Asia Pacific Journal of Tourism Research

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Health risks associated with group package tour:

implications from a study on tour leaders in
Taiwan

Fan-Yun Lan, Yen-Cheng Tseng, Shih-Bin Su, Chen-Long Wu & How-Ran Guo

To cite this article: Fan-Yun Lan, Yen-Cheng Tseng, Shih-Bin Su, Chen-Long Wu & How-Ran
Guo (2022) Health risks associated with group package tour: implications from a study on
tour leaders in Taiwan, Asia Pacific Journal of Tourism Research, 27:11, 1207-1216, DOI:
10.1080/10941665.2023.2166418

To link to this article: https://doi.org/10.1080/10941665.2023.2166418

Published online: 13 Feb 2023.

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ASIA PACIFIC JOURNAL OF TOURISM RESEARCH
2022, VOL. 27, NO. 11, 1207–1216
https://doi.org/10.1080/10941665.2023.2166418

Health risks associated with group package tour: implications from a

study on tour leaders in Taiwan
Fan-Yun Lana,b, Yen-Cheng Tsengc*, Shih-Bin Sud, Chen-Long Wua,e* and How-Ran Guoa,e,f,g*
a
Department of Occupational and Environmental Medicine, College of Medicine, National Cheng Kung University Hospital,
National Cheng Kung University, Tainan, Taiwan; bOccupational Medicine, Cambridge Health Alliance, Harvard Medical School,
Harvard University, Cambridge MA, USA; cDepartment of Tourism, Food, and Beverage Management, Chang Jung Christian
University, Tainan, Taiwan; dDepartment of Occupational Medicine, Chi-Mei Medical Center, Tainan, Taiwan; eDepartment of
Occupational and Environmental Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; fDepartment
of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan;
g
Occupational Safety, Health, and Medicine Research Centre, National Cheng Kung University, Tainan, Taiwan

ABSTRACT KEYWORDS
Group package tour (GPT) is more popular among Asia than in other regions. To visit Back pain; gastroesophageal
multiple attractions with a group of people within limited time at low costs, GPT is reflux; group package tour;
associated with some potential health hazards, including restricted meal time and peptic ulcer; tour leader; tour
long periods of time on ground transportation. Tour leaders are a good target for manager
assessing the associated health outcomes, and we conducted a questionnaire
survey on tour leaders in Taiwan. In addition to 152 tour leaders, we recruited
office staff of tour agencies as references. Tour leaders were more likely to have
peptic ulcer/gastritis, gastroesophageal reflux disease, and lower back pain. The
risks of these conditions increased as working on the job longer, indicating a
causal relationship. The results suggest that restricted meal time and long periods
of time travelling on ground transportation vehicles are potential health hazards
associated with GPT and may lead to certain health outcomes.

Introduction underlying illness of the individual may also affect tra-

Although tours delight tourists most of the time, tra-
velling is associated with some obvious health
hazards such as infection, circadian rhythm disrup-
tion, and motion sickness (Freedman et al., 2016).
Over the past several decades, Travel Medicine has
emerged as the health and well-being of international
travellers attracted attention, and this field of speci-
alty has been set up gradually in some countries
(Freedman et al., 2016). Most of the studies in this
field were on infectious diseases caused by viral, bac-
terial, or parasitical pathogens, which may result in
health outcomes such as COVID-19, influenza,
cholera, and malaria (Browne et al., 2016; Grobusch
et al., 2020; Khan et al., 2009; Mischlinger et al.,
2020; Riddle et al., 2017). In addition, health outcomes
resulting from the natural environment, activities, and
vellers. Therefore, the risks that travellers sustain
during travelling also include foodborne and water-
borne diseases, animals and insect bites, injury and
accidents, solar exposure, extreme weather, altitude
sickness, economy class syndrome, stress, etc. (Chio-
dini et al., 2012; Freedman et al., 2016).
Group package tour (GPT) and its significance
in tourism
Group package tour is a type of tour more frequently
taken by Asian tourists compared to Western tourists
(Wang et al., 2002). Prior to the COVID-19 pandemic,
GPT was the major income source of travel agencies
in Asia, contributing to a very large proportion of
the travel economy (Fu et al., 2021). In addition to

CONTACT How-Ran Guo hrguo@mail.ncku.edu.tw Department of Environmental and Occupational Health, College of Medicine,
National Cheng Kung University, 138 Sheng-Li Road, Tainan 704, Taiwan
*These authors contributed equally to this work.
© 2023 Asia Pacific Tourism Association
1208 F.-Y. LAN ET AL.
the Asia-Pacific region, GPT also played an important
role in the travel industry in Western countries. For
example, GPT in the U.S. have generated almost 2
million jobs, associated with over 86.4 billion U.S
dollars annual payoff (American Bus Association,
2022).
People choose GPT because it is convenient. In
addition to travelling with a group of people and
inclusion of meal, lodging, and some other expenses,
GPT usually involves visiting multiple attractions with
a planned itinerary (Cheng et al., 2017). From tourism
economy’s perspective, travelling in groups can mul-
tiply the spending of individual consumers, and there-
fore GPT is a welcoming way to thrive the whole
industry (Banerjee & Chua, 2020).
Risks associated with group package tour
While GPT can be beneficial to both consumers and
business, studies have indicated its risks. Cheng
et al. (2017) suggest that a lack of customer trust
and/or justice perception may enhance customers’
non-cooperative behaviours and further lead to their
dissatisfaction toward GPT. Poor quality shopping in
GPT, cancellation of a tour due to not enough partici-
pants, and accidental injury and death are among the
top GPT complaints (Chang & Chung, 2012). In terms
of particular risky behaviours, those perceived by
tour leaders included optional tour and shopping,
drivers’ problems, bribery and obstruction by
customs officers, hijacking and plane crash, luggage
lost and damaged, document and property stolen,
sexual harassment and accusation from tourists, etc.
(Wang et al., 2010). Regarding health risks, however,
when we searched in the Wed of Science and
PubMed databases using the combination of “group
package tour” and “health” as keywords, only a few
studies on acute infections were identified, including
typhoid fever (Cobelens et al., 2000), influenza
(Ansart & Caumes, 2006), and hepatitis A (Arnal
et al., 1997), but none on other health effects. While
it was not our intention to identify all related litera-
ture, the results indicated the lack of information on
this issue. Among the three studies identified, only
one targeted at GPT, which used a questionnaire to
study four groups of tourists stayed in the same
hotels along their tours (Cobelens et al., 2000).
To lower the price, GPT often covers a limited time
period and uses ground transportations most of the
time. Consequently, GPT is associated with some
potential health hazards, including restricted meal
time and long periods of time travelling on ground
transportation vehicles. However, even with the
advancement of travel medicine, the effects of these
hazards were seldom evaluated.
Health of tour leaders: an indicator of health
risks associated with group package tour
Regarding the health hazards associated with GPT,
existing theories may explain how GPT affects health
adversely. The ecosocial theory for disease develop-
ment and distribution highlights the role of ecology,
exposure, and social and behavioural factors in
health, considering evolving disease course over
time (Krieger, 2012). While customers may suffer
from health outcomes associated with GPT, tour
leaders are more likely to develop those outcomes
because they are much more frequently exposed to
those factors throughout their career. Therefore,
tour leaders, as the group of people most frequently
travel in the GPT mode, constitute a good target for
studying the effects of the health hazards associated
with GPT.
In GPT, a tour leader (also called “tour manager” or
“tour escort”) is in charge of leading the tour, mana-
ging the itineraries, and escorting the tourists. They
are front-line workers facing the customers and
accompanying with them throughout the whole trip
(Chiang & Chen, 2014) and constitute a very important
factor when tourists selecting GPT (Jin et al., 2014).
Nonetheless, tour leaders themselves generally do
not perceive the potential health risks associated
with GPT. For example, a survey of tour leaders in
Taiwan identified up to 12 risk factors associated
with GPT, but health risk was not included (Wang
et al., 2010). Therefore, we conducted a survey on
health conditions of tour agency employees in
Taiwan, adopting the standard questionnaire
implemented by the Taiwan Ministry of Labour for
workers’ health check-up with minor modifications
of the question on job history focusing on the job
as a tour leader, to evaluate whether GPT is associated
with certain health outcomes.
Materials and methods
Study hypothesis
In this study, we first compared the prevalence of
medical conditions and recent symptoms between
tour leaders and a reference group. Then, for those

with a higher prevalence in tour leaders, we further
evaluate if the associations are likely to be causal
relationship. If a medical condition (or symptom) is
attributable to working as a tour leader, the more
time working as a tour leader, the more likely an indi-
vidual presenting with the medical condition (or
symptom). Therefore, we assessed this “dose–
response relationship” to evaluate whether the
higher prevalence in tour leaders was likely to be
attributable to working as a tour leader and thus
attributable to health hazards associated with GPT.
Study participants
We recruited two groups of participants for compari-
son. The tour leader group was recruited with the
assistance of the Association of Tour Leaders,
Taiwan, and Tainan Association of Travel Agents. We
included both part-time and full-time tour leaders
and conducted questionnaire surveys when they
were attending the continuing education courses
held by the associations and during the Tainan Inter-
national Travel Fair. There was at least one person in
charge at each place to ensure that each tour leader
got only one questionnaire. To minimise potential
selection bias, we chose continuing education
courses of which the topics were not related to health.
The other group of participants was recruited from
office staff in tour agencies with the assistance of
Tainan Association of Travel Agents and a nationwide
tour company. We conducted surveys using the same
questionnaire in the offices of the tour company and
during the Tainan International Travel Fair. Likewise,
there was at least one person in charge at each
place ensuring that each office worker got only one
questionnaire.
Measurements
We sent anonymous questionnaires to the persons in
charge by mail for distribution which collected data
on demographic characteristics, medical history, and
work history. In addition, the participants were
asked to report medical history and symptoms in
the three-month period before the survey, which
was conducted from October 2014 to February
2015. Questions in the questionnaire were adopted
from the standard questionnaire implemented by
the Taiwan Ministry of Labor for workers’ health
check-up (Occupational Safety and Health Adminis-
tration, 2022), which has been widely used as
ASIA PACIFIC JOURNAL OF TOURISM RESEARCH 1209
mandated by law in Taiwan. We modified the ques-
tions on occupational history, which determined
respondents’ full-time, part-time, or non-tour leader
status; job tenure; and major tour leading areas. Ques-
tions regarding health remained unchanged, ensuring
the validity and reliability of the questionnaire.
Two measurements of working as a tour leader
were used to assess the dose–response relationships
between duration of work and health outcomes.
One was the proportion time working as a tour
leader in the whole working history, which was cate-
gorised as full-time, more than 1/2 of the time, and
less than 1/2 of the time. The other was the job
tenure. Because there were both full- and part-time
tour leaders, we used adjusted job tenure to assess
the dose–response relationships between duration
of work and health outcomes. Adjusted job tenure
was calculated as follows:
Adjusted job tenure = number of months on the job
× occupation code(0, 1, 2, 3)
43
where the occupation code value 0 was assigned to
working as an office staff, 1 to working part-time
with less than a half of the time as a tour leader, 2
to working part-time with greater than a half of the
time as a tour leader, and 3 to working as a full-time
tour leader.
Statistical analysis
In comparisons between the two groups, we used chi-
square or Fisher’s exact tests to evaluate differences in
categorical variables and two-sample t or Wilcoxon
rank sum tests to evaluate differences in continuous
variables. For each health outcome, we calculated
the odds ratio (OR) and associated 95% confidence
interval (CI). Considering stability of the estimates
and simplicity, we present only the results on con-
ditions that were observed in more than three partici-
pants. We used logistic regression models to evaluate
relationships between work exposure and health out-
comes. For health outcomes with a p value < 0.1 in
uni-variate analyses, we conducted multi-variate ana-
lyses. We used the stepwise model-building approach
with the forward Wald’s method and an exclusion
level of 0.15 to adjust for potential confounders
such as age, sex, and educational level.
We conducted further assessments of the dose–
response relationships between duration of work
1210 F.-Y. LAN ET AL.
history (using the proportion time working as a tour
leader in the whole working history and adjusted
job tenure) and health outcomes using tests for
trend. In addition, we made comparisons of health
outcomes among tour leaders who led tours to
different areas. For these comparisons, we adjusted
for potential confounders including age, sex, edu-
cational level, and personal factors.
We analysed the data using statistical software
SPSS V17.0 (SPSS Inc., Chicago, IL) and performed stat-
istical tests at the two-tailed significance level of 0.05.
Results
Characteristics of the participants
The overall response rate was 75.6%, with 70.0% in
the Association of Tour Leaders, 80.4% in the Tainan
Association of Travel Agents, and 76.7% in the tour
company. The differences in the response rate did
not reach statistical significance (p > 0.05). After
excluding 3 respondents who did not provide work
history, we analysed the data from 390 participants,
including 238 office staff, 95 part-time tour leaders,
and 57 full-time tour leaders. Of the part-time tour
leaders, 79 devoted less than a half of the time to
being a tour leader, and 16 devoted more than a
half of the time.
We found a female predominance in the office
staff, and the proportion was higher than that in
tour leaders (73.1% versus 52.0%, p < 0.01) (Table 1).
Tour leaders were older (average 46.8 versus 34.2
years old, p < 0.01) and had higher education levels
(p = 0.01) compared to office staff. As to life-style
characteristics, tour leaders had higher prevalence of
alcohol consumption (51.7% versus 33.2%, p < 0.01)
and slept less during a typical work day (average
5.8 ± 1.3 versus 6.9 ± 1.2 h, p < 0.01). In addition, tour
leaders seemed to have a lower prevalence of
Table 1. Demographic data and life-style characteristics of tour leaders and office staff.
Tour leader (n = 152)
Sex
Male 73 (48.0%)
Female 79 (52.0%)
Age
≤ 40 years 44 (29.4%)
＞40 years 106 (70.6%)
Education
Junior high or less 0 (0.0%)
Senior high 11 (7.4%)
College 113 (75.8%)
Graduate school 25 (16.8%)
Body mass index (kg/m2) 23.65 ± 3.75
“never smoke” (79.2% versus 87.2%, p = 0.06).
Because the number of hours of sleep during a
typical work day is highly correlated with the work
exposure (the number of hours spent on working),
we included only sex, age, educational levels,
alcohol consumption, and smoking history in the
multi-variate analyses.
Comparisons of health outcomes
We observed higher prevalence of hypertension,
peptic ulcer/gastritis, and gastro-oesophageal reflux
disease (GERD) in tour leaders compared to office
staff (Table 2). As to symptoms in the recent 3
months, tour leaders reported more lower back
pain, with an OR of 7.3 (95% CI: 2.1–26.2).
After adjusting for sex, age, educational levels,
alcohol consumption, and smoking, we found tour
leaders were more likely to have GERD (adjusted OR
3.8, 95% CI: 1.2–11.7) (Table 3). They also tended to
have peptic ulcer/gastritis (adjusted OR: 2.8, 95% CI:
1.0–8.3). As to recent symptoms, we found tour
leaders were more likely to have lower back pain
(adjusted OR: 6.1, 95% CI: 1.6–23.9).
After adjusting for sex, age, educational levels, and
alcohol consumption, we found that as the proportion
of working as a tour leader in the whole career
increased, the prevalence of peptic ulcer/gastritis
and lower back pain increased (both with p < 0.05)
(Table 4). Furthermore, as adjusted job tenure
increased, the prevalence of peptic ulcer/gastritis,
GERD, and lower back pain increased (p < 0.05 for all
tests for trend) (Table 4).
Discussion
Our study explored tour leaders’ health conditions,
which are seldom studied. They sustain not only
Office staff (n = 238) p value
< 0.01
64 (26.9%)
174 (73.1%)
< 0.01
192 (81.3%)
44 (18.7%)
0.01
0 (0.0%)
9 (3.9%)
200 (87.7%)
19 (8.3%)
22.86 ± 22.96 0.68
 ASIA PACIFIC JOURNAL OF TOURISM RESEARCH 1211

Table 2. Univariate analysis of health outcomes in tour leaders and GPT. Through a literature review, we identified
office staff. health hazards associated with GPT as a knowledge
Tour leader Office staff Odds ratio gap, and the current study can help fill in the gap.
(n = 152) (n = 238) (95% CI)
Specifically, being a tour leader is associated with a
Medical Condition
Hypertension 24 (15.8%) 18 (7.6%) 2.3 (1.2–4.4)* nearly threefold risk of having peptic ulcer/gastritis,
Diabetes mellitus 9 (5.9%) 6 (2.5%) 2.4 (0.9–7.0)† a nearly fourfold risk of GERD, and a higher than
Heart disease 2 (1.3%) 3 (1.3%) 1.0 (0.2–6.3) sixfold risk of lower back pain. These novel findings
Cancer 4 (2.6%) 1 (0.4%) 6.4 (0.7–58.0)†
Asthma 1 (0.7%) 7 (2.9%) 0.2 (0.1–1.8) call for the need of implementing active prevention
Liver disease 5 (3.3%) 1 (0.4%) 8.1 (0.9–69.7)† strategies for this population.
Anaemia 6 (3.9%) 5 (2.1%) 1.9 (0.6–6.4) Among those who sustain frequent travel-related
Thyroid disease 4 (2.6%) 2 (0.8%) 3.2 (0.6–17.6)
Peptic ulcer/ 12 (7.9%) 6 (2.5%) 3.3 (1.2–9.0)* risks, flight attendants can be a representative popu-
Gastritis lation and have been extensively investigated in
Gastroesophageal 15 (9.9%) 5 (2.1%) 5.1 (1.8–14.4)** term of health problems such as respiratory diseases,
reflux disease
Fracture 5 (3.3%) 3 (1.3%) 2.7 (0.6–11.3) malignancy, mental illness, and cardiovascular dis-
Surgical history 6 (3.9%) 3 (1.3%) 3.2 (0.8–13.1)† eases (Arjomandi et al., 2009; Beatty et al., 2011; Liu
Recent Symptom et al., 2016; McNeely et al., 2014; McNeely, Mordukho-
Cough 10 (6.6%) 9 (3.8%) 1.8 (0.7–4.5)
Sputum 4 (2.6%) 2 (0.8%) 3.2 (0.6–17.7) vich, Staffa, et al., 2018; McNeely, Mordukhovich,
Chest pain 4 (2.6%) 2 (0.8%) 3.2 (0.6–17.7) Tideman, et al., 2018; Pinkerton et al., 2016), which
Palpitation 6 (3.9%) 3 (1.3%) 3.2 (0.8–13.1)† were thought to be due to circadian rhythm disrup-
Dizziness 9 (5.9%) 12 (5.0%) 1.2 (0.5–2.9)
Headache 8 (5.3%) 13 (5.5%) 1.0 (0.4–2.4) tion, second-hand smoke, cosmic radiation exposure,
Tinnitus 6 (3.9%) 8 (3.4%) 1.2 (0.4–3.5) stressful working environment, and so on (Griffiths &
Fatigue 8 (5.3%) 9 (3.8%) 1.4 (0.5–3.8) Powell, 2012). While investigating flight attendants’
Abdominal pain 0 (0.0%) 4 (1.7%) 0.2 (0.01–3.2)
Constipation 6 (3.9%) 6 (2.5%) 1.6 (0.5–5.0) health helps figure out health hazards associated
Diarrhoea 1 (0.7%) 4 (1.7%) 0.4 (0.1–3.5) with air travel, it is not an optimal approach to evalu-
Upper back pain 12 (7.9%) 10 (4.2%) 2.0 (0.8–4.7) ate those associated with GPT. On the other hand, the
Lower back pain 13 (8.6%) 3 (1.3%) 7.3 (2.1–26.2)**
Limbs numbness 2 (1.3%) 6 (2.5%) 0.5 (0.1–2.6) occupation we examined in the current study, tour
Arthralgia 7 (4.6%) 5 (2.1%) 2.3 (0.7–7.2) leader, is one of the many jobs in the tourism industry
Polyuria/frequent 3 (2.0%) 2 (0.8%) 2.4 (0.4–14.4) besides flight attendants that are associated with
Body-weight loss 2 (1.3%) 4 (1.71%) 0.8 (0.1–4.3)
† highly frequent travels. Such a job is developed
0.05 < p < 0.1; *p < 0.05; **p < 0.01.
CI: confidence interval. mainly because of GPT, which is one of the main
modes of outbound travel in many Asian countries
acute (Freedman et al., 2016; Leder et al., 2015) but (Chiang & Chen, 2014; Luoh & Tsaur, 2013; Wang
also chronic health adversities attributable to fre- et al., 2002, 2010). While tour leaders appear to be a
quent travelling, particularly those associated with good target for studying health risks associated with

Table 3. Multivariate analysis for health outcomes reported by tour leaders and office staff.
Tour leader Office staff Full model Odds ratioa Final model Odds ratio
(n = 152) (n = 238) (95% CI) (95% CI) Variables adjusted
Medical Condition 152
Hypertension 24 18 0.8 (0.4–1.9) N/A age
Diabetes Mellitus 9 6 0.9 (0.3–3.2) N/A age, education,
smoking
Cancer 4 1 1.8 (0.1–36.7) N/A age, alcohol
Liver disease 5 1 7.4 (0.5–120.6) 8.3 (0.7–93.4)† alcohol
Peptic ulcer/Gastritis 12 6 3.0 (0.9–10.0)† 2.8 (1.0–8.3)† smoking
Gastroesophageal reflux 15 5 2.7 (0.8–9.4) 3.8 (1.2–11.7)* education, smoking
disease
Surgical history 6 3 1.3 (0.2–7.0) N/A education, smoking
Recent Symptom
Palpitation 6 3 2.9 (0.6–13.9) N/A none
Lower back pain 13 3 8.7 (1.7–44.9)* 6.1 (1.6–23.9)** alcohol
CI: confidence interval; N/A: not available (if “being a tour leader” was not selected in the final model).
a
Model includes job category, sex, age, education, alcohol (consumption), and smoking.
†
0.05 < p < 0.1; *p < 0.05; **p value < 0.01.
1212 F.-Y. LAN ET AL.
Table 4. Trend tests for health outcomes categorised by the proportion of work in the whole career and adjusted job tenure as a tour leader.
Proportion of work Office staff Part-time < 1/2
Case number 232 77
Peptic ulcer/Gastritis 6 (2.6%) 2 (2.6%)
Lower back pain 3 (1.3%) 5 (6.9%)
GERD 5 (2.2%) 5 (6.5%)
Adjusted job tenureb 0 ≤ 12 months
Case number 240
Peptic ulcer/Gastritis 7 (2.9%)
GERD 6 (2.5%)
Lower back pain 3 (1.3%)
GERD: gastro-oesophageal reflux disease.
a
Adjust for sex, age, educational level, and alcohol consumption.
b
Adjusted job tenure = tenure month × occupation code(0,1,2,3)/3.
code 0: office staff.
code 1: part-time tour leader < 1/2.
code 2: part-time tour leader > 1/2.
code 3: full-time tour leader.
GPT, related data are limited. In fact, when we
searched the literature in the Wed of Science and
PubMed databases using “group package tour,”
“tour leader,” “tour manager,” and “tour escort” com-
bining with “health” as keywords, no related reports
were identified.
In comparison with flight attendants, tour leaders
spend a relatively small part of their working time in
flight cabins, and thus are exposed to less cosmic radi-
ation. However, they sustain some other occupational
hazards associated with GPT. One important health
hazard is the limited time for having meals during
work. In a study of tourists joining GPT, limited time
for each meal was one common complaint from
them (Chang et al., 2011). An importance-perform-
ance analysis comparing individual tourists and GPT
tourists found that GPT tourists ranked “service
speed/efficiency of service” as the second most
important dining attribute while individual tourists
ranked it as the fifth to sixth (tied with “menu diver-
sity”) (Su, 2013), reflecting the constraint of meal
time during GPT. In agreement with the existing litera-
ture, we found gastrointestinal problems are preva-
lent among tour leaders.
A tour leader often has even less time for having
meals than the tourists. There are associations
between eating patterns and gastrointestinal illness
(Colombo et al., 2002; Nam et al., 2017; Newberry &
Lynch, 2019; Shaker et al., 2013). Physiologically, as
greater gastric distension secondary to the large
volumes of feed that are quickly instilled during
bolus feeding, lower oesophageal sphincter would
be weakened, which could result in gastroesophageal
reflux (Coben et al., 1994). This may explain why we
Part-time > ½ Full time p valuea
14 49
2 (14.3%) 8 (16.3%) < 0.01
2 (14.3%) 6 (11.8%) 0.02
2 (14.3%) 8 (16.3%) 0.09
> 12 months
54 53
4 (7.4%) 7 (13.2%) < 0.01
2 (3.7%) 9 (17.0%) < 0.01
6 (11.1%) 5 (9.4%) 0.02
found tour leaders, who have limited time having
meals during work, suffered from GERD more fre-
quently than office staff. Because GPT usually has
limited time for meals (Chang et al., 2011), tourists
joining such tours should be aware of the risk of
GERD.
In addition to GERD, peptic ulcer was another gas-
trointestinal illness reported more frequently by tour
leaders. Helicobacter pylori infection and nonsteroidal
anti-inflammatory drug use were currently considered
as the two major risk factors (Arroyo et al., 2004; Kuna
et al., 2019), and Helicobacter pylori infection plays a
more important role in the general population.
While the transmission of Helicobacter pylori is still in
debate, some evidence indicated that hygiene and
environmental factors may contribute to the trans-
mission because a higher overall prevalence of infec-
tion was observed in developing countries (Graham
et al., 1991), and further data suggested lower socio-
economic status as a predictor of infection within
some populations (Malaty et al., 2002). A literature
review proposed that water is a reservoir in faecal–
oral Helicobacter pylori transmission, explaining the
reason why a higher prevalence was observed in
developing countries (Bellack et al., 2006). Therefore,
it can be inferred that travellers who visit developing
countries are more likely to contract Helicobacter
pylori infection. A study followed the seroconversion
rate of 133 initially seronegative young Swedes travel-
ling to developing countries but observed a relatively
lower rate of evident Helicobacter pylori infection
(Lindkvist et al., 1995). An Israel study, however, exam-
ined the serology status of 104 backpackers travelling
to tropical countries and found 4 of them

seroconverted after the trip (Potasman & Yitzhak,
1998), which is compatible with our finding of a
higher prevalence rate of peptic ulcer among tour
leaders. Further studies such as follow-ups on serol-
ogy status of tour leaders are warranted to confirm
the hypothesis. Nonetheless, nonsteroidal anti-inflam-
matory drug use being the second leading cause of
peptic ulcer (Arroyo et al., 2004) could also contribute
to tour leaders’ elevated risk, as they may take these
medications more frequently to relieve their muscu-
loskeletal discomforts, such as lower back pain, as
demonstrated in our study.
Tour leaders also have occupational ergonomic
hazards that could result in musculoskeletal discom-
forts. Particularly, during GPT, much time is spent on
ground transportation vehicle, which is considered
as an important ergonomic hazard (Wang et al.,
2007). To investigate the issue, we collected some
typical itineraries of the popular GPTs in Taiwan
(with Mainland China, Northeast Asia, and Southeast
Asia as the destinations) and found the time spent
on vehicles were around 5–7 h per day on
average. In fact, vehicle-related adverse health
effects were reported in previous studies (Dabrh
et al., 2014; McCormack & Virk, 2014; Savage et al.,
2016). As to airplane transportations, a study inves-
tigating pilots on commercial flights showed that
lower back pain was a common health problem
(Prombumroong et al., 2011). Exposures to poor
body positioning for long periods of time and to
vibration were indicated as the primary risk factors
(Smith, 2006; Taneja, 2008). A high prevalence rate
of low back injuries in transit operators has been
reported, with a likely association with activities
requiring the use of non-neutral postures, prolonged
sitting, and whole body vibration (Albert et al., 2014;
Joseph et al., 2020). Therefore, in spite of a lack of
direct evidence in the literature, we would expect
tour leaders are likely to suffer from lower back
pain, as observed in our study. Tourists who join
GPT might also suffer from the condition.
Our study has some limitations. First of all, we used
a cross-sectional study design, which cannot provide
strong argument for causal relationship. However,
we used adjusted job tenure to perform dose–
response assessment and had similar findings on the
major findings – peptic ulcer/gastritis, GERD, and
lower back pain. A dose–response relationship can
support a causal relationship. A cross-sectional study
design may also suffer from prevalence-incidence
bias, which may erroneously identify factors
ASIA PACIFIC JOURNAL OF TOURISM RESEARCH 1213
affecting the duration of a given disease as factors
affecting its incidence and thus should be considered
in cases of longer-lasting diseases (Levin, 2006).
Therefore, being a tour leader might not be a risk
factor for developing the illness, but a factor contri-
buting the persistence of the illness. Another limit-
ation is that we did not confirm the illness reported
by the participants. In particular, subjective symptoms
may suffer from recall bias. However, we selected a
comparison group from tour agencies to achieve a
good comparability, because the office staff in tour
agencies tended to have almost the same population
of customers, professionalism, and so on, as tour
leaders. Therefore, we believe the misclassification
should be largely non-differential, and thus the rela-
tive risks tended to be underestimated rather than
overestimated. In such cases, findings of significant
associations are still reliable. There were some unmea-
sured confounders in the present study, such as exer-
cise patterns, eating behaviours, and stress. Whereas
the relatively large effect size is unlikely to be fully
explained by unmeasured confounders and the selec-
tion of a comparable reference group (i.e. office
workers in tour agencies) could minimise the poten-
tial confounding, further studies that account for
those factors should be conducted to confirm our
findings.
The COVID-19 pandemic has affected the tourism
industry globally (Bielecki et al., 2021; Zielinski &
Botero, 2020), and GPT has been banned in Taiwan
during the pandemic. As a result, many tour agencies
were out of business, and many tour leaders changed
their jobs. This demonstrates that pandemics of con-
tagious diseases may have devastating impacts on
GPT. Regarding health risks, a follow-up study on
tour leaders after the lift of the ban may support the
findings in the current study, if the adverse health
conditions improved after not engaging GPT for a
long period of time. However, some other approaches
for recruitment need to be applied because the
approaches adopted in the current study are not suit-
able for recruiting tour leaders who have changed
their jobs.
Our study also has some strengths. The response
rate was 75.6%, which is relatively high and thus can
minimise possible selection bias. In addition, the
questionnaire surveys were conducted in the continu-
ing learning courses with all topics except for health
related courses. By doing so, we could minimise the
selection bias from including the tour leaders caring
more about their health.
1214 F.-Y. LAN ET AL.
Conclusion
Our study showed that tour leaders had higher
prevalence of peptic ulcer/gastritis, GERD, and
lower back pain compared to office staff. In addition,
we found that as the duration of being a tour leader
increased, these outcomes were more likely to be
reported, indicating a causal relationship. Neverthe-
less, for causal inference, further longitudinal
studies are warranted.
In order to take effective reactive prevention
measures, the aetiology and pathogenesis of the
health outcomes need to be investigated, so that
the companies and the government can take reactive
prevention measures accordingly. For instance, if the
limited meal time in GPTs is the cause leading to
GERD, tour companies should make enough room in
the itinerary to allow tour leaders, as well as tourists,
to have sufficient meal time. Travel authorities may
implement regulations of meal time in GPTs or
include the items regarding meal arrangement in
tour operators’ evaluation. Likewise, if the long
periods of time spent on ground transportation
vehicles lead to lower back pain, breaks should be
provided during long distance ground transportation.
In addition to safety, tour operators and authorities
should pay attention to the ergonomics of vehicles
for preventing both acute and chronic musculoskele-
tal discomforts of tourists and tour leaders. Ergonomic
assessment should be made and related information
should be supplied by ground transportation provi-
ders. Regarding the other prevalent health adversities
we found in the present study, gastrointestinal system
examinations and Helicobacter pylori surveillance are
to be recommended for tour leaders.
Disclosure statement
No potential conflict of interest was reported by the authors.
Data availability
Data available on request from the authors.
Ethical statement
The study protocol was reviewed and approved by
Institutional Review Board of the National Cheng
Kung University Hospital, and we followed Declara-
tion of Helsinki throughout the study.
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