < 0.001). Use of malaria chemoprophylaxis deteriorated with increasing duration of time on the job site. None of the expatriates (0 of 9) who had been on the site for more than a year was still taking an antimalarial compared to those who had been there for 3 months or less (13 of 16) (p < 0.01). Forty‐three percent (18 of 42) of the respondents reported having had a respiratory infection in the past 3 months. Only 38% (15 of 39) received preplacement education on human immunodeficiency virus (HIV) risk. A higher proportion of those who received pretravel HIV education used condoms always (4 of 5) than those who did not receive HIV education (1 of 5).

Discussion The use of health advice and preventive measures was generally low among the expatriate corporate survey respondents. Adherence to preventive measures declined with the increase in length of stay. Corporations need to develop appropriate health promotion strategies targeting their expatriates in developing countries.

During the past several decades, political change, globalization of markets, and improvements in air travel have dramatically increased the number of workers who travel internationally on both short‐ and long‐term assignments. Selected expatriate corporate workers, especially technical staff involved in the construction of utilities, roadways, and other infrastructural projects and mining and mineral and fossil fuel exploration, may reside for prolonged periods in high‐risk, remote, rural areas of developing countries. In this setting, corporate expatriate employees are at significant health risks due to increased exposure to insect, food, water, and sexually transmitted infectious diseases.1–3 A number of these environment‐specific risks can exacerbate cryptic or low‐grade medical problems, which would not otherwise be a problem in developed countries. Careful pretravel medical evaluation and education targeted at specific problems of this special, high‐risk group can help reduce the likelihood of illness during extended international travel or overseas deployment.4

Although the knowledge, attitude, and practices of returning travelers have been described,5–7 relatively little information is available on how well corporate expatriate travelers follow pretravel advice while living overseas. Obtaining health information on the use of preventive practices while expatriates are living in remote, health resource–limited settings will facilitate the development of interventions to reduce their risk of illness. In this study, we investigated the primary sources of illness prevention information and preventive practices for selected high‐risk health conditions among expatriates working at a large power plant construction site in western Ghana.


In 1996, Tufts‐New England Medical Center (TNEMC), with the assistance of Rescue Medicine, Inc. (RM), established a construction work site health clinic in Takoradi, Ghana, to meet the health care needs of both the expatriate corporate communities and the local workforce. The expatriate employees were provided with comprehensive pretravel screening, occupational health work site evaluations, on‐site acute and emergency medical care, remote medical and surgical consultation by telemedicine, primary care services, emergency medical evacuation evaluation, and coordination of services by a team based at TNEMC in collaboration with RM. A community health outreach and education program for the local Ghanaian medical community was also provided.

A cross‐sectional survey was carried out among the 60 expatriate employees of the construction company’s Takoradi site between October 15 and December 31, 1998. A RM field medical officer (S. H. L.) distributed the anonymous survey questionnaire to all expatriate employees who were working on the construction project during this time period and asked them to return it in a sealed envelope on completion. To ensure confidentiality, each survey was coded with a number and the surveys were transferred to Boston in the original sealed envelopes. The construction company encouraged its employees to participate in the study on a voluntary basis, but the corporation was not allowed access to any of the information that was collected. The study was approved by the TNEMC Institutional Review Board.

A structured questionnaire was used for data collection. The questionnaire sought information on demographic background, use of pretravel medical services, current knowledge, and behavioral practices in relation to food‐ and waterborne disease prevention, diarrhea, malaria, respiratory infections, alcohol use, and high‐risk sexual activity. All the information collected was based on the participants’ activities during the preceding 3 months of the survey.

Data were entered into an Excel database. We examined selected demographic and behavioral characteristics of respondents in a descriptive manner. Proportionate differences were analyzed using chi‐square tests. A “p ” value of less than 0.05 was considered statistically significant (two tailed).


Of the 60 questionnaires distributed, 42 were completed and returned (70% response rate). As not all respondents completed every section of the questionnaire, the total number of responses varied for certain questions.

As shown in Table 1, most survey participants were men aged 41 to 50 years with previous job experience, slightly more than half attained education to university level or higher, most (73.8%) were from North America or Europe, and more than half of the respondents had been on the job site for 6 months or less.

View this table:
Table 1

Demographic characteristics of the expatriate population

Characteristic% (N = 42)
 % Male93
Age group
 21–30 y10
 31–40 y19
 41–50 y43
 51–60 y26
 >60 y2
Education level
 High school education or less47.5
 University‐level education or higher52.5
Region of origin
 North America*38
 UK 29
 European (other than UK) 7
 Developing countries§ 26
Previous international work experience79
Duration of time on the job site
 <1 mo19
 1–3 mo19
 4–6 mo26.2
 7–12 mo14.3
 >12 mo21.4
  • * Includes 15 US and 1 Canadian citizen.

  • Includes Britain (n = 9) and Ireland (n = 3).

  • Includes one citizen from Germany, Holland, and Yugoslavia.

  • § Includes citizens from Indonesia (n = 5), India (n = 2), China (n = 1), the Philippines (n = 1), South Korea (n = 1), and Egypt (n = 1).

Water‐ and food‐borne illness

Half of the respondents (21 of 42, 50%) reported that they received information from a physician regarding the prevention of travelers’ diarrhea and other food‐ and waterborne infections. Employers (17%) and fellow workers (16%) were identified as additional sources of preventive health information. Five individuals (15%) stated that they did not receive any information on diarrheal disease prevention. The majority of the expatriate workers stated that they drank only bottled or boiled water, ate only well‐cooked meat, and avoided foods prepared by street vendors, while a smaller proportion avoided ice in beverages and eating salads or other raw vegetables (Table 2).

View this table:
Table 2

Reported use of measures to prevent food‐, water‐, and vector‐borne diseases

Protective measure% (N = 42)
Food‐ and waterborne disease prevention100
 Drink only bottled or boiled water50
 Eat only well‐cooked meat78
 Avoid food from street vendors84
 Avoid ice in beverages68
 Avoid consuming salads and raw vegetables56
Use of antivector measures
 Insect repellent use
Use of antimalarial chemoprophylaxis57

Food safety practices were analyzed by time on the job site and based on the responses to six food safety recommendations (Box 1). A significantly higher proportion of respondents who had been on the job site for ≤6 months (52%, 14 of 27) than those who had been there for >6 months followed all six food safety recommendations (3 of 15, 20%) (p < 0.05). Eleven (73%) workers followed at least four of the recommendations, and 1 (6%) expatriate followed less than four of the common food safety recommendations. Interestingly, a slightly higher proportion of those who followed all food safety recommendations reported at least an episode of diarrhea (47% vs 40%; p > 0.05).

Box 1

Six food safety recommendations measured in the study8

Avoid raw vegetables and salad
Eat only fruit that you have washed or peeled yourself
Avoid products such as ice cream, yogurt, and mayonnaise
Drink only milk that is fresh and pasteurized
Avoid raw or undercooked meats, poultry, and seafood
Consume food or drinks from street vendors and buffet meals with great caution


Sixty‐five percent of expatriates (15 of 23) from developed countries reported at least one episode of diarrhea. In contrast, no expatriates (0 of 9) from resource‐poor countries reported diarrhea (p < 0.001). Nineteen of the 42 survey respondents reported a total of 121 episodes of diarrhea during their stay in Ghana. Nine of the 121 (7%) episodes of diarrhea were associated with fever and 1 with bloody diarrhea. Fifty‐eight (48%) of the diarrhea episodes were treated with antibiotics, and 40 episodes (33%) were treated with antimotility agents. In 26 (21%) episodes of diarrhea, the expatriate worker visited the job site clinic. Two respondents were not able to work, each for 1 day, as a result of their diarrhea. None of the respondents reported developing clinically symptomatic hepatitis. Information regarding duration of treatment, type and source of antibiotic of choice, and total duration of illness was not collected.

Malaria prevention

The use of antivector measures was low overall (Table 2). Although 75% of the workers reported having been advised to use insect repellent, a little more than a third never did so and about half used this measure only intermittently. Only 48% reported having been advised to use treated bed nets or to sleep in screened rooms. Nearly a quarter of the expatriates chose to limit their use of mosquito exposure control measures to times of the year when malaria transmission was most intense, ie, during and after the rainy season. Most respondents (68%) recalled having ≤3 mosquito bites in the past week, although five individuals (16%) reported 3 to 10 bites and five persons (16%) reported >10 bites.

Thirty‐four of the respondents (34 of 42, 80.9%) were prescribed an antimalarial chemoprophylactic medication prior to traveling to Ghana including mefloquine (47.6%), chloroquine plus proguanil (16.7%), doxycycline (9.5%), and chloroquine (7.1%). Most of the respondents who were not provided with an antimalarial before traveling to Ghana were natives of India and Indonesia. At the time of the survey, slightly more than half of the respondents were currently taking antimalarials (Table 2). Use of chemoprophylaxis deteriorated with longer duration of time at the site; 81.3% (13 of 16) of the respondents who had been on the job site for ≤3 months were taking an antimalarial for prophylaxis versus 27% (3 of 11) of those on site for 4 to 6 months and 13.3% (2 of 15) of those at the job site for ≥7 months. Of the latter group, none of the expatriates (0 of 9), all of whom were originally from Europe or the United States, who had been on the site for more than a year was still taking an antimalarial versus 81.3% (13 of 16) of those on the site for ≤3 months (p < 0.01). Common reasons cited for discontinuing malaria prophylaxis were medication side effects, low perceived malaria risk, and suggestions from colleagues on the job site. While none of the survey respondents reported having malaria, in the 12‐month period after the survey was conducted, several expatriates subsequently developed falciparum malaria, which was diagnosed by rapid antigen testing (Binax NOW Malaria).

Respiratory infections

Slightly less than half of the respondents (43%, 18 of 42) reported having had a respiratory infection in the past 3 months. Of these, 55.6% (10 of 18) had taken an antibiotic for treatment including 4 of the 10 who had self‐prescribed the antibiotic.

High‐risk behaviors

When asked about alcohol use, 44% (14 of 32) reported that their total alcohol consumption had not changed during their stay in western Ghana, whereas 34% (11 of 32) reported increased intake and 22% (7 of 32) reported reduced alcohol use. Only 38% (15 of 39) received preplacement education on how to reduce human immunodeficiency virus (HIV) risk. Nearly a quarter (24%, 10 of 42: nine men and one woman) of the expatriates reported sexual encounters with local partners. Half (5 of 10) of those who had sex with local partners did not use condoms all the time. A higher proportion of those who received pretravel HIV education used condoms always (4 of 5) than those who did not receive HIV education (1 of 5).


This survey of expatriates residing in western Ghana revealed several important findings. The relatively high survey response rate (70%) reflects the potential generalizability of these findings while stressing the interest in health‐related issues among corporate workers. The use of preventive measures to reduce the risk of diarrhea gradually decreased over time. In contrast, the use of antivector measures was relatively poor, and adherence to antimalarial chemoprophylaxis also deteriorated over time. The survey respondents frequently developed health problems including diarrhea and acute respiratory infections. Sexual encounters with members of the local community occurred; half of these did not involve safer sex practices.

Expatriates from developed countries had a high attack rate of diarrhea (65%) in contrast to the survey respondents originating from low‐income countries. Presumably, the latter group had underlying immunity from past exposure to gastrointestinal pathogens. In summarizing the experience from 34 prospective studies, median travelers’ diarrhea rates were 54% in Africa.9 A prospective active surveillance cohort study of expatriates living in Nepal found that adult residents had an average of 3.2 episodes of diarrhea per person per year.10 These studies thus clearly highlight the substantial risk of food‐ and waterborne infections for long‐term expatriate populations. Despite having frequently suffered from acute diarrhea, over time, our respondents tended to decrease their use of behaviors designed to reduce their risk of acquiring gastrointestinal pathogens. In our self‐reported survey, this change of behavior did not alter the risk of diarrhea. The failure of food safety precautionary measures to protect against diarrhea is consistent with findings of other studies.11,12

The risk of acquiring malaria is high for long‐term expatriates living in sub‐Saharan Africa.13 Although our survey respondents denied having had malaria during the past 3 months, this may have been due to the timing of the survey, which was carried out during the dry season when malaria transmission would be expected to be low. Nevertheless, these expatriates were at increased risk of malaria because they were not taking an antimalarial or had been prescribed a potentially ineffective drug for chemoprophylaxis (ie, chloroquine or chloroquine plus proguanil).14 Subsequent to the completion of this study, many members of the cohort acquired malaria. The most notable finding of this component of the survey was the rapid decline in the use of prophylactic antimalarials with increased time on the job site. While there were several different reasons why this occurred including fear of or actual adverse effects and conflicting advice from other expatriates at the job site, this behavior coupled with the inconsistent use of antivector measures placed the longer term residents at great risk for malaria. Corporations with large groups of expatriates living in sub‐Saharan Africa need to develop strategies that have a sustained effect on limiting the risk of malaria among their employees.

High rates of sexual activity with members of the local population, as found in our study, have been described in long‐term travelers.15 The proportion of expatriates using condoms (50%) consistently in this study was comparable to travelers departing from Hong Kong International Airport (47% used always).16 The Hong Kong study included Chinese (22%), Caucasian (45%), and others including non‐Chinese Asians and a few other nationalities (33%). Ward and Plourde17 reported that 33% to 50% of travelers do not consistently use condoms. Given the well‐known high prevalence of HIV infection in sub‐Saharan Africa, this low condom use rate indicates the need for rigorous sexually transmitted disease risk reduction education to all expatriates. Although the numbers were small in this component of the survey, four of the five respondents who received HIV education used condoms all the time, reflecting a positive impact of HIV risk reduction education.

There are several limitations of this study. First, the sample size was small because we used a convenience sample of expatriates who were based at the job site at the time of the survey. Second, most expatriates in the study were men. Although many expatriate communities, especially those at construction sites, are predominantly composed of men, the findings of this survey cannot be generalized to female expatriates. Third, expatriates in this study were from both high‐income and low‐income countries. Besides differences in social and behavioral issues, there could also be differences between exposures to health education materials, behavioral practices, and preexisting immunity to gastrointestinal pathogens. Due to the small sample size, we did not report the findings separately for these two groups of expatriates with the exception of the self‐reported diarrhea episodes. Finally, those who participated in the study may differ as a group from those who did not participate. Owing to the anonymous nature of the study, we were unable to compare the characteristics of nonparticipants. Despite the above inherent limitations of questionnaires, such surveys can provide baseline information to help direct prevention campaigns.

In conclusion, this study identified patterns of preventable practices on several key health issues among expatriates in Ghana. The use of health advice and preventive measures was generally low among the respondents. Adherence to preventive measures declined with increased length of stay. Corporations need to develop appropriate travel health promotion strategies targeting their expatriates in developing countries. Larger comprehensive studies need to be done to better define the reasons for good adherence and failure to follow preventive advice among corporate expatriate workers to optimize the development of health promotion strategies for this high‐risk group of travelers. Given recent evidence that opportunities for international assignments are increasing and that China and India are two of the top emerging destinations,18 there is a clear need for improved policies and guidelines for optimizing the provision of health care and prevention of disease in long‐term stay corporate expatriates.

Declaration of interests

D. H. H. is on the speaker bureau for GlaxoSmithKline, and he owns shares of Inverness Medical Innovations, Inc., a company that produces rapid diagnostic tests for malaria. The other authors state that they have no conflicts of interest.


We would like to acknowledge John Dornbusch for his assistance with distributing the surveys, Hal Foley for his kind support of this project, and the survey participants for taking the time to complete the detailed questionnaire.


  • This work was presented in part at the 6th conference of the International Society of Travel Medicine in Montreal, Canada (abstracts C26, C27, and L05).


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