Exploring Australian Hajj Tour Operators' Knowledge and Practices Regarding Pilgrims' Health Risks: A Qualitative Study

Hajj presents a challenge to disease control in Saudi Arabia, as more than 2 million people travel each year to commemorate the pilgrimage. This challenge is also international, with the risk of pilgrims importing infectious diseases into their home countries when they return. The Saudi Arabian Ministry of Health (MoH) and World Health Organization (WHO) have introduced and recommended various preventive health measures for pilgrims, including vaccines. Pilgrims must travel in groups by enrolling with an authorised travel agent. Quantitative studies have found that Hajj pilgrims report travel agents as one of their main sources of health information, and their advice was associated with increased likelihood of positive travel health behaviours. This qualitative study sought to better understanding travel agents' knowledge about the health risks at Hajj, what health advice they provide to the pilgrims, and their sources of health knowledge.

Between February and September 2016, in-depth interviews were conducted in Sydney, New South Wales (NSW), Australia. The study used grounded theory, which draws on an inductive approach, whereby a cycle of data collection (interviews) and analysis is followed by subsequent interview and analysis cycles. Of the 13 accredited Hajj travel agents in Sydney, 9 were interviewed. Participants were encouraged to narrate events and situations they experienced and to describe the circumstances around their behaviours and choices.

All Hajj travel agents conducted pre-Hajj seminars several weeks before travel to Hajj. While some discussion was included, there was no specific health session conducted as a part of these seminars. Advice provided by travel agents typically included the compulsory vaccination requirements for securing the Hajj visa, standard hygiene methods such as hand hygiene, and some safety advice to prevent injury or trauma during Hajj.

The meningococcal vaccine (ACWY) is a compulsory vaccine for obtaining the Hajj visa, and most travel agents described a high level of knowledge regarding meningococcal disease severity and vaccine effectiveness in protecting pilgrims. This knowledge was also shared with the pilgrims as a further incentive to get the vaccine. None of the travel agents recommended any vaccines other than the compulsory ones or those they considered compulsory; they considered this to be the doctors' job.

The study found that, with the exception of influenza, the agents reported very limited knowledge and advice about the risk of respiratory infectious diseases, which are the most common health hazards at Hajj. For example, few agents were aware of the emerging infection Middle East respiratory syndrome coronavirus (MERS-CoV), in Saudi Arabia. Of those who knew about it, there was a demonstrated lack of knowledge or incorrect beliefs about issues such as mode of transmission and appropriate preventive measures. Some participants mentioned that official advice about MERS-CoV was distributed only in 2014, but not in 2015 and 2016.

The Ministry of Hajj website and personal Hajj experience were the main sources of information. Although the Saudi Arabian MoH is the official source of information about the health conditions for Hajj travellers, none of the sampled travel agents reported it as a source of their health knowledge. None of the travel agents undertook any special pre-Hajj training programme, either as a requirement for approval from the Saudi Arabian authority or to update their knowledge of health regulations regarding Hajj.

All respondents reported that there were no barriers regarding health information access because much of the information is widely available through the internet. The travel agents assumed the information they provide to their clients is adequate to make the pilgrims' travel safe. However, travel agents suggested some methods to better deliver health information to Hajj pilgrims, including:

• providing health lectures for Australian pilgrims before travel, conducted by Muslim doctors;
• disseminating health booklets organised by the Saudi health authority at entry points to Saudi Arabia or through the Saudi embassies in pilgrims' original countries; and
• supplying the travel agents with adequate, factual health information so they can pass it on to pilgrims. It is notable that the current health guidelines for Hajj travellers are published in medical journals or other platforms primarily intended for healthcare providers, using technical/medical language. There is a need for a guideline published in simple and understandable language for lay pilgrims and tour operators.

Another recommendation centres around the Saudi Arabian Embassy, which is considered the first contact point for organising Hajj travel. This study found that information distributed by the embassy helped increase travel agents' knowledge of MERS-CoV in 2014. Saudi embassies around the world could be encouraged to disseminate accurate and adequate health information from the MoH to all authorised Hajj travel operators and to provide annual pre-Hajj training and educational programmes to the tour operators, encouraging them to distribute the information to their pilgrims.

In conclusion, this study identifies opportunities to use Hajj travel agents and Saudi embassies as "conduits for health promotion for Hajj pilgrims", which "can inform travel health policy and practice".