Barriers to immunization among children of migrant workers from Myanmar living in Tak province, Thailand.

528 Bull World Health Organ 2011;89:528–531 | doi:10.2471/BLT.10.084244 Lessons from the field Abstracts in بيرع, 中文, Français, Pусский and Español at the end of each article. Problem An estimated 2.7 million children die annually from vaccine- preventable diseases.1 Immunization is one of the most effec- tive existing strategies for preventing illness in children and it is widely seen as a beneficial, low-cost investment.2 The World Health Organization’s Expanded Programme on Immunization (EPI) is the first component of An essential public health package, a set of recommendations to improve child health at a low cost.3 Despite this, the implementation of immunization programmes varies greatly across different communities4 and approximately 34 million children worldwide do not have access to any im- munization services.4,5 Thailand is one of the most successful and stable economies in south-east Asia and draws tens of thousands of migrant work- ers from Myanmar each year. More than 2 million people from Myanmar live and work, predominantly illegally, in Thailand.6 Illegal migrants represent a significant public health issue. It is estimated that only 10% of migrants are legally registered in Thailand and most do not use the Thai health services; as a result, children of migrant workers rarely receive immunizations.7 The Thai Government maintains immunization records for all Thai children but not for migrant children living on the Myanmar border. The Thai district health authorities attributed this to difficulties completing immunization courses due to the mobile nature of these communities. Local setting Tak is a north-western province of Thailand, which shares its western border with Myanmar. Tak is a relatively small province with a population of about half a million people in addition to an estimated 200 000 migrants.8 Vaccine-preventable diseases, including measles, mumps, tuberculosis and hepatitis, are among the main causes of reported disease among the migrant popula- tion in Tak province.8 The provision of immunization services to children of migrants is neither systematic nor coordinated. The Thai Gov- ernment provides immunization services for migrants at health posts and public hospitals. Only one of the many humanitarian aid organizations working along the border with Myanmar is implementing immunization programmes for children of mi- grant workers. In an attempt to address the problem, the Shoklo Malaria Research Unit (SMRU) launched a mass immunization campaign for 10 000 children of migrant workers residing in four districts of Tak province and implemented a systematic immunization programme in four of its border clinics. Although research conducted internationally has identified several barriers to successful implementation of such programmes in migrant populations,9–12 it was important to identify context-specific barriers to inform the planning and delivery of migrant immu- nization programmes in Tak province, Thailand. Approach We conducted focus groups at three different SMRU clinic sites in three different geographical areas along the border with Myanmar in Tak province, Thailand: Wang Pha, Mawker Thai and Mae Kon Ken districts between 14 May and 10 July, 2009. Qualitative re- search is the most appropriate methodology for exploring people’s understandings and perceptions in depth. These sites were selected because the clinic population would be the target population for the immunization programmes. We ran a total of 53 focus groups involving 371 participants in three sites; details of participants are summarized in Table 1. All participants were migrants and were parents of a child aged less than 12 years. They were all residing on the border area within SMRU campaign limits. Parents who came to seek free medical care at selected SMRU clinics were invited to join the focus group discussions. Recruitment was done at the clinic waiting area. Of those invited to participate, 90% took part. The majority of those Barriers to immunization among children of migrant workers from Myanmar living in Tak province, Thailand. Sara Canavati,a Emma Plugge,b Suporn Suwanjatuporn,a Suteera Sombatrungjaroena & François Nostenc Problem Immunization is a cost-effective means of improving child survival but implementation of programmes in low- and middle- income countries is variable. Children of migrants are less likely to be immunized. Approach The qualitative study aimed to identify barriers to the successful implementation of migrant immunization programmes in Tak province, Thailand. We ran a total of 53 focus groups involving 371 participants in three sites. Local setting Tak province in Thailand borders Myanmar and has an estimated 200 000 migrants from Myanmar. Vaccine-preventable diseases are a documented cause of morbidity in this population but there is no systematic or coordinated immunization programme in the area. Relevant changes As a result of the findings, the subsequent immunization campaign targeted children in school to overcome those barriers of distance to immunization services, fear of arrest, not remembering immunization appointments, and the disruption of parental work. The campaigns also included immunization education for both parents and teachers. Lessons learnt Migrant parents identified similar barriers to accessing childhood immunization programmes as migrant populations elsewhere in the world, although a unique barrier identified by parents from Myanmar was “fear of arrest”. The subsequent school- based strategy to overcome these barriers appears to be effective. a Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, 68/30 Bantung Road, Mae Sod, 63110, Bangkok, Thailand. b Department of Public Health and Primary Health Care, University of Oxford, Oxford, England. c Centre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, Oxford, England. Correspondence to Sara Canavati (e-mail: s.canavatidelatorre@kellogg.oxon.org). (Submitted: 6 December 2010 – Revised version received: 1 April 2011 – Accepted: 10 April 2011 – Published online: 20 May 2011 ) L ns from the field Bull World Health Organ 2011;89:528–531 | doi:10.2471/BLT.10.084244 529 Lessons from the field Barriers to immunization among migrants from Myanmar in ThailandSara Canavati et al. who refused did so because they were not feeling well enough to participate. The focus groups were held in a quiet area at the clinics. There was no gift or compensation given directly from this study. The researchers were specially trained members of the SMRU vaccine team who were all fluent in Thai and Karen languag- es; two of them spoke the Myanmar lan- guage as well. They used a discussion guide, which enabled team members to run focus groups independently using a standardized format. The discussion guide format used was recommended by the children’s vac- cine programme at PATH.5 The language of interview was chosen according to the members of the group; the language most used was Karen. Every focus group session was composed of one facilitator and two note takers, who differed among groups. Notes were taken in Thai language and subsequently translated into English. The data were then coded and categorized and analysed using thematic analysis by two independent researchers. Differences were resolved by discussion. Findings Participants considered that vaccinating their children was a good thing. They were able to identify several benefits that im- munization conferred upon their children. One parent’s view was typical of many other participants: “When children get vaccinated they become strong and cannot get diseases” (focus group 11). Despite this positive view of immuni- zation, the participants identified several difficulties they faced when immunizing their children. The main barriers identified in this study were: continued migration, distance to immunization services, fear of side-effects (particularly fever), fear of arrest, not remembering immunization appointments, and the necessity of work. Several of the key findings from this study were consistent with the findings of previ- ous research identified in the international literature.9–12 Access – both geographical and financial – was a considerable issue; one participant expressed succinctly the concerns of many others: “I have too many children, my house is too far and I cannot walk because of heavy rain and flooding, besides that there is no transportation; the only transportation available is motorcycle but it is very expensive and I have no money” (focus group 51). The fear of arrest was a finding unique to this context. Some parents said they did not have their children immunized because they were afraid of getting arrested on the way to the clinic or at the clinic by the Thai police: “The only reason we would risk accessing a Thai clinic is when our child is very ill because under those circumstances the Thai police would not do anything to us” (focus group 22). Parents expressed strong fear of coming to the vaccine site: “We are afraid of the police. There are several checkpoints from our place to the vaccine site and we can get arrested anytime” (focus group 30). Lessons learnt This report presents the first exploration of the barriers to immunization among children of migrant workers from Myan- mar living in Tak province, Thailand, from the perspective of the parents (Box 1). It was important to involve the migrant parents in the development of the immunization programme in this area as they are key to deciding whether to immunize their children. Identifying perceived barriers also identifies oppor- tunities for developing an acceptable and accessible immunization programme. In the light of these findings, we de- cided to implement the immunization programme at schools specifically set up for migrant children. We targeted 49 migrant schools in Tak province run by nongovernmental organizations that have transportation services. This change in approach helped overcome those barriers of distance, the necessity of work and the fear of arrest; all issues raised by the parents. We addressed parents’ fear of fever by providing paracetamol preparations at every school, including detailed instructions on dosage in case of fever. In addition, we provided training to parents and teachers on immunization benefits and side-effects. We established strong relationships with teachers and this also helped us to follow-up children who dropped out from school and were unable to complete their immunization schedule. The campaign was designed in five rounds and a monitoring session was held at the end of each round. The final evaluation took place immediately after the 2009–2010 mass immunization cam- paign. Vaccination coverage estimates were obtained by dividing the number of doses administered by the number of children of eligible age. All coverage rates achieved in the SMRU immuniza- tion campaign were over the threshold of 80–90% needed for herd immunity. The SMRU programme among migrant school children has achieved similar rates to Thailand’s national coverage and above the World Health Organization minimum targets. ■ Table 1. Social characteristics of the 371 focus group participants in Tak province, Thailand Characteristic Value Median age (years) 31 Median number of children 3 Ethnicity (%) Karen 49 Burman 44 Pho O 7 Occupation (%) Farmer 71 Housewife 20 Factory worker 3 Other 6 Religion (%) Christian 16 Buddhist 80 Muslim 4 Box 1. Summary of main lessons learnt • Migrant parents should be involved in the development of immunization programmes. • Immunization services should be offered at schools attended by migrant children to help overcome barriers of distance, parental work commitments and fear of arrest. • Parents and teachers should be trained on the benefits and side-effects of immunization. We addressed fear of fever by providing parents with paracetamol and dosage instructions. Bull World Health Organ 2011;89:528–531 | doi:10.2471/BLT.10.084244530 Sara Canavati et al.Barriers to immunization among migrants from Myanmar in Thailand Lessons from the field Acknowledgements We would like to thank the Tak pro- vincial health department for their invaluable support, the SMRU vaccina- tion team for their hard work and the Burmese Migrant Workers Education Committee and Help without Frontiers for offering us constant support. Like- wise, we thank Andrew Pollard, Cindy Chu and Verena Carrara for their advice throughout the vaccination campaign and Adrian Smith for his assistance in this study. Sara Canavati is also affiliated with the Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. François Nosten is also affiliated with the Shoklo Malaria Research Unit and the Mahidol-Oxford Tropical Medicine Re- search Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. Funding: Department of Public Health and Primary Health Care, University of Oxford, and Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahi- dol University. The vaccination campaign was funded by the Sherpa Foundation and the European Union. Competing interests: None declared. صخلم ةيدنلاياتلا كات ةعطاقم في نوشيعيو رانمايم نم نيرجاهلما لماعلا لافطأ عينتم مامأ تابقع لافطلأا ءاقب ينسحتل ةفلكتلا ءاقل دودرم تاذ ًةليسو ُعينمتلا ُدَعُي ةلكشلما ةضفخنلما نادلبلا في عينمتلا جمارب ذيفنت في نيابت كانه نكلو ،ةايحلا ديق لىع صرفب نيرجاهلما لماعلا لافطأ ،حجرلأا لىع ،ىظحي لا و ،لخدلا ةطسوتلماو .عينمتلا ةبسانم جمارب ذيفنت حاجن مامأ تابقعلا ديدحت لىإ ةيعونلا ةساردلا فدهت ةقيرطلا 53 نوثحابلا جردأ دقو .دنلايات في كات ةقطنم في ينميقلما نيرجاهملل عينمتلا .عقاوم ةثلاث في ًاكراشم 371 مضت ةيرؤب ةعومجم ددعلا غلبيو ،رانمايم موخت لىع ةيدنلاياتلا كات ةعطاقم عقت ليحلما عضولا ضارملأا نأ عمو .رجاهم فلأ 200 اهيف رانمايم نم نيرجاهملل يريدقتلا ،ناكسلا ءلاؤه ينب ةقّثوم تايفو عوقو في تببست تاحاقللاب اهيقوت نكملما .ةقطنلما هذه في قسنم يجهنم عينتم جمانرب دجوي لا هنأ لاإ ةقحلالا عينمتلا ةلمح تفدهتسا ،جئاتنلا كلتل ةجيتنو ةلصلا ةقيثو تايرغتلا لىإ لوصولل ةفاسلما دْعُب لثم تابقع لىع بلغتلل كلذو سرادلما لافطأ عاطقناو ،عينمتلا ديعاوم رّكذت مدعو ،لاقتعلاا نم فوخلاو ،عينمتلا تامدخ لوح ينسردلماو ءابلآا فيقثت ًاضيأ تلامحلا تلمتشا ماك .لمعلا نع نيوبلأا .عينمتلا جمارب لىإ مهلوصو مامأ تابقع نورجاهلما لماعلا ددح ةدافتسلما سوردلا في نيرجاهلما رئاس اهل ّضرعتي يتلا تابقعلا عم هباشتت يهو لافطلأا عينتم نم نيرجاهلما ءابلآا مامأ ديرف قئاع كانه ناك نكلو ،لماعلا عاقب فلتخم ةيسردلما ةيجيتاترسلاا نأ ودبيو .”لاقتعلال ّضرعتلا نم مهفوخ“ وهو رانمايم .ةلاّعف تناك تابقعلا كلت لىع بلغتلل ةقحلالا 摘要 泰国达克省缅甸移民儿童免疫接种障碍 问题 ：免疫是一种具有成本效益的、提高儿童存活率的方 式，但中低收入国家免疫计划的实施存在变数。移民儿童 接受免疫的可能性较低。 方法 ：本次定性研究旨在确认在泰国达克省成功实施移民 免疫计划所存在的障碍。我们对三个城市中53个焦点小组 总计371位参与者进行了研究。 当地状况 ：泰国达克省与缅甸接壤，从缅甸移民到该省 工作的人预计有200,000人。根据记录，疫苗可预防的疾 病是该人群生病的病因，但该地区并无系统性或协调性 的免疫计划。 相关变化 ：由于发现上述情况，后续的免疫活动旨在让学 校儿童克服免疫接种服务距离、担心被捕、忘记免疫接种 预约、父母亲工作干扰等障碍。活动还包括给父母和老师 提供免疫教育。 经验教训 ：移民父母确认了参与儿童免疫计划的障碍，与 世界上其他地方移民人群类似的障碍相比，缅甸父母确认 的一个独特障碍就是“担心被捕”。后续的基于学校的旨 在克服这些障碍的策略似乎有效。 Résumé Obstacles à l’immunisation chez les enfants des travailleurs immigrés du Myanmar résidant dans la province de Tak en Thaïlande Problème L’immunisation est un moyen rentable d’améliorer la survie des enfants, mais la mise en œuvre des programmes dans les pays à revenu faible et moyen est variable. Les enfants des immigrés ont moins de chances d’être immunisés. Approche L’étude qualitative visait à identifier les obstacles à la mise en œuvre réussie des programmes d’immunisation des immigrés dans la province de Tak, en Thaïlande. Nous avons effectué cette étude sur un total de 53 groupes cibles, impliquant 371 participants sur trois sites. Environnement locale La province de Tak en Thaïlande est frontalière du Myanmar et accueille approximativement 200 000 immigrés du Myanmar. Les maladies à prévention vaccinale sont une cause attestée de la morbidité dans cette population, mais il n’existe aucun programme d’immunisation systématique ou coordonné dans la région. Changements significatifs Suite aux résultats, la campagne de vaccination qui a suivi ciblait les enfants d’une école pour surmonter ces obstacles liés à la distance des services de vaccination, à la peur de l’arrestation, à l’oubli des rendez-vous de vaccination, ainsi qu’à la défaillance de la responsabilité parentale. Les campagnes comprenaient également l’éducation à la vaccination pour les parents et les enseignants. Bull World Health Organ 2011;89:528–531 | doi:10.2471/BLT.10.084244 531 Sara Canavati et al. Barriers to immunization among migrants from Myanmar in Thailand Lessons from the field Резюме Факторы, препятствующие иммунизации детей рабочих-мигрантов из Мьянмы, проживающих в таиландской провинции Так Проблема Иммунизация является экономически эффективным средством повышения выживаемости детей, однако результаты внедрения программ иммунизации в странах с низким и средним доходом противоречивы. Вероятность того, что дети мигрантов пройдут иммунизацию, невысока. Подход Целью проведенного качественного исследования было выявление факторов, препятствующих успешному осуществлению программ иммунизации мигрантов в таиландской провинции Так. В общей сложности мы создали 53 фокус-группы, в которые входили 371 участников из трех округов. Местные условия Таиландская провинция Так граничит с Мьянмой. По оценкам, в ней насчитывается 200 000 мигрантов из этой страны. Документально подтверждено, что болезни, для профилактики которых имеются эффективные вакцины, являются причиной заболеваемости в этой группе населения, однако в данном районе не осуществляется системная или скоординированная программа иммунизации. Осуществленные изменения По результатам нашего исследования была организована кампания иммунизации, адресно ориентированная на детей, посещающих школу, с целью преодоления таких препятствий, как отдаленность пунктов, где предоставляются услуги по иммунизации, боязнь ареста, забывчивость, возможность потери работы родителями. Эти кампании также включали в себя санитарное просвещение родителей и учителей по вопросам иммунизации. Выводы В качестве причин, затрудняющих доступ к программам иммунизации, родители-мигранты называли те же факторы, о которых говорят мигранты в других странах мира. В то же время уникальным препятствием, названным родителями из Мьянмы, была «боязнь ареста». Стратегия преодоления этих барьеров, внедряемая по результатам исследования, представляется эффективной. Resumen Obstáculos para la vacunación de los hijos de trabajadores inmigrantes procedentes de Myanmar en la provincia de Tak, Tailandia Situación La vacunación es un método rentable para mejorar la supervivencia infantil, aunque la aplicación de este tipo de programas resulta variable en países de ingresos medios y bajos. Los hijos de inmigrantes tienen menos probabilidades de vacunarse. Enfoque Estudio cualitativo para identificar los obstáculos existentes para la correcta aplicación de los programas de vacunación de inmigrantes en la provincia de Tak, en Tailandia. Establecimos un total de 53 grupos muestrales, con un total de 371 participantes de tres emplazamientos. Marco regional La provincia de Tak se sitúa en la frontera de Tailandia con Myanmar y en ella habitan aproximadamente 200 000 inmigrantes procedentes de dicho país. Las enfermedades vacunables son una causa documentada de morbilidad en esta población, pero no existe un programa de vacunación sistemática y coordinada en esta área. Cambios importantes Como consecuencia de los resultados, la subsiguiente campaña de vacunación estuvo dirigida a los niños escolarizados, con el fin superar los obstáculos relacionados con la distancia de los servicios de vacunación, el miedo a ser arrestados, el olvido de las citas de vacunación y la discontinuidad del trabajo parental. Las campañas incluyeron educación sobre la vacunación, tanto para los padres como para los profesores. Lecciones aprendidas Los padres inmigrantes encuentran obstáculos similares en cualquier parte del mundo a la hora de acceder a los programas de vacunación infantil, aunque la única barrera que identificaron los padres de Myanmar fue la del «miedo a ser arrestado». La subsiguiente estrategia centralizada en los colegios parece resultar efectiva a la hora de superar estos obstáculos. References 1. Immunization summary: the 2007 edition. Geneva: United Nations Children’s Fund & World Health Organization; 2007. 2. Bloom DE, Canning D, Weston M. The value of immunization. World Econ 2005;6:15–39. 3. The World Bank. World development report 1993: investing in health. New York: Oxford University Press; 1993. 4. Lee JW. Child survival: a global health challenge. Lancet 2003;362:262. 5. Achieving our immunization goal. Geneva: GAVI Alliance; 2003. 6. Fast facts on Burma [Internet]. Mae Tao Clinic; Mae Sot; 2011. 7. World development report 2009: reshaping economic geography. Washington: The World Bank; 2009. 8. Overview of Thai/Myanmar border health situation 2005. Thailand: Ministry of Public Health & World Health Organization; 2005. 9. Kiros GE, White MJ. Migration, community context, and child immunization in Ethiopia. Soc Sci Med 2004;59:2603–16. 10. Cassell JA, Leach M, Fairhead JR, Small M, Mercer CH. The social shaping of childhood immunization practice in rural and urban Gambia. Health Policy Plan 2006;21:373–91. 11. Attitudes towards immunization in Cambodia: a qualitative study of health worker and community knowledge, attitudes and practices in Kompong Chhnang. Cambodia: PATH & Australian International Health Institute; 2002. 12. Fowler GL, Weintraub E, Kennedy A, Luman ET, Shui I, Khromava A et al. Vaccine safety perceptions and experience with adverse events following immunization in Uzbekistan. Public Health 2008;122:412–6. Leçons tirées Les parents immigrés ont identifié des obstacles à l’accès aux programmes d’immunisation infantile similaires à ceux des populations immigrées du monde entier, bien qu’un seul obstacle identifié par les parents originaires du Myanmar ait été «la peur de l’arrestation». La stratégie scolaire ultérieure permettant de surmonter ces obstacles semble être efficace.