Between the sea and the sky: A social practice investigation into health behaviours during cruise travel

1 INTRODUCTION

Until the start of the COVID-19 pandemic, cruise ship holidays were an exponentially growing popular mode of travel and attracted large numbers of people from all over the world. In Australia, cruising ranked among the fastest growing tourism sectors, with 5.8% of the population cruising by 2018.¹ Since cruise ships resemble small towns, carrying up to 9000 people, public health challenges associated with cruising are substantial, exacerbated by semi-confined spaces, shared facilities, and perceptions and claims of safe and carefree environments.

The complexity and variety of illnesses on cruise ships has shifted over the past three decades, moving from food-borne bacteria outbreaks to viral outbreaks, caused by the norovirus – the leading cause of human acute viral gastroenteritis^{2, 3} – and, most recently, the lethal coronavirus strain. These health risks have the potential to develop into health-related crises, which can impact the personal health and wellbeing of passengers, crewmembers, and even local residents.^{4, 5}

Despite cruise ships being perfect incubators for microbiological infections from viruses and bacteria due to the constant socialising within closed spaces, the fact that many older (retired) people, who often already have certain health conditions like cruise travel, and the popularity of group activities on cruise ships, most passengers and crewmembers are largely unconcerned by certain health issues and pay little attention to what public health authorities call “healthy cruising” behaviour.^{4, 6}

This is not for the lack of trying. Government health agencies have developed digital and traditional information and education in the past four decades. For instance, in the United States, the Centres for Disease Control (CDC) started their Vessel Sanitation Program (VSP) in the 1970s.² With Sydney being Australia's largest cruise gateway, the responsible authority – the South Eastern Sydney Public Health Unit (SESPHU), an agency within one of the 15 local health districts of NSW Health – began their cruise ship health surveillance and inspection program in 1992. As part of that, it has absorbed a passenger information and education role, which runs under the header “Your guide to healthy cruising.”⁷ It is a short electronic pamphlet available through their website that provides a dot point list of things to do in preparation for a cruise (see your doctor, ensure you have enough of your regular medications, organise insurance, check what public health issues your destinations may have) and during the cruise (wash hands and use sanitiser, use your own cabin bathrooms, avoid uncooked meals, fill your water bottle on board, use mosquito repellents and seek medical attention if you become unwell).

Not unlike any other attempt to communicate disease prevention messages to the public, travel health communication exists within a complex social context. People are exposed to a range of health information and advice in their everyday lives. Much of this may not be personally relevant and thus is easily ignored. But even when health communication and promotion efforts are relevant, there may be a range of reasons why they do not connect with people. Top-down communication models might attribute this disconnect to ignorance (deficit) or even a blatant refusal to comply. However, we suggest the how and why of accessing and embracing health information, particularly in pursuit of some form of behaviour change, is a much more complex and complicated matter. Persuading people to change their existing behaviours isn't all that easy, especially if it requires the abandonment of a behaviour that has been constructed because of ongoing communicative interactions at varying intensities with expert, social and/or lay sources.^8-10

If we accept that people's general beliefs about health derive partly from the degree to which people feel they have control over their daily lives,¹¹ it is important to understand that people interpret and enact ‘healthy’ behaviours in the context of their attempts to achieve or preserve their own living conditions and circumstances. From this perspective, official health information is interpreted through the lens of what it means for one's current life, whether one can do what is being asked or required of them and if the infrastructure and materials enabling them to do that are available.¹⁰ Without understanding these personal conversions, the many health messages that come with ‘best practice’ suggestions (do this, don't do that) can easily lead to a clash of viewpoints that may not only irritate or alienate the very groups that are targeted,¹² but also have great potential to be perceived as paternalistic infringements on one's autonomy by the message sender. While information and education approaches to changing people's attitudes and behaviours remain an important component of travel health promotions and programs, we argue effective communication requires more than the mere distribution of information or risk warnings.¹³

The present study draws on a social practice framework developed by Shove et al¹⁴ to investigate people's health understandings and behaviours in preparation for and during a cruise holiday. Social practice theory shifts the focus of inquiry away from the attitudes, discrete behaviours, and choices of individuals to socially embedded practices that are shaped by one's habitus and socialisation.^{10, 14, 15} Practices are seen as comprising several interconnected elements. Although various configurations have been proposed, the model proposed by Shove et al,¹⁴ devising an interplay between competence (the skill to engage in a practice), material (the availability of required tools or infrastructures, eg access to information), and meaning (understandings shared by a group about the practice), has great potential when targeting behaviour change by intervention campaigns/policies.¹⁶ To visualise how these influence factors correlate, see the structure of the practice elements from Shove et al,¹⁴ shown in Appendix A. While social practice theory has yet to have a major influence on mainstream health communication research and prevention campaigns, sociologists of health and illness have provided valuable insights.¹⁷

Health behaviour before and during cruise travel as a social practice is the basic unit of analysis, whereby cruise travellers are decentralised as carriers of this practice. This stance is in stark contrast to that in most pro-health behaviour studies, where people are at the centre of analysis and their satisfaction, motivation, and attitude (toward the specific healthy behaviour that is studied) are primarily examined.¹⁸ Translating this to our focus on cruise travel, our aim was to understand travel health perceptions and behaviours in the context of the meanings, competences and materials associated with cruise travel. The application of social practice theory thus affords a middle path to reinterpret the relationship between agency and structure, and accordingly, could avoid both the trap of methodological individualism and that of holism.¹⁹ Those will provide guidance on how industry and authorities can develop more effective strategies. This includes paying attention to how current intervention messages connect or resonate with cruise travel and travel preparation practices. To arrive at this, we probed participants’ ideas of what (own behaviours and external circumstances) makes the cruise fun and enjoyable as well as what (own behaviours and external circumstances) makes the cruise safe and healthy.

We employed a variety of participatory methodologies to capture embodiments of social practices in their context.^{20, 21} This included participants providing their own photographs – known as photo elicitation technique^{22, 23} – about fun and health during the cruise. These allowed participants to reconstruct how they were feeling at the time the photograph was taken. These were later included in ethnographic, narrative interviews to elicit family practices regarding their travel.^{24, 25} This type of interviewing allowed participants to tell their stories in the way they choose, using their photographs as inputs and mnemonic devices to recall experiences.

2 METHODS

3 RESULTS

4 DISCUSSION

To summarise our findings and illustrate them visually, we revisit the Shove et al¹⁴ model and apply it to our healthy cruising behaviour context (Appendix A). As we can see, the provision of safety/health information and support of health-aware skills are relevant factors, but they are both reliant upon the meaning making an individual traveller deduces from it and/or wishes to engage with it. In short, the effectiveness of advocacy and enablement are dependent upon community participation and acceptance when it comes to promotional activities. Agencies responsible for providing cruise health information to prospective travellers need to consider a variety of factors. We will come back to this below.

The responsible health agencies for cruise ports and travel typically strive to provide sufficient information and communication efforts regarding infectious disease risks toward prospective and actual travellers for those to engage in healthy cruise behaviours and stay healthy. Yet, we found that the pre- and during-cruise health behaviours displayed by our respondents echo basic behavioural patterns (eg handwashing, packing necessary medication, drinking water, wearing hat/sunscreen) that seem common-sensical and are known to and executed by our respondents, who claim to not know about the materials published by public health agencies. How then can these findings inform the health promotion efforts of entities responsible for providing cruise health advice to prospective travellers?

This qualitative ethnographic study of the health perceptions and behaviours of cruise travellers in preparation for and during their cruise holiday is an important first step to inform cruise health promotion efforts in accordance with the Ottawa Charter and strategies that enable, mediate and advocate, enlisting the participation of a variety of sectors.³⁹ A cruise ship is in many ways a unique setting in which cruise companies, responsible government agencies and individual cruisers each have important roles to play in ensuring disease prevention measures and positive health outcomes for cruise travellers and crew alike. The COVID-19 pandemic has certainly highlighted that it is in the interests of all concerned for the cruise environment to be a safe and healthy one and for the mechanisms that regulate and monitor disease outbreaks, for example, to be transparent and coordinated. Thus, while we have focused in this study on individual cruise travellers, its findings reflect and must be understood within this larger context. Cruise companies have a clear interest in promoting cruises as a fun, relaxing, entertaining holiday option and, along with travellers, a clear interest in ensuring that these aspirations are realised in conjunction with, rather than at the expense of, health and safety.

Applying a social practice framework¹⁴ we note that most people display the required competence to safeguard against unforeseen illnesses and health risks (many packed seasickness pills, everyday over-the-counter medication, sunscreen, and regularly used provided sanitiser stations). Some of the ‘materials’ to enable and encourage health protective behaviours existed (eg the above-mentioned sanitiser stations), while others were either perceived as unavailable (specialist medical care) or regarded as unaffordable (on-board pharmacy products). In terms of promoting awareness of healthy cruise behaviours, it is the meaning dimension of cruising as a social practice that health agencies need to better understand, particularly as going on a cruise is associated with many health promoting activities (eg relieving stress). Most participants displayed a sense that worrying about one's health is not an enjoyable or beneficial attitude during a fun time, especially when there is an expectation that cruise companies will be on top of any possible health risk. A cruise holiday primarily means fun and relaxation, which perhaps explains why serious health concerns were not at the forefront of people's minds and, when prompted, they tended to think about health through the lens of their everyday routine health-related practices and their general cruise activities.

To address health promotion for future cruisers one first needs to understand the position of that group. Our results help to explain inadequacies of current approaches where factual data points and suggested behaviours are dot-points, listed on the government website. We do not deny that top-down messaging tone may work well enough when people are in a heightened state of concern and actively seek out information⁴⁰ (eg COVID-19 messaging may be a case in point here), as it is conceivable that a viral pandemic (like the current one) will instil in the average person a bigger drive to seek out and consult government and related information sources on health protective behaviours.

However, if health concerns are not present or are superseded by other beliefs and behavioural orientations, top-down information dissemination is likely to have limited effectiveness, even if multiple channels (traditional and digital media) are used. It reminds one of the proverbial “field of dreams” concept (build it and they will come) where the simple dissemination of a message ensures engagement and adequate behavioural responses. Our study shows that even if such information is available – in whatever form and via whatever channel – people still need to be motivated to seek it out, which they are not predisposed to doing because ‘health’ is not at the forefront of their minds when preparing for and enjoying a cruise holiday. Participants did not report a great deal of concern or preparedness in relation to seeking out health information prior to their cruise.

What a social practice approach then contributes for the development of health promotion strategies is to reflect on message content and delivery not so much from a goal-orientation or risk avoidance purpose but from the reception or receptivity of an audience amid their everyday routines and distractions. In this context, efforts to promote health as a priority concern for cruise travellers would do well to pay attention and seek to link into, without interfering with or imposing on, people's ideas about cruise holidays as times of fun, leisure, relaxation, which are also health promoting. Aside from more radical ideas of consumer consulting panels co-deciding on messages and distribution, a possible avenue for that would be an integration of those messages in travellers’ everyday practices, including typical media engagements, or proper partnership selection to achieve a 360-degree approach.

5 CONCLUSIONS

A central point is that government health promotion on this issue is driven by a linear concept espoused by health psychology of behaviour being a direct result of variations in preceding cues, such as norms, influential cues on attitudes and the like. Subsequently, as Cohn has argued,¹⁷ “[t]he social, affective, material and interrelational features of human activity are effectively eliminated, as behaviour becomes viewed as an outcome of the individual and determined only by such things as motives, intentions and the subjective reception of norms and cues.”

Although the public health impact of cruise travel could be regarded as among the less crucial items on a government public health agenda, the sudden impact, and catastrophic consequences of the COVID-19 pandemic on ocean cruising are an extreme demonstration of its importance. Once cruising resumes, it will be necessary to reconsider cruise passenger practices, and a health or social practice perspective provides context and a better understanding of the essential complexity of human behaviour. It offers prevention and awareness campaigns a different approach from the usual causal risk-response model (this risk requires that individual behaviour) but includes the variety of social factors that drive practice. This may also apply to other contexts.

Studying how travel and travel-preparation practices for cruise holidays fit with practices in other travel modes as well as in domains such as work, family and leisure will help us understand how interventions alter practices by changing elements (using nudging approaches), disrupting connections between practice elements, or changing the relationship between those that compete for time. For example, what health risks of holidaymaking mentioned in information pamphlets coincide with cruise travellers’ own definitions of what staying healthy means? Will current practices persist or continue in a slightly altered form (eg visit a doctor prior to travel)? Will people just move to other forms of travel as a result? How do different population segments respond to the same message? Is there a benefit to early or separate communication versus point-of-sale connected messaging (eg during ticket purchase, while coming aboard)? The processes mentioned in these questions reveal the complexity and interconnectedness of behavioural practices that are not only dynamic but a result of lived experiences and social influences.^{41, 42}

The insights obtained via a social practice framework consider how healthy cruising policies and population-level interventions or awareness campaigns might differentially affect different travel practices. The practice framework we applied indicated that the culturally ingrained travel practices of cruise travellers are influenced by the availability of visible hygiene stations and what risks, or health concerns are envisioned to need preparation. This suggests that any relevant cruise health information could be connected to the cleanliness and quality assurance of cruise lines, triggering further health decisions.

In closing, the development of innovative and creative health communication and promotion strategies that are responsive to the interconnected meanings, competences and materials can have a bearing on how cruise travellers understand and enact health-related behaviours in preparation for and during a cruise holiday.⁴³

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ETHICS APPROVAL

Thank you for submitting the following Human Research Ethics Application (HREA) for HREC review; 2018/ETH00657. This project was considered by the South Eastern Sydney Local Health District HREC LNR Committee at its meeting held on 02/04/2019 and was determined to meet the requirements of the National Statement on Ethical Conduct in Human Research (2007). This project has been approved to be conducted at the following sites: South Eastern Sydney Local Health District (Site).