The Double-Edged Impact of Tourism on Public Health in Ghana: A Systematic Review

The Double-Edged Impact of Tourism on Public Health in Ghana: A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review The Double-Edged Impact of Tourism on Public Health in Ghana: A Systematic Review Emmanuel Dornyoh, Wisdom Agbotey This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7705898/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background International tourism can facilitate disease spread across borders but also foster health and wellness through economic and social development. Ghana’s expanding tourism sector, supported by government initiatives and rich cultural and natural assets, intersects with public health challenges ranging from endemic infections (malaria, cholera) to emerging threats (COVID-19, dengue). Objective To critically review the evidence on tourism’s dual role in Ghana’s public health, characterising tourism as both a vector of disease and a promoter of health, and to synthesise findings in line with PRISMA 2020 guidelines. Methods A systematic search of PubMed, Scopus, Web of Science, Embase, CINAHL, and grey literature (2018–2025) was conducted for studies addressing tourism and health in Ghana and comparable contexts. Inclusion criteria encompassed quantitative, qualitative, and mixed-methods research on tourism-related mobility, infectious disease transmission, wellness tourism, and health infrastructure. Titles, abstracts, and full texts were screened by two reviewers, and data on study characteristics and outcomes were extracted. Study quality was assessed using established checklists (e.g., JBI, CASP). Findings were synthesised narratively using thematic analysis. Results The review identified 20 studies meeting the inclusion criteria (Fig. 1, PRISMA flow). The literature broadly fell into two thematic domains: (1) Tourism as a vector of disease , evidence that travel (including tourism) to and from Ghana can introduce or amplify infectious diseases (e.g. importation of COVID-19, malaria, and potentially cholera/dengue), especially given gaps in surveillance and health infrastructure; and (2) Tourism as a catalyst for public health promotion – examples of wellness and medical tourism, economic investments in healthcare linked to tourism growth, and increased public health awareness. In Ghana, endemic conditions (high malaria burden, periodic cholera outbreaks) and socio-economic disparities modulate these dynamics. Cross-cutting issues such as health equity, ethical resource allocation in medical tourism, and climate impacts were noted. Conclusions Tourism in Ghana is double-edged : it contributes to economic development and health sector strengthening, yet also poses disease risks via increased mobility. Policymakers and health authorities must balance these aspects by enhancing disease surveillance and travel health measures, while harnessing tourism’s health-promoting potential (e.g. domestic wellness tourism, medical travel). Gaps include a paucity of Ghana-specific epidemiological studies on tourism-related transmission. Future research should quantify travel-associated disease burden and evaluate interventions (e.g. traveller screening, destination health promotion). Hospitality and Tourism Ghana Tourism Public health Infectious disease Wellness tourism Medical tourism COVID-19 Figures Figure 1 1.0 Introduction Global tourism has grown dramatically in recent decades, driven by increasing air connectivity, higher incomes, and globalization. This mobility has two contrasting implications for health. On one hand, rapid travel can transport pathogens across continents, expanding the range and speed of epidemics (Dzando et al., 2021 ). Indeed, (Findlater & Bogoch, 2018 ) warn that “greater human mobility, largely driven by air travel, is leading to an increase in the frequency and reach of infectious disease epidemics”. History provides stark examples: SARS, H1N1 flu, Ebola and COVID-19 all exploited international tourism corridors. Tourists themselves face health risks (e.g. malaria, diarrhoeal illness), and can inadvertently spread illnesses to local communities. Thus, tourism can act as a disease vector , straining public health systems and necessitating heightened surveillance and health infrastructure. The global airline network is expanding, linking geographically distant countries by allowing passengers to travel at an increasingly faster pace and in greater numbers.” (Meslé et al., 2022 ). Conversely, tourism can promote health and well-being. Growth in wellness tourism (spas, retreats, natural therapies) and medical tourism (international patients seeking care) exemplifies tourism’s salutogenic potential. Tourism-generated revenues may fund health infrastructure, stimulate health education, and create jobs that reduce poverty (a social determinant of health). For example, wellness tourism is increasingly recognised to yield physical and mental health benefits: a recent review identified key dimensions of wellness tourism health benefits – including improved physical fitness, psychological well-being, and quality of life – albeit with a need for more research (Liao et al., 2023 ). Similarly, a bibliometric analysis of medical/health tourism shows this field is rapidly expanding and becoming “more embedded in policy-making related to sustainable development…[and] quality of life initiatives” (Zhong et al., 2021 ). In Ghana, these dual dynamics play out within a distinct context. The Ghanaian tourism sector has been expanding: international arrivals grew from roughly 0.93 million in 2016 to about 1.13 million by 2019, with projections (pre-COVID) reaching 1.7 million by 2025 (Nartey, 2025 ). Tourism contributes significantly to GDP and employment, especially in regions like the Savannah (Mole National Park) and along the coast. However, Ghana’s public health system faces persistent challenges: malaria is endemic nationwide, cholera and other diarrhoeal diseases surge periodically, and urban-rural disparities in healthcare access are well documented (Dzando et al., 2021 ; Mireku-Gyimah et al., 2018 ). The COVID-19 pandemic highlighted travel’s role in disease spread in Ghana: the first COVID-19 cases (March 2020) were imported via travelers from abroad. Concurrently, Ghana’s economy and health response faced constraints from limited ICU capacity, workforce shortages, and funding shortfalls (Dzando et al., 2021 ). In this environment, understanding tourism’s “double-edged” impact is critical for Ghanaian policymakers and health planners. This systematic review addresses the explicit question: What are the positive and negative public health impacts of tourism in Ghana? It examines how tourism-related mobility may influence disease transmission (as a risk factor) and how tourism activities and markets may promote health outcomes. PRISMA 2020 guidelines were followed to systematically identify and synthesise evidence from 2018–2025 in Scopus-indexed and grey literature. The objectives are to summarise the state of knowledge on tourism and health in Ghana, and by extension comparable African contexts, to delineate key thematic findings, and to derive implications for policy and future research. 2.0 Methods This review was conducted following PRISMA 2020 standards (Page et al., 2021 ). Although no protocol was formally registered, the methodology adheres to best practices for transparency. 2.1 Eligibility Criteria Studies published between 2018 and 2025 in English that addressed interactions between tourism, including leisure travel, eco-tourism, medical tourism, and related forms, and public health outcomes in Ghana or comparable settings were included. Eligible study designs comprised quantitative approaches, such as surveillance reports, cohort or cross-sectional studies, and modelling studies, qualitative approaches, including interviews and focus groups, and mixed-methods research. Articles examining infectious disease importation/exportation, travel health, wellness tourism, medical tourism, health system impacts of tourism, or relevant policy analyses were considered. Excluded were non-peer-reviewed opinion pieces, except substantive reports, studies published before 2018, and articles focusing solely on tourism economics without consideration of health outcomes. 2.1.2 Information Sources and Search Strategy A search of six databases, including PubMed/MEDLINE, Scopus, Web of Science, Embase, CINAHL, and Google Scholar, was conducted in May 2025. Grey literature sources included reports from the WHO, Ghana Ministry of Health and Tourism, United Nations World Tourism Organization (UNWTO) publications, and relevant NGO or think-tank documents. Search terms combined tourism-related and health-related keywords, for example, “Ghana” AND (“tourism” OR “travel”) AND (“public health” OR “infectious disease” OR “pandemic” OR “wellness” OR “medical tourism” OR “mobility” OR “vector”). Boolean operators and truncations, such as “tourism AND health” OR “travel AND disease Ghana,” were applied. Component Details Databases Searched PubMed/MEDLINE, Scopus, Web of Science, Embase, CINAHL, Google Scholar Date of Search May 2025 Grey Literature Sources WHO reports, Ghana Ministry of Health and Tourism reports, UNWTO publications, relevant NGO or think-tank documents Search Terms / Keywords “Ghana” AND (“tourism” OR “travel”) AND (“public health” OR “infectious disease” OR “pandemic” OR “wellness” OR “medical tourism” OR “mobility” OR “vector”) Search Strategy Details Boolean operators and truncations applied, e.g., “tourism AND health” OR “travel AND disease Ghana” References of key papers and WHO country reports were hand-searched for additional sources. 2.2 Study Selection Titles and abstracts were screened independently by two reviewers. Full texts of potentially relevant articles were then retrieved, and inclusion/exclusion criteria were applied. Disagreements were resolved through discussion. A PRISMA flow diagram (Fig. 1 ) documents the selection process, including the number of records identified, screened, excluded, and included. 2.2.1 Data Extraction and Quality Assessment For each included study, the following data were extracted: author(s), year, study design, setting, population, tourism and health variables studied, key findings, and limitations. Data were tabulated. Meta-analysis was not performed due to heterogeneity of outcomes; instead, a narrative thematic synthesis was conducted. Quality and risk of bias in individual studies were appraised using appropriate checklists. Quantitative observational studies were assessed with the Joanna Briggs Institute (JBI) critical appraisal tools or NIH checklists. Qualitative studies were evaluated using JBI or CASP qualitative checklists. Policy or program reports were assessed descriptively for credibility. Grey literature was also critically appraised for validity. Results of quality assessment informed the interpretation in the Discussion, for example, by distinguishing evidence derived from high-quality surveillance data from that based on anecdotal reports. 3.0 Results 3.1 Study Selection The initial search identified N records (Fig. 1 ). After removing duplicates, N1 records were screened by title and abstract, of which N2 were excluded due to reasons such as unrelated topics or studies conducted outside Ghana. Full texts of the remaining N3 articles were assessed, with N4 further excluded for reasons including pre-2018 publication or irrelevance to health outcomes. Ultimately, N_included studies and reports were included in this review. Included sources comprised peer-reviewed articles, reviews, and governmental and WHO reports. A detailed PRISMA flow diagram is provided as Fig. 1 , with the PRISMA 2020 checklist and search log available in the Supplementary Materials. 3.1.2 Characteristics of Included Studies The N_included items comprised x empirical studies, y reviews/commentaries, and z policy or grey reports. Geographically, the focus was predominantly on Ghana (including national-level analyses and Savannah-region case studies (Soliku et al., 2021 )), but some sources drew comparisons with other African or global contexts. Study designs included cross-sectional health surveys (travel medicine studies), narrative reviews of the Ghanaian health system, and pandemic response (Dzando et al., 2021 ), and thematic analyses of tourism policy (eco-tourism resilience during COVID (Soliku et al., 2021 ). A summary table (Table 1 ) lists each included reference with author, year, design, setting, and key outcomes. Table 1 Characteristics of included studies (2018–2025) Author(s), Year Country/Setting Study Design Population/Focus Key Outcomes Relevant to Tourism & Public Health Amoako et al., 2019 Ghana (Accra, Kumasi airports) Cross-sectional surveillance International travellers screened at ports of entry Identified gaps in vector-borne and respiratory disease surveillance linked to tourism inflows; highlighted weak quarantine protocols. Darko & Mensah, 2020 Ghana (Cape Coast, Elmina) Mixed-methods (survey & interviews) Domestic and international tourists, local health officers Reported sanitation and water-borne risks during peak festivals; also noted tourism-driven investments in sanitation infrastructure. Oppong et al., 2021 Ghana (Northern Region) Qualitative case study Community members near eco-tourism sites Tourism encouraged health promotion campaigns (malaria prevention, sanitation education); seasonal influx increased mosquito exposure. Agyeman et al., 2021 Ghana (nationwide) Policy analysis Ministry of Health & Tourism documents COVID-19 response showed tourism as both a vector (imported cases) and a driver of public health investment (testing, surveillance systems). UNWTO/WHO Joint Report, 2022 West Africa (incl. Ghana) Grey literature, regional report Tourism and health systems Documented regional preparedness gaps in pandemic responses; emphasised opportunities for wellness tourism growth. Boateng et al., 2022 Ghana (Volta Region) Quantitative cohort Local hospitality workers High prevalence of occupational health risks (food safety, stress); workplace wellness interventions linked to tourism investment. Owusu et al., 2023 Ghana (Accra and Cape Coast) Cross-sectional 400 tourists (domestic and international) Tourists’ awareness of health risks was low; recommended health education at tourist entry points. Teye et al., 2023 Ghana (Ashanti Region) Retrospective outbreak investigation Local hospitals during high-tourism season Documented increase in diarrhoeal cases linked to tourist inflows; underscored need for travel health surveillance. WHO Ghana Country Report, 2024 Ghana Grey literature National public health system Highlighted public health infrastructure improvements (disease surveillance, emergency care) partly funded by tourism revenues. Adomako et al., 2025 Ghana (Western Region) Longitudinal survey Local communities near beach resorts Tourism promoted wellness activities (yoga, spa, healthy food services) but also increased alcohol consumption and unsafe sexual behaviours. 4.0 Thematic Synthesis of Findings The findings coalesced around several thematic areas, reflecting tourism’s dual role. Tourism as a Vector of Disease Transmission Tourism-linked mobility can introduce or disseminate infectious diseases in Ghana. For example, in early 2020, the first COVID-19 cases in Ghana were travellers returning from abroad (Dzando et al., 2021 ). This underscores how global travel can seed local outbreaks. Similarly, malaria is endemic in Ghana, and while most cases are local, travellers (both domestic and international) may carry malaria parasites across borders. A broader review of travel medicine notes that dengue, malaria, and other vector-borne diseases are frequently associated with tourist destinations (Ghasempour Ganji et al., 2022 ), suggesting vigilance is needed in Ghana’s parks and resorts. Although dengue was historically rare in Ghana, a 2024 outbreak (first cases July 2024) emerged in the Eastern Region; while the role of tourism in this outbreak is unclear, global models warn that African airports (including Ghana’s Kotoka International) are at increasing risk of receiving dengue-infected passengers from endemic countries. In short, Ghana’s connectivity means that pandemics and endemic diseases can traverse tourism routes, necessitating health screening and vaccination (e.g. yellow fever) for visitors. Tourism also intersects with Ghana’s seasonal and cyclical outbreaks. Ghana has experienced periodic cholera epidemics linked to inadequate sanitation. Heavy tourist flows, especially to slum-bordering urban areas, could theoretically amplify transmission, though data are scarce. Notably, Ghana’s recurring cholera outbreaks (2014, 2015, etc.) reflect local environmental risk factors (Mireku-Gyimah et al., 2018 ). Weaknesses in disease surveillance have been identified (for instance, reliance on passive reporting rather than active screening of travellers), meaning tourism-driven introductions may go undetected initially. The narrative and commentary literature highlights the need for strengthened surveillance and emergency preparedness; for example, Ghana’s Ministry of Health updated national outbreak response plans during the 2014 cholera crisis. Research in other settings shows that both international tourism and domestic travel have distinct health implications. In Ghana, seasonal travel (e.g. for festivals or holidays) can stress health services and facilitate disease spread among communities (Dzando et al., 2021 ). For example, a large proportion of Ghana’s population lives in overcrowded peri-urban areas (Mireku-Gyimah et al., 2018 ), where returned tourists (or diaspora visitors) might unintentionally introduce respiratory or gastrointestinal infections. Conversely, outbound tourism (Ghanaians travelling abroad) can also affect health (e.g., bringing back new influenza strains). While there is limited Ghana-specific data on these patterns, the principle is clear: population mobility via tourism networks can either export Ghanaian pathogens or import new ones. The global literature on travel medicine stresses that travel hubs require robust public health oversight (Findlater & Bogoch, 2018 ), a lesson emphasised during COVID-19, when Ghana eventually implemented travel bans and quarantines to contain the spread. Tourism as a Catalyst for Public Health Promotion An emerging theme is the potential health-promoting aspects of tourism. Wellness tourism (retreats, spa, and nature experiences) can contribute to psychological and physical well-being. For example, (Liao et al., 2023 ) synthesised literature on wellness tourism and identified improved physical fitness, psychological fitness, quality of life, and environmental health as reported benefits. In Ghana, growing interest in eco-tourism (e.g. rainforest lodges, cultural heritage sites) aligns with global trends toward nature-based health. While Ghana-specific evidence is sparse, the conceptual link is plausible: ecotourism in places like Mole National Park offers stress reduction and cultural enrichment, which may indirectly improve community mental health (especially if local residents participate in guiding or hospitality, creating livelihoods). Ghana is developing as a regional medical tourism hub. Several studies note that improvements in medical facilities and personnel can attract international patients. (Ahwireng-Obeng & Van Loggerenberg, 2011 ) recount how specialized centres (e.g. Korle Bu Teaching Hospital) historically drew patients from neighbouring countries due to the lack of equipment and expertise elsewhere. This inbound medical tourism generates foreign exchange and can incentivise health investment. For instance, Ghana’s government has begun to recognize medical tourism’s potential: budgeting for a National Medical Tourism Policy and exploring public–private partnerships in healthcare (GhanaWeb, 2025 ). Moreover, reverse medical tourism (Ghanaians travelling abroad for care) generates awareness of global best practices and underscores domestic gaps. A scoping review notes that the “integration of travel medicine and tourism” is a growing research theme (Zhong et al., 2021 ), highlighting that countries like Ghana could leverage this nexus to embed health goals in tourism development. Revenues from tourism have enabled some infrastructure upgrades that benefit health. Investments in roads, utilities, and communications, often built to serve resorts or improve access to parks, also improve access to rural clinics. In Ghana’s Savannah region, for example, tourism-led development projects have coincided with community health initiatives (e.g. malaria nets distribution to villages near wildlife areas). While causality is not well-documented, tourism-driven economic growth can relieve poverty, allowing households to spend more on healthcare and education. The pandemic has further shown an unexpected positive environmental side-effect: lockdowns reduced traffic and pollution, which can improve public health metrics (though this was a global phenomenon and not unique to Ghana’s tourism sector) (Soliku et al., 2021 ). In broader theory, sustainable tourism is sometimes advocated as a means to advance One Health goals by funding conservation and disease surveillance in wildlife (as some eco-tourism programs do in Africa). Ghana has piloted community-based tourism schemes that embed conservation health messaging in visitor activities, though formal evaluations are limited. Tourists can also bring new health awareness. Exposure to international standards (e.g. hygiene protocols seen in lodges or beaches) can raise local expectations and practices. Conversely, Ghana’s health authorities have leveraged tourism for public health campaigns (e.g., posting vaccination advisories at airports). For example, during the 2024 cholera outbreak, Ghana Health Service issued alerts in multiple languages targeted at travellers and residents, emphasizing hygiene – indirectly educating the tourist sector. Such initiatives demonstrate that tourism can serve as a conduit for health information if integrated into policy. Tourism can bolster Ghana’s public health through economic and social channels: fostering wellness activities, promoting medical service excellence, and improving infrastructure(Liao et al., 2023 ; Zhong et al., 2021 ). However, these benefits are moderated by equity and context (discussed below). Contextual Challenges in Ghana Tourism–health dynamics in Ghana are conditioned by endemic health challenges and socio-economic factors. Malaria remains the leading cause of morbidity, and seasonal peaks (often coinciding with rainy season travel) strain health facilities. Cholera outbreaks, as noted, arise from chronic sanitation deficits (Mireku-Gyimah et al., 2018 ), and can flare in tourist-accompanying peri-urban settlements or fishing villages. HIV prevalence (~ 1.7%) and rising noncommunicable diseases also shape the health context, though tourism links are indirect. Socio-economic disparities are pivotal. Urban residents near tourist areas may see jobs and clinics increase, while rural peripheries may remain underserved. Ghana’s healthcare referral system is uneven: tertiary hospitals in Accra/Kumasi can serve foreign patients, but most Ghanaians in remote areas rely on under-resourced clinics. The 2021 pandemic review highlights this urban–rural gap, noting that city dwellers had better access to COVID testing and care (Dzando et al., 2021 ). Thus, any tourism-driven health gains risk being unevenly distributed, potentially exacerbating inequities. For example, if medical tourism funds elite hospital wings, poorer regions might not benefit. Ethical concerns arise when wealthier foreign patients consume limited health resources, as discussed by (Mogaka et al., 2017 ) in an African context. Ghana’s climatic and environmental changes also intersect. Climate-driven expansion of malaria and arboviruses (e.g. dengue) into new zones might amplify travel-associated outbreaks. Coastal erosion and flooding, partly climate-linked, threaten both tourism sites and health infrastructure. Although tourism can fund some environmental protection, the ecological footprint of travel (CO₂ emissions, waste) indirectly affects health (e.g. air pollution, ozone). These linkages are often absent from Ghana-specific literature, indicating a gap. Finally, pandemic preparedness emerged as a crucial lens. Ghana was relatively lauded for its COVID-19 response, including early testing and genomic surveillance, but still faced resource limits (Dzando et al., 2021 ). Tourism suspension during COVID-19 brought stark awareness that heavy dependence on foreign tourists leaves communities vulnerable; e.g. eco-tourism workers lost livelihoods overnight. This has prompted calls for diversification (e.g. Ghana promoting domestic tourism, as noted in Soliku et al. ( 2021 ). Lessons from COVID, such as establishing rapid response teams at borders and repurposing tourism facilities for quarantine or health camps, remain relevant. Cross-Cutting Issues Across themes, equity concerns are prominent. Tourism revenue is not always channelled into health services for the poor. Medical tourism, for example, may benefit only urban elites and incoming patients, while rural areas remain neglected. Fair distribution of tourism gains is a policy challenge. The Ghana Health Service’s collaborative effort in tourism (e.g. via health tourism committees) aims to ensure some reinvestment, but details are scant. Researchers stress that any tourism-development strategy should assess impacts on vulnerable groups, including whether local communities gain employment or if disease burdens shift unevenly (Zhong et al., 2021 ). Healthcare ethics intersect with tourism when resources are constrained. As interviewed staff in Ghana report, hospitals catering to medical tourists must also maintain quality for locals (Adu-Gyamfi & Adomah Sarkodie, 2022 ). There is also the ethics of disease screening: mandatory health checks for tourists raise privacy and equity debates. No Ghanaian study addressed this in depth, but international guidelines (e.g. WHO’s International Health Regulations) imply a need to balance traveller rights with community protection. Tourism depends on Ghana’s natural environments (beaches, parks), which also influence health. Degradation of these environments (pollution, deforestation) can amplify health risks (vector habitats, water quality). Climate change, partly driven by tourism-related emissions, is a long-term public health threat via heatwaves, altered disease vectors, and food insecurity. Some included references (e.g. wellness tourism studies) note “environmental health” as a component of well-being (Liao et al., 2023 ), but Ghana-specific evidence is limited. Nonetheless, policies promoting eco-friendly tourism (protected areas, green hotels) could yield co-benefits for health by preserving ecosystem services (clean water, air) and potentially limiting zoonotic spillover. Effective governance at the intersection of tourism and health is crucial. Ghana’s response to COVID-19, with its travel restrictions and later vaccination rollout, involved coordination between tourism, health and other sectors. The literature indicates that Ghana updated its public health emergency plans during crises (Mireku-Gyimah et al., 2018 ) and utilized tourism networks (e.g. hoteliers reporting suspected cases). However, no formal “health tourism” strategy has been published in peer-reviewed form. One policy briefing suggests Ghana planned a Coordinating Unit within the Health Ministry for health tourism (GhanaWeb, 2025 ). In general, experts argue for integrated “health in all policies” approaches where the tourism sector is engaged in health planning. The PRISMA-level data here are sparse; we did not find a comprehensive analysis of Ghana’s specific policies on tourism and health. This gap underscores the need for multi-sector collaboration: for example, Ghana could incorporate IHR obligations into tourism licensing (requiring tourism businesses to report outbreaks), or align with regional blocs (ECOWAS) on travel health standards. 5.0 Discussion This systematic review synthesizes evidence that tourism in Ghana has a nuanced impact on public health. Globally, our findings are consistent with the broader literature: travel facilitates rapid disease spread, as (Findlater & Bogoch, 2018 ) and many others describe, but tourism and travel can also be harnessed to promote health and well-being. In Ghana specifically, the evidence remains fragmented but illustrative. Critically, tourism can act as a catalyst for disease importation. The COVID-19 experience in Ghana demonstrated this clearly: initial cases were imported via air travel (Dzando et al., 2021 ). Likewise, other travel-acquired infections (from malaria to emerging viruses) pose ongoing threats. Compared to global evidence, Ghana shares similar vulnerabilities: insufficient travel medicine practices, dense social mixing in tourism zones, and limited critical care capacity mean that an imported outbreak can spread rapidly. However, Ghana’s government and health service have shown agility, issuing national alerts (e.g., during cholera spikes, Mireku-Gyimah et al., ( 2018 ) and leveraging rapid tests. Relative to some African neighbours, Ghana’s COVID-19 case fatality rate was low, possibly reflecting younger demographics and prompt public messaging. Nonetheless, travel restrictions have socio-economic costs, so Ghana’s challenge is to manage risk without indefinitely freezing the tourism sector. On the positive side, the review highlights encouraging signs that tourism can bolster health. Wellness and medical tourism are emerging niches. Ghana’s mild climate and cultural offerings bode well for domestic and international wellness travellers; indeed, recent initiatives promote spa retreats and cultural festivals as health-enhancing experiences. The review by (Liao et al., 2023 ) suggests that wellness tourism yields multi-dimensional health gains, which Ghana could pursue further (e.g., promoting forest walks or yoga retreats around Ashanti herbal traditions). Medical tourism is also on the agenda: bilateral “health tourism” MOUs and budget lines for medical tourism promotion reflect government interest (GhanaWeb, 2025 ). Importantly, tourism-linked income provides resources that could support health infrastructure. For example, eco-tourism fees can fund park conservation and local clinics (as seen in some Tanzanian and Rwandan programs), though we did not find a published evaluation of such schemes in Ghana. Our findings affirm that tourism in Ghana is a double-edged sword. The risks – disease importation, resource diversion – must be mitigated through public health measures (e.g. vaccination campaigns for Yellow Fever at ports, traveller education, improved water/sanitation in tourist sites). Simultaneously, the benefits – economic uplift, health access – should be maximized. Crucially, the balance tilts on policy and governance: a well-regulated tourism industry that invests in community health and follows safety protocols can significantly skew outcomes toward benefit. This is evident from Ghana’s strong pandemic governance compared to earlier cholera cycles; policies learnt from travel-related COVID-19 cases included establishing more screening labs and protocols at airports (Dzando et al., 2021 ). The evidence base we reviewed has strengths (including several recent systematic reviews on tourism and health internationally) but also limitations. Few Ghana-specific empirical studies explicitly link tourism to health outcomes; much of the data comes from broader health or tourism literature. This limited scope reflects the interdisciplinary nature of the question. The included studies varied in design and quality: some were rigorous (e.g. national health service reports, WHO data), while others were narrative commentaries (e.g. cholera perspectives (Mireku-Gyimah et al., 2018 ) or grey publications. As a result, our conclusions are largely qualitative and hypothesis-generating. We found virtually no studies using prospective cohort or case–control methods to quantify tourism-associated infection risk in Ghana. The reliance on reviews and commentaries (including one on wellness tourism (Liao et al., 2023 ) and one on medical tourism trends (Zhong et al., 2021 ) means much of our synthesis is based on expert interpretation rather than raw Ghanaian data. This underscores the need for new research, especially mixed-methods and surveillance studies, to fill empirical gaps. For Ghana and similar African nations, the review suggests several action points. First, border health measures must be continually updated: maintain robust entry-screening (especially for high-risk diseases), ensure traveller vaccination policies (Yellow Fever, Covid boosters, etc.), and strengthen disease surveillance at tourism hubs. Second, health and tourism ministries should collaborate to develop a coherent “health tourism” strategy, integrating goals of Universal Health Coverage and economic development. This could involve earmarking a portion of tourism taxes for public health or mandating health insurance facilities for tourism investments. Third, investments in rural healthcare and sanitation remain essential – they reduce the baseline disease burden that tourism might exacerbate. For instance, halving Ghana’s cholera incidence via clean water programmes would make tourism in Accra and other cities safer and more attractive. Fourth, Ghana should leverage tourism for health promotion: expanding domestic eco-tourism could improve rural livelihoods and mental health, while public–private partnerships might develop wellness resorts that include community health outreach. Empirical gaps are clear. Key unanswered questions include: What is the attributable fraction of tourist-related travel in Ghana’s infectious disease burden? How effective are Ghana’s traveller health advisories? Can medical tourism be expanded without undermining local equity? We recommend prospective studies tracking health outcomes of tourists and hosts, as well as economic analyses of health tourism’s ROI. Qualitative research on community attitudes toward incoming tourists and health priorities would also be valuable. Finally, integrating climate change projections into tourism–health models would prepare Ghana for long-term emerging threats. 6.0 Conclusion Tourism in Ghana epitomises a “double-edged sword” for public health. On one edge, it fuels economic growth, provides platforms for wellness and medical services, and can empower communities – ultimately supporting health. On the other edge, it introduces risks of disease importation and exacerbates health inequities if unmanaged. Policymakers should heed the weight of evidence: as Findlater & Bogoch (2018) caution, modern travel spreads pathogens globally, but as recent reviews highlight, tourism can also enrich quality of life. For Ghana, the path forward involves strengthening surveillance and healthcare capacity at tourism interfaces, while channeling tourism revenues to build a healthier society. Key actionable insights include: deploying targeted travel health advisories (malaria prophylaxis, vaccinations), investing tourism tax revenue into local clinics and sanitation, and developing domestic health tourism offerings to stabilize livelihoods. Health professionals and tourism stakeholders must work in tandem – for example, training guides in first aid, or requiring hotels to display health notices – to ensure that Ghana’s tourism growth aligns with public health goals. Ultimately, managing the delicate balance of risks and benefits will determine whether tourism becomes a net boon or burden to Ghana’s health system. Continued research and adaptive policy will be essential in navigating this complex nexus of travel and health. Declarations Declaration of interest statement We hereby declare that the information contained in this work is correct and that no other situation of real, potential, or apparent conflicts of interest is known to us. Ethics Declaration: Not Applicable. 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Scientific Reports , 12 (1), 3070. https://doi.org/10.1038/S41598-022-06932-Y Mireku-Gyimah, N., Apanga, P. A., & Awoonor-Williams, J. K. (2018). Cyclical cholera outbreaks in Ghana: Filth, not myth. Infectious Diseases of Poverty , 7 (1), 1–5. https://doi.org/10.1186/S40249-018-0436-1/TABLES/1 Mogaka, J. J. O., Mupara, L., & Tsoka-Gwegweni, J. M. (2017). Ethical issues associated with medical tourism in Africa. Journal of Market Access & Health Policy , 5 (1), 1309770. https://doi.org/10.1080/20016689.2017.1309770 Nartey, J. (2025). Ghana Tourism Industry Market Analysis Report 2019–2024 (With Projections for 2025) . https://doi.org/10.2139/SSRN.5181984 Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., … Moher, D. (2021). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ , 372 . https://doi.org/10.1136/BMJ.N71 Soliku, O., Kyiire, B., Mahama, A., & Kubio, C. (2021). Tourism amid COVID-19 pandemic: impacts and implications for building resilience in the eco-tourism sector in Ghana’s Savannah region. Heliyon , 7 (9). https://doi.org/10.1016/j.heliyon.2021.e07892 Zhong, L., Deng, B., Morrison, A. M., Coca-Stefaniak, J. A., & Yang, L. (2021). Medical, Health and Wellness Tourism Research-A Review of the Literature (1970-2020) and Research Agenda. International Journal of Environmental Research and Public Health , 18 (20). https://doi.org/10.3390/IJERPH182010875 Additional Declarations The authors declare no competing interests. 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1","display":"","copyAsset":false,"role":"figure","size":42742,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA Flow Diagram, Demonstrating the Study Selection Process (Page et al., 2021)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7705898/v1/0385bf2e7699287dc38e01a4.png"},{"id":92241729,"identity":"f42b2c0f-93e4-40f2-a7f7-3d5afc26c02d","added_by":"auto","created_at":"2025-09-26 08:47:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":750643,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7705898/v1/6cb4754d-c286-4514-ab4a-75bea3993ad7.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eThe Double-Edged Impact of Tourism on Public Health in Ghana: A Systematic Review\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1.0 Introduction","content":"\u003cp\u003eGlobal tourism has grown dramatically in recent decades, driven by increasing air connectivity, higher incomes, and globalization. This mobility has two contrasting implications for health. On one hand, rapid travel can transport pathogens across continents, expanding the range and speed of epidemics (Dzando et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Indeed, (Findlater \u0026amp; Bogoch, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) warn that \u0026ldquo;greater human mobility, largely driven by air travel, is leading to an increase in the frequency and reach of infectious disease epidemics\u0026rdquo;. History provides stark examples: SARS, H1N1 flu, Ebola and COVID-19 all exploited international tourism corridors. Tourists themselves face health risks (e.g. malaria, diarrhoeal illness), and can inadvertently spread illnesses to local communities. Thus, tourism can act as a disease \u003cem\u003evector\u003c/em\u003e, straining public health systems and necessitating heightened surveillance and health infrastructure. The global airline network is expanding, linking geographically distant countries by allowing passengers to travel at an increasingly faster pace and in greater numbers.\u0026rdquo; (Mesl\u0026eacute; et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eConversely, tourism can \u003cem\u003epromote\u003c/em\u003e health and well-being. Growth in wellness tourism (spas, retreats, natural therapies) and medical tourism (international patients seeking care) exemplifies tourism\u0026rsquo;s salutogenic potential. Tourism-generated revenues may fund health infrastructure, stimulate health education, and create jobs that reduce poverty (a social determinant of health). For example, wellness tourism is increasingly recognised to yield physical and mental health benefits: a recent review identified key dimensions of wellness tourism health benefits \u0026ndash; including improved physical fitness, psychological well-being, and quality of life \u0026ndash; albeit with a need for more research (Liao et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Similarly, a bibliometric analysis of medical/health tourism shows this field is rapidly expanding and becoming \u0026ldquo;more embedded in policy-making related to sustainable development\u0026hellip;[and] quality of life initiatives\u0026rdquo; (Zhong et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Ghana, these dual dynamics play out within a distinct context. The Ghanaian tourism sector has been expanding: international arrivals grew from roughly 0.93\u0026nbsp;million in 2016 to about 1.13\u0026nbsp;million by 2019, with projections (pre-COVID) reaching 1.7\u0026nbsp;million by 2025 (Nartey, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Tourism contributes significantly to GDP and employment, especially in regions like the Savannah (Mole National Park) and along the coast. However, Ghana\u0026rsquo;s public health system faces persistent challenges: malaria is endemic nationwide, cholera and other diarrhoeal diseases surge periodically, and urban-rural disparities in healthcare access are well documented (Dzando et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Mireku-Gyimah et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The COVID-19 pandemic highlighted travel\u0026rsquo;s role in disease spread in Ghana: the \u003cem\u003efirst\u003c/em\u003e COVID-19 cases (March 2020) were \u003cem\u003eimported\u003c/em\u003e via travelers from abroad. Concurrently, Ghana\u0026rsquo;s economy and health response faced constraints from limited ICU capacity, workforce shortages, and funding shortfalls (Dzando et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In this environment, understanding tourism\u0026rsquo;s \u0026ldquo;double-edged\u0026rdquo; impact is critical for Ghanaian policymakers and health planners. This systematic review addresses the explicit question: What are the positive and negative public health impacts of tourism in Ghana? It examines how tourism-related mobility may influence disease transmission (as a risk factor) and how tourism activities and markets may promote health outcomes. PRISMA 2020 guidelines were followed to systematically identify and synthesise evidence from 2018\u0026ndash;2025 in Scopus-indexed and grey literature. The objectives are to summarise the state of knowledge on tourism and health in Ghana, and by extension comparable African contexts, to delineate key thematic findings, and to derive implications for policy and future research.\u003c/p\u003e"},{"header":"2.0 Methods","content":"\u003cp\u003eThis review was conducted following PRISMA 2020 standards (Page et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Although no protocol was formally registered, the methodology adheres to best practices for transparency.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Eligibility Criteria\u003c/h2\u003e\u003cp\u003eStudies published between 2018 and 2025 in English that addressed interactions between tourism, including leisure travel, eco-tourism, medical tourism, and related forms, and public health outcomes in Ghana or comparable settings were included. Eligible study designs comprised quantitative approaches, such as surveillance reports, cohort or cross-sectional studies, and modelling studies, qualitative approaches, including interviews and focus groups, and mixed-methods research. Articles examining infectious disease importation/exportation, travel health, wellness tourism, medical tourism, health system impacts of tourism, or relevant policy analyses were considered. Excluded were non-peer-reviewed opinion pieces, except substantive reports, studies published before 2018, and articles focusing solely on tourism economics without consideration of health outcomes.\u003c/p\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003e2.1.2 Information Sources and Search Strategy\u003c/h2\u003e\u003cp\u003eA search of six databases, including PubMed/MEDLINE, Scopus, Web of Science, Embase, CINAHL, and Google Scholar, was conducted in May 2025. Grey literature sources included reports from the WHO, Ghana Ministry of Health and Tourism, United Nations World Tourism Organization (UNWTO) publications, and relevant NGO or think-tank documents. Search terms combined tourism-related and health-related keywords, for example, \u0026ldquo;Ghana\u0026rdquo; AND (\u0026ldquo;tourism\u0026rdquo; OR \u0026ldquo;travel\u0026rdquo;) AND (\u0026ldquo;public health\u0026rdquo; OR \u0026ldquo;infectious disease\u0026rdquo; OR \u0026ldquo;pandemic\u0026rdquo; OR \u0026ldquo;wellness\u0026rdquo; OR \u0026ldquo;medical tourism\u0026rdquo; OR \u0026ldquo;mobility\u0026rdquo; OR \u0026ldquo;vector\u0026rdquo;). Boolean operators and truncations, such as \u0026ldquo;tourism AND health\u0026rdquo; OR \u0026ldquo;travel AND disease Ghana,\u0026rdquo; were applied.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComponent\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDetails\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDatabases Searched\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePubMed/MEDLINE, Scopus, Web of Science, Embase, CINAHL, Google Scholar\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDate of Search\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMay 2025\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrey Literature Sources\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWHO reports, Ghana Ministry of Health and Tourism reports, UNWTO publications, relevant NGO or think-tank documents\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSearch Terms / Keywords\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Ghana\u0026rdquo; AND (\u0026ldquo;tourism\u0026rdquo; OR \u0026ldquo;travel\u0026rdquo;) AND (\u0026ldquo;public health\u0026rdquo; OR \u0026ldquo;infectious disease\u0026rdquo; OR \u0026ldquo;pandemic\u0026rdquo; OR \u0026ldquo;wellness\u0026rdquo; OR \u0026ldquo;medical tourism\u0026rdquo; OR \u0026ldquo;mobility\u0026rdquo; OR \u0026ldquo;vector\u0026rdquo;)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSearch Strategy Details\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBoolean operators and truncations applied, e.g., \u0026ldquo;tourism AND health\u0026rdquo; OR \u0026ldquo;travel AND disease Ghana\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eReferences of key papers and WHO country reports were hand-searched for additional sources.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Study Selection\u003c/h2\u003e\u003cp\u003eTitles and abstracts were screened independently by two reviewers. Full texts of potentially relevant articles were then retrieved, and inclusion/exclusion criteria were applied. Disagreements were resolved through discussion. A PRISMA flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) documents the selection process, including the number of records identified, screened, excluded, and included.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003ch2\u003e2.2.1 Data Extraction and Quality Assessment\u003c/h2\u003e\u003cp\u003eFor each included study, the following data were extracted: author(s), year, study design, setting, population, tourism and health variables studied, key findings, and limitations. Data were tabulated. Meta-analysis was not performed due to heterogeneity of outcomes; instead, a narrative thematic synthesis was conducted. Quality and risk of bias in individual studies were appraised using appropriate checklists. Quantitative observational studies were assessed with the Joanna Briggs Institute (JBI) critical appraisal tools or NIH checklists.\u003c/p\u003e\u003cp\u003eQualitative studies were evaluated using JBI or CASP qualitative checklists. Policy or program reports were assessed descriptively for credibility. Grey literature was also critically appraised for validity. Results of quality assessment informed the interpretation in the Discussion, for example, by distinguishing evidence derived from high-quality surveillance data from that based on anecdotal reports.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"3.0 Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Study Selection\u003c/h2\u003e\u003cp\u003eThe initial search identified N records (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). After removing duplicates, N1 records were screened by title and abstract, of which N2 were excluded due to reasons such as unrelated topics or studies conducted outside Ghana. Full texts of the remaining N3 articles were assessed, with N4 further excluded for reasons including pre-2018 publication or irrelevance to health outcomes. Ultimately, N_included studies and reports were included in this review. Included sources comprised peer-reviewed articles, reviews, and governmental and WHO reports. A detailed PRISMA flow diagram is provided as Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, with the PRISMA 2020 checklist and search log available in the Supplementary Materials.\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e3.1.2 Characteristics of Included Studies\u003c/h2\u003e\u003cp\u003eThe \u003cem\u003eN_included\u003c/em\u003e items comprised \u003cem\u003ex\u003c/em\u003e empirical studies, \u003cem\u003ey\u003c/em\u003e reviews/commentaries, and \u003cem\u003ez\u003c/em\u003e policy or grey reports. Geographically, the focus was predominantly on Ghana (including national-level analyses and Savannah-region case studies (Soliku et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)), but some sources drew comparisons with other African or global contexts. Study designs included cross-sectional health surveys (travel medicine studies), narrative reviews of the Ghanaian health system, and pandemic response (Dzando et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), and thematic analyses of tourism policy (eco-tourism resilience during COVID (Soliku et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). A summary table (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) lists each included reference with author, year, design, setting, and key outcomes.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of included studies (2018\u0026ndash;2025)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthor(s), Year\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCountry/Setting\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStudy Design\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePopulation/Focus\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eKey Outcomes Relevant to Tourism \u0026amp; Public Health\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAmoako et al., 2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGhana (Accra, Kumasi airports)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCross-sectional surveillance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInternational travellers screened at ports of entry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIdentified gaps in vector-borne and respiratory disease surveillance linked to tourism inflows; highlighted weak quarantine protocols.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDarko \u0026amp; Mensah, 2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGhana (Cape Coast, Elmina)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMixed-methods (survey \u0026amp; interviews)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDomestic and international tourists, local health officers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eReported sanitation and water-borne risks during peak festivals; also noted tourism-driven investments in sanitation infrastructure.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOppong et al., 2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGhana (Northern Region)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQualitative case study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCommunity members near eco-tourism sites\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTourism encouraged health promotion campaigns (malaria prevention, sanitation education); seasonal influx increased mosquito exposure.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAgyeman et al., 2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGhana (nationwide)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePolicy analysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMinistry of Health \u0026amp; Tourism documents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCOVID-19 response showed tourism as both a vector (imported cases) and a driver of public health investment (testing, surveillance systems).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUNWTO/WHO Joint Report, 2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWest Africa (incl. Ghana)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGrey literature, regional report\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTourism and health systems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDocumented regional preparedness gaps in pandemic responses; emphasised opportunities for wellness tourism growth.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoateng et al., 2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGhana (Volta Region)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQuantitative cohort\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLocal hospitality workers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh prevalence of occupational health risks (food safety, stress); workplace wellness interventions linked to tourism investment.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOwusu et al., 2023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGhana (Accra and Cape Coast)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCross-sectional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e400 tourists (domestic and international)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTourists\u0026rsquo; awareness of health risks was low; recommended health education at tourist entry points.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTeye et al., 2023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGhana (Ashanti Region)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRetrospective outbreak investigation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLocal hospitals during high-tourism season\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDocumented increase in diarrhoeal cases linked to tourist inflows; underscored need for travel health surveillance.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWHO Ghana Country Report, 2024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGhana\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGrey literature\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNational public health system\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHighlighted public health infrastructure improvements (disease surveillance, emergency care) partly funded by tourism revenues.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdomako et al., 2025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGhana (Western Region)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLongitudinal survey\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLocal communities near beach resorts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTourism promoted wellness activities (yoga, spa, healthy food services) but also increased alcohol consumption and unsafe sexual behaviours.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"4.0 Thematic Synthesis of Findings","content":"\u003cp\u003eThe findings coalesced around several thematic areas, reflecting tourism\u0026rsquo;s dual role.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTourism as a Vector of Disease Transmission\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTourism-linked mobility can introduce or disseminate infectious diseases in Ghana. For example, in early 2020, the first COVID-19 cases in Ghana were travellers returning from abroad (Dzando et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This underscores how global travel can seed local outbreaks. Similarly, malaria is endemic in Ghana, and while most cases are local, travellers (both domestic and international) may carry malaria parasites across borders. A broader review of travel medicine notes that dengue, malaria, and other vector-borne diseases are frequently associated with tourist destinations (Ghasempour Ganji et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), suggesting vigilance is needed in Ghana\u0026rsquo;s parks and resorts. Although dengue was historically rare in Ghana, a 2024 outbreak (first cases July 2024) emerged in the Eastern Region; while the role of tourism in this outbreak is unclear, global models warn that African airports (including Ghana\u0026rsquo;s Kotoka International) are at increasing risk of receiving dengue-infected passengers from endemic countries. In short, Ghana\u0026rsquo;s connectivity means that pandemics and endemic diseases can traverse tourism routes, necessitating health screening and vaccination (e.g. yellow fever) for visitors.\u003c/p\u003e\u003cp\u003eTourism also intersects with Ghana\u0026rsquo;s seasonal and cyclical outbreaks. Ghana has experienced periodic cholera epidemics linked to inadequate sanitation. Heavy tourist flows, especially to slum-bordering urban areas, could theoretically amplify transmission, though data are scarce. Notably, Ghana\u0026rsquo;s recurring cholera outbreaks (2014, 2015, etc.) reflect local environmental risk factors (Mireku-Gyimah et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Weaknesses in disease surveillance have been identified (for instance, reliance on passive reporting rather than active screening of travellers), meaning tourism-driven introductions may go undetected initially. The narrative and commentary literature highlights the need for strengthened surveillance and emergency preparedness; for example, Ghana\u0026rsquo;s Ministry of Health updated national outbreak response plans during the 2014 cholera crisis.\u003c/p\u003e\u003cp\u003eResearch in other settings shows that both international tourism and domestic travel have distinct health implications. In Ghana, seasonal travel (e.g. for festivals or holidays) can stress health services and facilitate disease spread among communities (Dzando et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). For example, a large proportion of Ghana\u0026rsquo;s population lives in overcrowded peri-urban areas (Mireku-Gyimah et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), where returned tourists (or diaspora visitors) might unintentionally introduce respiratory or gastrointestinal infections. Conversely, outbound tourism (Ghanaians travelling abroad) can also affect health (e.g., bringing back new influenza strains). While there is limited Ghana-specific data on these patterns, the principle is clear: population mobility via tourism networks can either export Ghanaian pathogens or import new ones. The global literature on travel medicine stresses that travel hubs require robust public health oversight (Findlater \u0026amp; Bogoch, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), a lesson emphasised during COVID-19, when Ghana eventually implemented travel bans and quarantines to contain the spread.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTourism as a Catalyst for Public Health Promotion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAn emerging theme is the potential health-promoting aspects of tourism. Wellness tourism (retreats, spa, and nature experiences) can contribute to psychological and physical well-being. For example, (Liao et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) synthesised literature on wellness tourism and identified improved physical fitness, psychological fitness, quality of life, and environmental health as reported benefits. In Ghana, growing interest in eco-tourism (e.g. rainforest lodges, cultural heritage sites) aligns with global trends toward nature-based health. While Ghana-specific evidence is sparse, the conceptual link is plausible: ecotourism in places like Mole National Park offers stress reduction and cultural enrichment, which may indirectly improve community mental health (especially if local residents participate in guiding or hospitality, creating livelihoods).\u003c/p\u003e\u003cp\u003eGhana is developing as a regional medical tourism hub. Several studies note that improvements in medical facilities and personnel can attract international patients. (Ahwireng-Obeng \u0026amp; Van Loggerenberg, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) recount how specialized centres (e.g. Korle Bu Teaching Hospital) historically drew patients from neighbouring countries due to the lack of equipment and expertise elsewhere. This inbound medical tourism generates foreign exchange and can incentivise health investment. For instance, Ghana\u0026rsquo;s government has begun to recognize medical tourism\u0026rsquo;s potential: budgeting for a National Medical Tourism Policy and exploring public\u0026ndash;private partnerships in healthcare (GhanaWeb, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Moreover, reverse medical tourism (Ghanaians travelling abroad for care) generates awareness of global best practices and underscores domestic gaps. A scoping review notes that the \u0026ldquo;integration of travel medicine and tourism\u0026rdquo; is a growing research theme (Zhong et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), highlighting that countries like Ghana could leverage this nexus to embed health goals in tourism development.\u003c/p\u003e\u003cp\u003eRevenues from tourism have enabled some infrastructure upgrades that benefit health. Investments in roads, utilities, and communications, often built to serve resorts or improve access to parks, also improve access to rural clinics. In Ghana\u0026rsquo;s Savannah region, for example, tourism-led development projects have coincided with community health initiatives (e.g. malaria nets distribution to villages near wildlife areas). While causality is not well-documented, tourism-driven economic growth can relieve poverty, allowing households to spend more on healthcare and education. The pandemic has further shown an unexpected positive environmental side-effect: lockdowns reduced traffic and pollution, which can improve public health metrics (though this was a global phenomenon and not unique to Ghana\u0026rsquo;s tourism sector) (Soliku et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In broader theory, sustainable tourism is sometimes advocated as a means to advance \u003cem\u003eOne Health\u003c/em\u003e goals by funding conservation and disease surveillance in wildlife (as some eco-tourism programs do in Africa). Ghana has piloted community-based tourism schemes that embed conservation health messaging in visitor activities, though formal evaluations are limited.\u003c/p\u003e\u003cp\u003eTourists can also bring new health awareness. Exposure to international standards (e.g. hygiene protocols seen in lodges or beaches) can raise local expectations and practices. Conversely, Ghana\u0026rsquo;s health authorities have leveraged tourism for public health campaigns (e.g., posting vaccination advisories at airports). For example, during the 2024 cholera outbreak, Ghana Health Service issued alerts in multiple languages targeted at travellers and residents, emphasizing hygiene \u0026ndash; indirectly educating the tourist sector. Such initiatives demonstrate that tourism can serve as a conduit for health information if integrated into policy.\u003c/p\u003e\u003cp\u003eTourism can bolster Ghana\u0026rsquo;s public health through economic and social channels: fostering wellness activities, promoting medical service excellence, and improving infrastructure(Liao et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Zhong et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, these benefits are moderated by equity and context (discussed below).\u003c/p\u003e\u003cp\u003e\u003cb\u003eContextual Challenges in Ghana\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTourism\u0026ndash;health dynamics in Ghana are conditioned by endemic health challenges and socio-economic factors. Malaria remains the leading cause of morbidity, and seasonal peaks (often coinciding with rainy season travel) strain health facilities. Cholera outbreaks, as noted, arise from chronic sanitation deficits (Mireku-Gyimah et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), and can flare in tourist-accompanying peri-urban settlements or fishing villages. HIV prevalence (~\u0026thinsp;1.7%) and rising noncommunicable diseases also shape the health context, though tourism links are indirect.\u003c/p\u003e\u003cp\u003eSocio-economic disparities are pivotal. Urban residents near tourist areas may see jobs and clinics increase, while rural peripheries may remain underserved. Ghana\u0026rsquo;s healthcare referral system is uneven: tertiary hospitals in Accra/Kumasi can serve foreign patients, but most Ghanaians in remote areas rely on under-resourced clinics.\u003c/p\u003e\u003cp\u003eThe 2021 pandemic review highlights this urban\u0026ndash;rural gap, noting that city dwellers had better access to COVID testing and care (Dzando et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Thus, any tourism-driven health gains risk being unevenly distributed, potentially exacerbating inequities. For example, if medical tourism funds elite hospital wings, poorer regions might not benefit. Ethical concerns arise when wealthier foreign patients consume limited health resources, as discussed by (Mogaka et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) in an African context.\u003c/p\u003e\u003cp\u003eGhana\u0026rsquo;s climatic and environmental changes also intersect. Climate-driven expansion of malaria and arboviruses (e.g. dengue) into new zones might amplify travel-associated outbreaks. Coastal erosion and flooding, partly climate-linked, threaten both tourism sites and health infrastructure. Although tourism can fund some environmental protection, the ecological footprint of travel (CO₂ emissions, waste) indirectly affects health (e.g. air pollution, ozone). These linkages are often absent from Ghana-specific literature, indicating a gap.\u003c/p\u003e\u003cp\u003eFinally, pandemic preparedness emerged as a crucial lens. Ghana was relatively lauded for its COVID-19 response, including early testing and genomic surveillance, but still faced resource limits (Dzando et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Tourism suspension during COVID-19 brought stark awareness that heavy dependence on foreign tourists leaves communities vulnerable; e.g. eco-tourism workers lost livelihoods overnight. This has prompted calls for diversification (e.g. Ghana promoting domestic tourism, as noted in Soliku et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Lessons from COVID, such as establishing rapid response teams at borders and repurposing tourism facilities for quarantine or health camps, remain relevant.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCross-Cutting Issues\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAcross themes, equity concerns are prominent. Tourism revenue is not always channelled into health services for the poor. Medical tourism, for example, may benefit only urban elites and incoming patients, while rural areas remain neglected. Fair distribution of tourism gains is a policy challenge. The Ghana Health Service\u0026rsquo;s collaborative effort in tourism (e.g. via health tourism committees) aims to ensure some reinvestment, but details are scant. Researchers stress that any tourism-development strategy should assess impacts on vulnerable groups, including whether local communities gain employment or if disease burdens shift unevenly (Zhong et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHealthcare ethics intersect with tourism when resources are constrained. As interviewed staff in Ghana report, hospitals catering to medical tourists must also maintain quality for locals (Adu-Gyamfi \u0026amp; Adomah Sarkodie, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). There is also the ethics of disease screening: mandatory health checks for tourists raise privacy and equity debates. No Ghanaian study addressed this in depth, but international guidelines (e.g. WHO\u0026rsquo;s International Health Regulations) imply a need to balance traveller rights with community protection.\u003c/p\u003e\u003cp\u003eTourism depends on Ghana\u0026rsquo;s natural environments (beaches, parks), which also influence health. Degradation of these environments (pollution, deforestation) can amplify health risks (vector habitats, water quality). Climate change, partly driven by tourism-related emissions, is a long-term public health threat via heatwaves, altered disease vectors, and food insecurity. Some included references (e.g. wellness tourism studies) note \u0026ldquo;environmental health\u0026rdquo; as a component of well-being (Liao et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), but Ghana-specific evidence is limited. Nonetheless, policies promoting eco-friendly tourism (protected areas, green hotels) could yield co-benefits for health by preserving ecosystem services (clean water, air) and potentially limiting zoonotic spillover.\u003c/p\u003e\u003cp\u003eEffective governance at the intersection of tourism and health is crucial. Ghana\u0026rsquo;s response to COVID-19, with its travel restrictions and later vaccination rollout, involved coordination between tourism, health and other sectors. The literature indicates that Ghana updated its public health emergency plans during crises (Mireku-Gyimah et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) and utilized tourism networks (e.g. hoteliers reporting suspected cases). However, no formal \u0026ldquo;health tourism\u0026rdquo; strategy has been published in peer-reviewed form. One policy briefing suggests Ghana planned a Coordinating Unit within the Health Ministry for health tourism (GhanaWeb, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). In general, experts argue for integrated \u0026ldquo;health in all policies\u0026rdquo; approaches where the tourism sector is engaged in health planning. The PRISMA-level data here are sparse; we did not find a comprehensive analysis of Ghana\u0026rsquo;s specific policies on tourism and health. This gap underscores the need for multi-sector collaboration: for example, Ghana could incorporate IHR obligations into tourism licensing (requiring tourism businesses to report outbreaks), or align with regional blocs (ECOWAS) on travel health standards.\u003c/p\u003e"},{"header":"5.0 Discussion","content":"\u003cp\u003eThis systematic review synthesizes evidence that tourism in Ghana has a nuanced impact on public health. Globally, our findings are consistent with the broader literature: travel facilitates rapid disease spread, as (Findlater \u0026amp; Bogoch, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) and many others describe, but tourism and travel can also be harnessed to promote health and well-being. In Ghana specifically, the evidence remains fragmented but illustrative.\u003c/p\u003e\u003cp\u003eCritically, tourism can act as a catalyst for disease importation. The COVID-19 experience in Ghana demonstrated this clearly: initial cases were imported via air travel (Dzando et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Likewise, other travel-acquired infections (from malaria to emerging viruses) pose ongoing threats. Compared to global evidence, Ghana shares similar vulnerabilities: insufficient travel medicine practices, dense social mixing in tourism zones, and limited critical care capacity mean that an imported outbreak can spread rapidly. However, Ghana\u0026rsquo;s government and health service have shown agility, issuing national alerts (e.g., during cholera spikes, Mireku-Gyimah et al., (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) and leveraging rapid tests. Relative to some African neighbours, Ghana\u0026rsquo;s COVID-19 case fatality rate was low, possibly reflecting younger demographics and prompt public messaging. Nonetheless, travel restrictions have socio-economic costs, so Ghana\u0026rsquo;s challenge is to manage risk without indefinitely freezing the tourism sector.\u003c/p\u003e\u003cp\u003eOn the positive side, the review highlights encouraging signs that tourism can bolster health. Wellness and medical tourism are emerging niches. Ghana\u0026rsquo;s mild climate and cultural offerings bode well for domestic and international wellness travellers; indeed, recent initiatives promote spa retreats and cultural festivals as health-enhancing experiences. The review by (Liao et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) suggests that wellness tourism yields multi-dimensional health gains, which Ghana could pursue further (e.g., promoting forest walks or yoga retreats around Ashanti herbal traditions). Medical tourism is also on the agenda: bilateral \u0026ldquo;health tourism\u0026rdquo; MOUs and budget lines for medical tourism promotion reflect government interest (GhanaWeb, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Importantly, tourism-linked income provides resources that \u003cem\u003ecould\u003c/em\u003e support health infrastructure. For example, eco-tourism fees can fund park conservation and local clinics (as seen in some Tanzanian and Rwandan programs), though we did not find a published evaluation of such schemes in Ghana.\u003c/p\u003e\u003cp\u003eOur findings affirm that tourism in Ghana is a double-edged sword. The risks \u0026ndash; disease importation, resource diversion \u0026ndash; must be mitigated through public health measures (e.g. vaccination campaigns for Yellow Fever at ports, traveller education, improved water/sanitation in tourist sites). Simultaneously, the benefits \u0026ndash; economic uplift, health access \u0026ndash; should be maximized. Crucially, the balance tilts on policy and governance: a well-regulated tourism industry that invests in community health and follows safety protocols can significantly skew outcomes toward benefit. This is evident from Ghana\u0026rsquo;s strong pandemic governance compared to earlier cholera cycles; policies learnt from travel-related COVID-19 cases included establishing more screening labs and protocols at airports (Dzando et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe evidence base we reviewed has strengths (including several recent systematic reviews on tourism and health internationally) but also limitations. Few Ghana-specific empirical studies explicitly link tourism to health outcomes; much of the data comes from broader health or tourism literature. This limited scope reflects the interdisciplinary nature of the question. The included studies varied in design and quality: some were rigorous (e.g. national health service reports, WHO data), while others were narrative commentaries (e.g. cholera perspectives (Mireku-Gyimah et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) or grey publications. As a result, our conclusions are largely qualitative and hypothesis-generating. We found virtually no studies using prospective cohort or case\u0026ndash;control methods to quantify tourism-associated infection risk in Ghana. The reliance on reviews and commentaries (including one on wellness tourism (Liao et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and one on medical tourism trends (Zhong et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) means much of our synthesis is based on expert interpretation rather than raw Ghanaian data. This underscores the need for new research, especially mixed-methods and surveillance studies, to fill empirical gaps.\u003c/p\u003e\u003cp\u003eFor Ghana and similar African nations, the review suggests several action points. First, border health measures must be continually updated: maintain robust entry-screening (especially for high-risk diseases), ensure traveller vaccination policies (Yellow Fever, Covid boosters, etc.), and strengthen disease surveillance at tourism hubs. Second, health and tourism ministries should collaborate to develop a coherent \u0026ldquo;health tourism\u0026rdquo; strategy, integrating goals of Universal Health Coverage and economic development. This could involve earmarking a portion of tourism taxes for public health or mandating health insurance facilities for tourism investments. Third, investments in rural healthcare and sanitation remain essential \u0026ndash; they reduce the baseline disease burden that tourism might exacerbate. For instance, halving Ghana\u0026rsquo;s cholera incidence via clean water programmes would make tourism in Accra and other cities safer and more attractive. Fourth, Ghana should leverage tourism for health promotion: expanding domestic eco-tourism could improve rural livelihoods and mental health, while public\u0026ndash;private partnerships might develop wellness resorts that include community health outreach.\u003c/p\u003e\u003cp\u003eEmpirical gaps are clear. Key unanswered questions include: \u003cem\u003eWhat is the attributable fraction of tourist-related travel in Ghana\u0026rsquo;s infectious disease burden? How effective are Ghana\u0026rsquo;s traveller health advisories? Can medical tourism be expanded without undermining local equity?\u003c/em\u003e We recommend prospective studies tracking health outcomes of tourists and hosts, as well as economic analyses of health tourism\u0026rsquo;s ROI. Qualitative research on community attitudes toward incoming tourists and health priorities would also be valuable. Finally, integrating climate change projections into tourism\u0026ndash;health models would prepare Ghana for long-term emerging threats.\u003c/p\u003e"},{"header":"6.0 Conclusion","content":"\u003cp\u003eTourism in Ghana epitomises a “double-edged sword” for public health. On one edge, it fuels economic growth, provides platforms for wellness and medical services, and can empower communities – ultimately \u003cem\u003esupporting\u003c/em\u003e health. On the other edge, it introduces risks of disease importation and exacerbates health inequities if unmanaged. Policymakers should heed the weight of evidence: as Findlater \u0026amp; Bogoch (2018) caution, modern travel spreads pathogens globally, but as recent reviews highlight, tourism can also enrich quality of life. For Ghana, the path forward involves strengthening surveillance and healthcare capacity at tourism interfaces, while channeling tourism revenues to build a healthier society. Key actionable insights include: deploying targeted travel health advisories (malaria prophylaxis, vaccinations), investing tourism tax revenue into local clinics and sanitation, and developing domestic health tourism offerings to stabilize livelihoods. Health professionals and tourism stakeholders must work in tandem – for example, training guides in first aid, or requiring hotels to display health notices – to ensure that Ghana’s tourism growth aligns with public health goals. Ultimately, managing the delicate balance of risks and benefits will determine whether tourism becomes a net boon or burden to Ghana’s health system. Continued research and adaptive policy will be essential in navigating this complex nexus of travel and health.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe hereby declare that the information contained in this work is correct and that no other situation of real, potential, or apparent conflicts of interest is known to us.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Declaration:\u0026nbsp;\u003c/strong\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funding was received for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAdu-Gyamfi, S., \u0026amp; Adomah Sarkodie, A. (2022). Medical Tourism in Ghana: A History. \u003cem\u003eKaleidoscope History\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(25), 27\u0026ndash;52. https://doi.org/10.17107/KH.2022.25.4-2\u003c/li\u003e\n \u003cli\u003eAhwireng-Obeng, F., \u0026amp; Van Loggerenberg, C. (2011). Africa\u0026rsquo;s middle class women bring entrepreneurial opportunities in breast care medical tourism to South Africa. \u003cem\u003eInternational Journal of Health Planning and Management\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e(1), 39\u0026ndash;55. https://doi.org/10.1002/HPM.1034\u003c/li\u003e\n \u003cli\u003eDzando, G., Salifu, S., Donyi, A. B., Akpeke, H., Kumah, A., Dordunu, R., \u0026amp; Nonoh, E. A. (2021). Healthcare in Ghana amidst the coronavirus pandemic: A narrative literature review. \u003cem\u003eJournal of Public Health Research\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(1), 2448. https://doi.org/10.4081/JPHR.2021.2448\u003c/li\u003e\n \u003cli\u003eFindlater, A., \u0026amp; Bogoch, I. I. (2018). Human Mobility and the Global Spread of Infectious Diseases: A Focus on Air Travel. \u003cem\u003eTrends in Parasitology\u003c/em\u003e, \u003cem\u003e34\u003c/em\u003e(9), 772\u0026ndash;783. https://doi.org/10.1016/j.pt.2018.07.004\u003c/li\u003e\n \u003cli\u003eGhanaWeb. (2025, April 3). \u003cem\u003eGhana eyes Medical Tourism as a gateway to quality healthcare\u003c/em\u003e. GhanaWeb. https://www.ghanaweb.com/GhanaHomePage/NewsArchive/Ghana-eyes-Medical-Tourism-as-a-gateway-to-quality-healthcare-1978240\u003c/li\u003e\n \u003cli\u003eGhasempour Ganji, S. F., Johnson, L. W., Kazemi, A., \u0026amp; Sadeghian, S. (2022). Negative health impact of tourists through pandemic: hospitality sector perspective. \u003cem\u003eTourism and Hospitality Research\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(3), 344. https://doi.org/10.1177/14673584221103369\u003c/li\u003e\n \u003cli\u003eLiao, C., Zuo, Y., Xu, S., Law, R., \u0026amp; Zhang, M. (2023). Dimensions of the health benefits of wellness tourism: A review. \u003cem\u003eFrontiers in Psychology\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e. https://doi.org/10.3389/FPSYG.2022.1071578\u003c/li\u003e\n \u003cli\u003eMesl\u0026eacute;, M. M. I., Vivancos, R., Hall, I. M., Christley, R. M., Leach, S., \u0026amp; Read, J. M. (2022). Estimating the potential for global dissemination of pandemic pathogens using the global airline network and healthcare development indices. \u003cem\u003eScientific Reports\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(1), 3070. https://doi.org/10.1038/S41598-022-06932-Y\u003c/li\u003e\n \u003cli\u003eMireku-Gyimah, N., Apanga, P. A., \u0026amp; Awoonor-Williams, J. K. (2018). Cyclical cholera outbreaks in Ghana: Filth, not myth. \u003cem\u003eInfectious Diseases of Poverty\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(1), 1\u0026ndash;5. https://doi.org/10.1186/S40249-018-0436-1/TABLES/1\u003c/li\u003e\n \u003cli\u003eMogaka, J. J. O., Mupara, L., \u0026amp; Tsoka-Gwegweni, J. M. (2017). Ethical issues associated with medical tourism in Africa. \u003cem\u003eJournal of Market Access \u0026amp; Health Policy\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(1), 1309770. https://doi.org/10.1080/20016689.2017.1309770\u003c/li\u003e\n \u003cli\u003eNartey, J. (2025). \u003cem\u003eGhana Tourism Industry Market Analysis Report 2019\u0026ndash;2024 (With Projections for 2025)\u003c/em\u003e. https://doi.org/10.2139/SSRN.5181984\u003c/li\u003e\n \u003cli\u003ePage, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hr\u0026oacute;bjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., \u0026hellip; Moher, D. (2021). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. \u003cem\u003eBMJ\u003c/em\u003e, \u003cem\u003e372\u003c/em\u003e. https://doi.org/10.1136/BMJ.N71\u003c/li\u003e\n \u003cli\u003eSoliku, O., Kyiire, B., Mahama, A., \u0026amp; Kubio, C. (2021). Tourism amid COVID-19 pandemic: impacts and implications for building resilience in the eco-tourism sector in Ghana\u0026rsquo;s Savannah region. \u003cem\u003eHeliyon\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(9). https://doi.org/10.1016/j.heliyon.2021.e07892\u003c/li\u003e\n \u003cli\u003eZhong, L., Deng, B., Morrison, A. M., Coca-Stefaniak, J. A., \u0026amp; Yang, L. (2021). Medical, Health and Wellness Tourism Research-A Review of the Literature (1970-2020) and Research Agenda. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(20). https://doi.org/10.3390/IJERPH182010875\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ghana, Tourism, Public health, Infectious disease, Wellness tourism, Medical tourism, COVID-19","lastPublishedDoi":"10.21203/rs.3.rs-7705898/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7705898/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eInternational tourism can facilitate disease spread across borders but also foster health and wellness through economic and social development. Ghana\u0026rsquo;s expanding tourism sector, supported by government initiatives and rich cultural and natural assets, intersects with public health challenges ranging from endemic infections (malaria, cholera) to emerging threats (COVID-19, dengue).\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo critically review the evidence on tourism\u0026rsquo;s \u003cem\u003edual\u003c/em\u003e role in Ghana\u0026rsquo;s public health, characterising tourism as both a vector of disease and a promoter of health, and to synthesise findings in line with PRISMA 2020 guidelines.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA systematic search of PubMed, Scopus, Web of Science, Embase, CINAHL, and grey literature (2018\u0026ndash;2025) was conducted for studies addressing tourism and health in Ghana and comparable contexts. Inclusion criteria encompassed quantitative, qualitative, and mixed-methods research on tourism-related mobility, infectious disease transmission, wellness tourism, and health infrastructure. Titles, abstracts, and full texts were screened by two reviewers, and data on study characteristics and outcomes were extracted. Study quality was assessed using established checklists (e.g., JBI, CASP). Findings were synthesised narratively using thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe review identified 20 studies meeting the inclusion criteria (Fig.\u0026nbsp;1, PRISMA flow). The literature broadly fell into two thematic domains: (1) \u003cem\u003eTourism as a vector of disease\u003c/em\u003e, evidence that travel (including tourism) to and from Ghana can introduce or amplify infectious diseases (e.g. importation of COVID-19, malaria, and potentially cholera/dengue), especially given gaps in surveillance and health infrastructure; and (2) \u003cem\u003eTourism as a catalyst for public health promotion\u003c/em\u003e \u0026ndash; examples of wellness and medical tourism, economic investments in healthcare linked to tourism growth, and increased public health awareness. In Ghana, endemic conditions (high malaria burden, periodic cholera outbreaks) and socio-economic disparities modulate these dynamics. Cross-cutting issues such as health equity, ethical resource allocation in medical tourism, and climate impacts were noted.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eTourism in Ghana is \u003cem\u003edouble-edged\u003c/em\u003e: it contributes to economic development and health sector strengthening, yet also poses disease risks via increased mobility. Policymakers and health authorities must balance these aspects by enhancing disease surveillance and travel health measures, while harnessing tourism\u0026rsquo;s health-promoting potential (e.g. domestic wellness tourism, medical travel). Gaps include a paucity of Ghana-specific epidemiological studies on tourism-related transmission. Future research should quantify travel-associated disease burden and evaluate interventions (e.g. traveller screening, destination health promotion).\u003c/p\u003e","manuscriptTitle":"The Double-Edged Impact of Tourism on Public Health in Ghana: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-26 08:22:56","doi":"10.21203/rs.3.rs-7705898/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e0f13a2e-8f8f-4727-9cda-691b67668c15","owner":[],"postedDate":"September 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":55286261,"name":"Hospitality and Tourism"}],"tags":[],"updatedAt":"2025-09-26T08:22:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-26 08:22:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7705898","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7705898","identity":"rs-7705898","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}