# Backpackers' Tourism and Health: A Narrative Literature Review

Sebastien Fleuret

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## To cite this version:

Sebastien Fleuret. Backpackers' Tourism and Health: A Narrative Literature Review. Geographies, 2024, 4 (1), pp.12. 10.3390/geographies4010003. halshs-04383374

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Review

# Backpackers' Tourism and Health: A Narrative Literature Review

Sebastien Fleuret

department/school/faculty/campus, ESO-University of Angers, 49100 Angers, France; sebastien.fleuret@universangers.fr

**Abstract:** Backpackers are an unusual category of travellers. Their unique mobility patterns, spatial practices, and the areas they travel through expose them to health situations that remain largely unexplored to date. This article conducts a narrative literature review (across six different databases in English and French) in this domain and highlights key contributions. The results show that backpackers frequently experience health problems during their trips. They are described as being more at risk than other tourists and more inclined to adopt harmful behaviours. However, the majority of related studies lack contextualisation, which is an advantage of geographical analysis. Moreover, given the limited volume of the existing literature, this review serves as an invitation to geographers to delve deeper into this intriguing field.

**Keywords:** backpackers; health; travel; tourism; literature review

## 1. Introduction

Backpackers are a category of travellers that has evolved in its composition and definition since the earliest studies that referred to them as “drifters” [1] or “wanderers” [2], both of which contained a sense of marginality. Today, the vision of this category of traveller has been fleshed out by numerous studies, including those by Riley [3], who refers to long-term budget travellers, and Pearce [4], who adds the criteria of youth, flexibility of itinerary, preference for low-cost accommodation, and an inclination to take part in informal activities. To sum up, backpackers typically travel solo or in small groups on tight budgets, often seeking economical accommodations and relying on personal load-carrying equipment, notably backpacks [5].

Bearing in mind the heterogeneity of this group [6], research on backpacking tourism has approached the phenomenon from various angles [7]. For instance, Sorensen conducted an ethnographic study [8], while empirical studies have explored it in terms of tourist origins and visited destinations [9]. "A challenger of mass tourism and, more broadly, of Western consumer society, the backpacker is at the same time described as alienated from his own illusions of freedom and reduced to signposted itineraries and accommodation" [10]. According to Reichenberger and Lucca Iaquinto [11], Backpackers are in "search for experiences enabling existential authenticity and freedom", and this remain consistent with time "despite significant demographic, social, cultural and behavioural variation among backpackers". In terms of health, this means that backpackers are on the fringes of the healthcare system, possibly adopting a posture of defiance, but at the same time, they are subject to constraints from which they cannot escape (the need for care when illness occurs), but which can potentially put them at risk. They are, for example, inclined to seek out thrills through adventure sports, but also to seek out wellness experiences, particularly through traditional practices in the places they visit [12] and, more broadly, they are seen as a category of travellers particularly in search of self-development [11].

**Citation:** Fleuret, S. Backpackers' Tourism and Health: A Narrative Literature Review. *Geographies* 2024, 4, x. https://doi.org/10.3390/xxxxx

Academic Editor(s): Elisabete Figueiredo

Received: 11 September 2023

Revised: 13 December 2023

Accepted: 2 January 2024

Publishe: date

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**Copyright:** © 2023 by the authors. Submitted for possible open access publication under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
However, the linkage between this mode of travel and health issues remains strik-
ingly underrepresented in the literature, with only sporadic investigations primarily
within the realms of travel medicine and tourism studies, exemplified by references like
[13].

Before starting this article, we conducted an exploratory bibliographic search, revealing a limited number of pertinent references and significant overlap across bibliographic databases bridging the domains of SSH (Social Sciences and Humanities) and health. Consequently, we opted for a narrative review instead of a scoping or systematic review, given the dearth of content in the field.

The primary aim here was descriptive in nature: to provide an overview of the exist-
ing grey literature and to identify gaps in coverage. On this basis, this article presents a
narrative literature review as a preliminary exploration of the backpacker phenomenon,
subsequently contextualizing it within a geographical framework. It is worth noting that
backpackers have received minimal attention in the field of geography, with rare excep-
tions like the works of Visser and Barker [9] and Le Bigot [14]. Surprisingly, the sub-dis-
cipline of health geography has not studied this population any further, despite the fact
that their mobility patterns, frequented spaces, and associated health issues fall squarely
within this disciplinary field.

The bibliographic research conducted necessitated the exploration of several key as-
sumptions.

The first is risky behaviour. Are backpackers “more at risk” [5]? Do they exhibit a higher propensity for risk-taking compared to other types of travellers? Do they proactively prepare for potential risks by taking out insurance? What are the potential health consequences of the experimentation inherent to long-distance travel, including activities impacting both physical and mental health? This risk-taking mentality is intrinsically tied to the backpacker’s identity, as outlined in [15]. The pursuit of an “anti-tourist” journey, driven by a desire for purity and an element of transgression, can manifest in the rejection of conventions associated with the “system,” which extends to healthcare choices, such as avoidance of medications (deemed profit generators for multinational corporations), vaccinations, or other forms of allopathic care. Conversely, modern-day backpacking routes are often well defined, which has significant implications for healthcare, especially in terms of preventative measures.

The second assertion revolves around the interplay of places, resources, and behav-
iours in the context of health considerations. Health considerations come into play in both
the preparation for and the practical organization of backpacking trips. Backpackers pos-
sess various resources that they deploy to varying extents in the regions they explore. This
prompts questions such as how does health become an integrated aspect of the journeys
undertaken by global nomads? and on a regional scale, how do healthcare systems adapt
to cater to the needs of these travellers?

Given this foundational framework, the analysis presented in this article relies on a selective bibliographic search conducted through a narrative literature review. The research was conducted in both English and French between November 2022 and January 2023.

## 2. Methodology

### 2.1. *Inclusion Strategy*

From the outset, the decision was made to clearly define the field of research in order
to specify the choice of keywords to be used. Historical confusion between backpackers
and drifters, as exemplified in studies such as Kerouac's portrayal [16] and Cohen's stud-
ies [17] led us to exclude all results that dealt with vagrancy, homelessness, and, by exten-
sion, the health problems of the homeless, which have no connection with tourism. Drift-
ers used to travel off the beaten track. Today, the paths seem to be well marked out, which
may be important in the health field, particularly in terms of prevention.
The backpacker category also overlaps with that of world travellers and other long-distance travellers. Here again, some results that focused on the specific categories of travellers such as bicycle tourists and sailors were discarded, although these categories are interesting. It was more challenging to separate out the results on trekkers, and we retained some overlaps.

The primary criterion for determining the relevance or inclusion/exclusion of references in this study was whether they explicitly addressed health concerns, either directly or indirectly linked to backpacker tourists. Often, references would surface in bibliographic searches due to the presence of search terms but lacked substantive connections to the backpacker context. In such cases, these references were excluded from consideration.

## 2.2. *Search Strategy*

Having clarified the criteria for inclusion while maintaining a very broad and inclusive approach to the phenomenon, the decision was taken to undertake an exploratory bibliographical search across six different sources: three in English (Google Scholar, Web of Sciences, and PubMed) and three in French (Cairn, OEJ, and Erudit).

As mentioned in the introduction, an initial observation quickly revealed that the literature associated with backpacking as a means of travel and health is extremely scarce, and in French, it is almost non-existent. Following this initial observation, the literature review was extended and structured. Several Boolean equations were chosen by testing word associations in the six bibliographic databases.

The initial searches were conducted with no restriction on publication date, using various combinations of terms related to backpacking and health, and then, the word tourism was added to limit the results to references actually dealing with leisure travel (Table 1).

Care was taken to use capital letters and inverted commas in all the advanced search engines.

<table><caption>**Table 1.** Associations of words.</caption><thead><tr><th colspan="2">Associations Tested in English</th></tr></thead><tbody><tr><td>Word 1:</td><td>Backpacker(s)</td></tr><tr><td>Word 2:</td><td>Healthcare or Care or Risk or Medical or travel medicine</td></tr><tr><td>Word 3:</td><td>tourism</td></tr></tbody><thead><tr><th colspan="2">Associations Tested in French</th></tr></thead><tbody><tr><td>Word 1:</td><td>Routard (s) or backpacker (s) (the English word Backpacker is sometimes used in the French literature)</td></tr><tr><td>Word 2:</td><td>Santé ou soins ou soins de santé ou médical ou médecine du voyage</td></tr><tr><td>Word 3:</td><td>Tourisme</td></tr></tbody></table>

## 2.3. *Review Procedure*

It quickly became clear that certain distinctions, such as those between “health” and “healthcare”, were not productive. On the other hand, there were instances where it proved useful to group more than three words together. The French search produced fewer than 25 results, all of which were reviewed but did not substantially align with the search query. *PubMed* also proved to be of little relevance. *Web of Science* displayed greater promise, although there was significant overlap with *Google Scholar*, which is unsurprising since the latter search engine picks up sources of the others.

For more efficiency, we focused exclusively on the Google Scholar database. The results presented here are based on six search equations denoted R1 to R6 in Table 2. The table provides a detailed breakdown of these equations, including the number of references identified, the number of references selected as relevant, and the results produced.
<table><caption>**Table 2.** Search equations and associated number of references.</caption><thead><tr><th>Equations</th><th>Words Used</th><th>References</th><th>Retained</th><th>Duplicates with the above Equation</th></tr></thead><tbody><tr><td>R1</td><td>«BACKPACKERS» AND «HEALTH» AND «CARE» AND «TOURISM»</td><td>278</td><td>58</td><td>NA</td></tr><tr><td>R2</td><td>«BACKPACKERS» AND «MEDICAL» AND «TOURISM»</td><td>280</td><td>36</td><td>53</td></tr><tr><td>R3</td><td>«BACKPACKERS» AND «HEALTH» AND «RISK» AND «TOURISM»</td><td>249</td><td>5</td><td>67</td></tr><tr><td>R4</td><td>«BACKPACKERS» AND «TRAVEL MEDICINE» AND «TOURISM»</td><td>88</td><td>0</td><td>55</td></tr><tr><td>R5</td><td>«BACKPACKERS» AND «HEALTH»</td><td>534</td><td>15</td><td>97</td></tr><tr><td>R6</td><td>«BACKPACKERS» AND «HEALTHCARE SEEKING»</td><td>27</td><td>11</td><td>2</td></tr><tr><td>TOTAL</td><td></td><td>1456</td><td>125</td><td></td></tr></tbody></table>

References that referred only to records or citations and those that were not available via institutional subscriptions were not included. Dissertations and non-academic works were also excluded.

The order in which the searches were carried out was strategically planned to facilitate the identification of duplicate references. For instance, by not commencing with the simplest equation, “backpackers + health”, it became possible to focus on retaining only those references not yet present in the database when exploring this equation.

Finally, at the end of the initially planned five rounds, it became apparent that there were very few studies on access to healthcare. Accordingly, a sixth equation was added to complete the bibliographic database on this issue, although only a small number of additional references were found.

The table should be read carefully. Each equation was considered as a search round and preceded the next. Thus, equation R1 was used before R2 and so on. To avoid duplication in each round, only new references are noted in the column “retained”. Results found with one equation but already retained with the previous equation are counted in the right column but are not retained twice. For example, for equation R4, there were 55 relevant references, but all had already been included in equations R1, R2, and R3.

In the end, 125 references were retained for this literature review.

## 3. Results

Studies on the health of backpackers are relatively rare. One example is a study of 420 backpackers in 2015 on Khao San Road in Bangkok [13]. This study revealed that 10% of backpackers had experienced a health problem during their trip, mostly minor ailments such as diarrhoea or stomach aches. Of those who were ill, one-third recovered without seeking medical attention, one-fifth self-medicated with their travel first-aid kit, another one-fifth bought over-the-counter (OTC) medicines, and only 5 out of the 420 people questioned needed to visit a hospital (only one serious hospitalisation occurred, for Dengue fever). In their discussion, the authors note that their rate of 10.2% of respondents reporting health problems was relatively low compared to other studies in developing countries, where the rate of reported health problems varies between 25% and 70% (the wide range is due to very disparate methodologies). One of the limitations of this study is that the
questionnaire was administered in the street at a specific point in time, without distin-
guishing what stage of the journey the backpackers were on. Perhaps geographers could
have suggested that doctors provide information on the travellers' itinerary including fac-
tors such as how long they had been on the road, the places they had visited, whether
Thailand was their initial destination, and whether they had experienced illness else-
where.

Few studies explicitly focused on the health of backpackers, such as the one men-
tioned above, and the information on the relationship between health and backpacking
tourism is usually included in more general studies. The findings of our literature review
are thus organized according to the most prevalent categories identified across the re-
ferred studies. Subsequently, we engage in a somewhat broader discussion and place our
results within a geographical context.

3.1. *Are Backpackers at Risk?*

The most common category of references explores the relationship between back-
packers and health, often framing backpackers as a population at risk. This question ap-
pears in many studies on the incidence of diseases affecting tourists. The word cloud
shown here (figure 1) reflects the frequency of references related to various diseases. The
most frequently mentioned (13 times) is traveller's diarrhoea (turista), but there are also
numerous studies on parasitic infections (6), malaria (5), sexually transmitted infections
(STIs) (4), rabies, and hepatitis (3).

<figure><img src="image_4.png" /><figcaption>**Figure 1.** Word cloud of the main occurrences recorded.</figcaption></figure>

Some of these studies are empirical [18,19], while others involve literature reviews [20], but in the vast majority of cases, backpackers are just one category among many. And more often than not, they are described as a population at greater risk because of the way they travel: they stay in less hygienic hotels, are less careful about their diet and hygiene, and often engage in riskier activities and behaviours such as extreme sports, unprotected sexual encounters, or the use of psychotropic substances. A significant body of research also exists in the field of accident analysis [21].

The problem is that the assumption that backpackers are a category at risk is gener-
ally based on citations from few empirical studies [22]. Yet this assertion is seldom verified
or challenged. For instance, one study [23] found that backpackers tend to take more pre-
cautions in terms of vaccinations when they travel to high-risk areas.

In terms of geography, the majority of the studies considering health issues for back-
packers are located in the Global South.

3.2. *Nationalities and Destinations*

The second category of research is made up of articles that look at backpackers by nationality and/or destination (table 3). Unsurprisingly, the destinations correspond to popular backpacking hotspots, i.e., Southeast Asia, Latin America, the USA, India,
Australia (and to a lesser extent New Zealand) are the primary destinations, and Africa is less popular (Adam, op.cit.).

In terms of nationalities, Australian backpackers are by far the most extensively studied population [18,24], which may introduce bias, as the studies are calibrated according to the characteristics of this population and in particular their understanding of the healthcare system and health insurance. However, these points are not discussed in the articles.

<table><caption>**Table 3.** Destinations and nationalities (the totals do not correspond to the number of references compiled, as most of them do not target a specific destination or source).</caption><thead><tr><th>Destinations Most Frequently Used as Case Studies</th></tr></thead><tbody><tr><td>Australia (5), India (2), Southeast Asia (2), Latin America (1), USA (1), and Africa (1)</td></tr><tr><th>Nationalities Most Frequently Studied</th></tr><tr><td>Australians (5), Germans (2), Israelis (2), Italians (1), Americans (1), Dutch (1), British (1), and Spanish (1)</td></tr></tbody></table>

### 3.3. *Behaviour, Attitudes, and Perceptions*

A third category of references includes those that approach the subject by analysing behaviours, attitudes, and perceptions [25]. Within this category, like the references on disease risk, there is a recurring notion that backpackers tend to engage in riskier behaviours, whether consciously or unconsciously. For example, some may opt for unsafe modes of transportation due to budget constraints, thus increasing their risk of accidents. Backpackers are also often associated with a proclivity for outdoor adventures and extreme sports, entailing additional hazards [26].

Some studies suggest that backpackers may be poorly informed or negligent about health concerns and preventive measures. For example, studies report a high rate of unprotected sex among backpackers [27]. As a rule, the subject of behaviours associated with sexual health and the risks of sexually transmitted infections is frequently addressed [28]. However, other studies show that backpackers are attentive to their health and fully aware of the risks [29] or do not perceive themselves as an at-risk group [30]. The same contradictory opinions can be found on the subject of vaccinations prior to travel [31]. It would appear that backpackers' behaviour toward health issues is a multidimensional phenomenon, and the perception of risk during a backpacking experience varies depending on the individual's characteristics, such as age, gender, and past experiences [32].

Regardless of the specific subject, these studies typically rely on a very small number of empirical studies, and more often than not, they are literature reviews (like our study) that reuse the same data without further analysis.

### 3.4. *Health Systems*

The next category pertains to healthcare systems. This subject appeared in the results of the first five Boolean equations, initially concerning the healthcare systems in the travellers' home countries.

For this first point related to healthcare systems, one key issue is pre-travel medical visits and prevention recommendations [5,33,34]. Once again, the vast majority of studies are literature reviews. However, some of them are highly focused and targeted on a specific issue, such as HIV and post-exposure prophylaxis, with clear operational guidelines [35]. Other publications in this area deal with travel medicine in general [36], and only a few provide specific information on backpackers. Despite this, and with the usual precautions associated with the scarcity of sources, these studies seem to contradict the idea that backpackers do not adequately prepare for their trips. The majority of them seek advice and take out insurance before leaving. However, whether they do so in the most effective manner is a question warranting further investigation, but our bibliographic search did not yield studies addressing this query.
For the second point regarding healthcare systems and the management of diseases or injuries at the travel destinations, we had to search for a specific combination of terms (R6: “backpackers “+”health care seeking” —see Table 2) to bring up a few references, but none of them addressed the question as a whole: do backpackers have difficulty accessing healthcare? The few references that were found touched upon this issue only through examples pertaining to specific pathologies, such as the management of diarrhoea [37] and treatment of chlamydia [38]. There is very little research specifically on access to care. A summary text does exist [5], but it is not fully satisfactory, as it is not based on a case study but rather on a series of considerations by doctors, drawn from their experience, without any explanation of the methodology used.

### 3.5. Alcohol, Drugs, and Risky Behaviour

This category of references perhaps contains the most empirical research, with case studies from various countries (Peru, Thailand, and India). The number of references is small, but they are almost exclusively case studies that describe a population more prone to risky behaviour and substance consumption associated with health risks: diarrhoea stemming from sharing bottles at parties, sexual risk during unprotected intercourse under the influence of alcohol, sexual abuse facilitated by drunkenness, etc.

The connection between alcohol consumption and risk-taking has also been highlighted, for example, in a study conducted in Cusco, Peru [39]. A study in India even mentions drug use as a motive for travelling, specifically mentioning “cannabis tours”, although this study does not directly link drug use in India to health data [40].

### 3.6. Food, Hygiene, and Travel Style

The last category, containing a significant number of references, features studies that do not necessarily focus primarily on backpackers, but portray them as individuals more exposed to food and hygiene-related risks due to their travel style, particularly when categorized as adventure travellers [41]. In this literature, long-term travel is presented as an additional risk factor for digestive tract diseases (associated with water and food), parasitic infections, dermatitis and parasite-borne infections contracted in unsanitary accommodation (ticks and bedbugs) or during outdoor activities (ticks, bites, and various skin irritations), and for more serious diseases like rabies [42]. Poor compliance with preventive treatments such as malaria chemoprophylaxis is also mentioned as a risk factor that may be more significant amongst backpackers than other tourists [43].

In these studies, which are mainly in the field of travel medicine, backpackers are just one category in a typology of exposure or vulnerability. Long-term travellers like backpackers are also compared with immigrants in the context of imported infectious diseases [44].

Finally, in this category of travel styles, there are two original references, albeit on the periphery of the topic, which offer a biomedical perspective on musculoskeletal disorders associated with backpacking [45,46]. These studies are worth mentioning here because they are among the few empirical studies to use health data on backpackers. They discuss the osteoarticular risks associated with walking while carrying heavy loads and make recommendations. Backpackers are compared with hikers and soldiers on exercise.

### 3.7. Emerging Trends: Some Novel Perspectives

Alongside these primary categories (comprising a significant number of references), there are a few more unusual thematic categories, each containing just one, two, or at most three references, which are nonetheless worthy of attention because they are novel or innovative. These are gender, age, and transformative tourisms.
### 3.7.1. Female Travellers

Irmgard Bauer, for example, has published a study on "the modern female traveller" [47]. Although it does not focus only on backpackers, it describes situations and needs, particularly in terms of health, encountered by women travelling alone with backpacks. It is a literature review, not an empirical study. Bauer's work has two main themes: (1) personal hygiene and gynaecology and (2) safety and security. Concerning the first topic, she highlights various issues such as managing menstruation, the challenges of carrying or buying hygiene products while travelling, adjustments to contraception necessitated by travel conditions, and the potential for irregular or interrupted menstrual cycles due to travel. Pregnancy and the precautions it requires when travelling are also discussed. Finally, Bauer reports research linking difficulties in accessing clean sanitary facilities to an increased risk of urogenital tract infections, particularly affecting women backpackers. The use of cosmetics, which can present health risks (e.g., henna), is also discussed.

On the second point of safety and security, Bauer cites various studies and all of them report that women encounter situations of fear and vulnerability more frequently than men while travelling. However, these studies also show that these experiences lead women to adopt more cautious behaviours. This issue of the association between risk and gender among travellers, particularly among backpackers, addressed by Bauer from a travel health perspective, is also discussed in the tourism management literature [48].

### 3.7.2. Are Backpackers Getting Older? The Grey Nomads

During this literature search, the term *grey nomads* emerged. There are two main references in this field. The first is by M. Yates et al. on senior citizens who travel across Australia in campervans or caravans rather than backpacks [49]. The second reference is another publication by I. Bauer [50] dealing with senior adventure tourism in Peru. Once again, it concerns Australian tourists and is based on a literature review. The first publication is more general and outlines potential angles for studying this population, including a question on pre-travel health-related planning and preparation. The second publication identifies and describes the general travel health considerations that senior travelers may encounter. What is interesting about these two studies is that they set a threshold (50 years old for Yates and 55 for Bauer) beyond which a change of category seems to take place, with backpackers transitioning into grey nomads.

Put in another way, if we look at the issue of backpackers' health, should we exclude people over a certain age along with their unique challenges because these people form a different category? Doing so might mean overlooking exceptional cases. For instance, there is a story of an 89-year-old backpacker featured on a website (https://www.timetravelturtle.com/worlds-oldest-backpacker/<fnref n="1" />). Or should we merge these categories and study them cumulatively?

### 3.7.3. Transformative Tourism

The concept of transformative tourism, although not new, has gained prominence recently (figure 2). It encompasses the idea that travel can be a transformative experience, akin to a rite of passage, where individuals undergo personal changes. There has been a substantial increase in articles on this theme, as well as fresh approaches [51].

<footnote n="1">¹ Accessed on 8 January 2024</footnote>
<figure><img src="image_5.png" /><figcaption>**Figure 2.** Growth in transformational tourism publications between 1978 and 2020 [52] (Adapted from Roshini Nandasena et al., 2022).</figcaption></figure>

Several studies explicitly mention the health benefits of travel [53], and in particular, the therapeutic virtues of the tourist experience in terms of mental health and wellbeing. Travel, particularly long-haul travel undertaken by backpackers, provides a break from daily routines, encourages personal development, increases self-confidence and self-enrichment, and helps manage negative emotions (anxiety, fears, phobias). One of the most positive aspects reported is socialisation through interactions with local communities [54] [55], with whom backpackers engage with more frequently than “conventional” tourists. In an empirical study, Pung [56] suggests that transformations after long journeys lead to lasting and permanent personal transformation, without specifically discussing backpacking.

**4. Discussion and Conclusions**

The findings presented in the preceding sections can be discussed in several ways.

Firstly, the narrative literature review has its limitations. Despite searching six databases, one database, Google Scholar, predominates. Further work is underway to analyse the bibliographies of each of the 125 references compiled in this study to expand the database.

We believe that certain categories identified in the narrative literature review should be the subjects of literature reviews in their own right. For instance, the topics of senior backpackers or transformative tourism, linked to well-being and mental health, warrant separate examinations. Mental health, in particular, seems to be a subject that has been largely ignored.

Generally speaking, an inherent limitation of a literature review concerns the criteria for including or excluding references. Some categories of long-distance travellers were not included in the scope of the research, such as cyclists, hikers, and round-the-world sailors. However, some of these categories appeared alongside the “classic” backpacker category in the research results, because the boundaries between the types of long-term travellers
are quite faded. A more exhaustive literature review in this regard could yield valuable insights.

Conversely, certain categories of population did not appear at all in the research results. For example, if any research has emerged on the topic of gender, it has exclusively focused on female travellers, with no research found on the health of homosexual or transgender backpackers. Is it because these categories do not make sense? Or because such research does not exist? Or because the research equations used were not designed to show them?

Moreover, certain subjects did not appear or appeared only rarely. In relation to the question of risk, we might have expected to find references to health insurance, but this was not the case. We undertook an exploratory complementary search using the terms "backpackers" + "insurance", which produced unconvincing results.

The literature review was carried out too soon after the pandemic to have sufficient hindsight to include the pandemic in the scope of the analysis. A majority of the first articles published during and after the crisis tackle the disruption, or even interruption, of tourism including backpacker's travels but without specifically focusing on this category. However, it seems certain that the way in which a health issue has brought the tourist industry to a standstill, closed the borders, and immobilised backpackers will have consequences and should constitute a substantial body of literature in the future "as political, social cultural and technological changes caused by the pandemic give rise to feelings of depression, distrust, detachment and alienation, the search for a more authentic, truer self is likely to see individuals reposition themselves spatially, temporally and socially through travel and backpacking once more" [57].

Finally, from a geographer's point of view, the results of this narrative literature review invite reflection on the issues underlying the endeavour: what could geography contribute?

In some cases, a more geographical approach would help to contextualise the observations. References based on empirical case studies rarely examine the effects of context and refrain from asking whether what is observed in one place is unique to a particular location or more universally found in other parts of the world.

Moreover, the literature we identified primarily falls within two major domains, i.e., travel medicine and tourism studies, both dominated by a strong management focus. Neglected in this research is the exploration of observation scales, a crucial aspect within geography.

Looking at backpacking from the angle of mobility also raises questions about the geography of health. It involves international mobility over long periods of time and is neither a form of migration nor a conventional form of tourism. Individuals engaged in this type of mobility maintain connections with their country of origin, including its healthcare system and health-related norms, while simultaneously navigating local healthcare systems in the countries they traverse. This confrontation rooted in geographical spaces is certainly a research issue in its own right.

Aside from the relative absence of geography, the small number of disciplines involved partly explains the low number of references identified in this literature review. We found very few specialised articles on the relationship between health and backpacking. In broader terms, there is not a great deal of grey literature on the relationship between tourism and health, and the geography of health is just beginning to explore this issue [58]. We might wonder whether the scarcity of studies on backpackers' health stems from their status as a minority group among tourists and travellers, or whether it is subject ripe for future exploration, which we believe to be the case.

Finally, we need to return to the assumptions that informed the beginning of this literature search. The initial questions were as follows: Are backpackers a high-risk population considering their travel styles? Do they adopt specific health behaviours? How do they integrate health considerations into their travels, and are the healthcare systems in their destinations able to provide the type of care these populations require?
These questions remain largely unanswered due to a glaring lack of empirical data in the existing literature, which predominantly consists of interrelated literature reviews.

This situation strongly suggests the need for fieldwork, a domain where geographers excel, to gather data and conduct empirical studies. While the content of this literature review does not answer all the questions, it does provide a starting point for developing survey plans.

**Funding:** This research received no external funding

**Conflicts of Interest:** The authors declare no conflict of interest.

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