LESSONS FROM THE FIELD
Obstacles à l'immunisation chez les enfants des travailleurs immigrés du Myanmar résidant dans la province de Tak en Thaïlande
Obstáculos para la vacunación de los hijos de trabajadores inmigrantes procedentes de Myanmar en la provincia de Tak, Tailandia
Sara CanavatiI,*; Emma PluggeII; Suporn SuwanjatupornI; Suteera SombatrungjaroenI; François NostenIII
IShoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, 68/30 Bantung Road, Mae Sod, 63110, Bangkok, Thailand
IIDepartment of Public Health and Primary Health Care, University of Oxford, Oxford, England
IIICentre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, Oxford, England
PROBLEM: Immunization is a cost-effective means of improving child survival but implementation of programmes in low- and middleincome 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 schoolbased strategy to overcome these barriers appears to be effective.
PROBLÈME: L'immunisation est un moyen rentable d'améliorer la survie des enfants, mais la mise en oeuvre 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 oeuvre 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.
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.
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.
An estimated 2.7 million children die annually from vaccinepreventable diseases.1 Immunization is one of the most effective 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 immunization services.4,5
Thailand is one of the most successful and stable economies in south-east Asia and draws tens of thousands of migrant workers 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.
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 population in Tak province.8
The provision of immunization services to children of migrants is neither systematic nor coordinated. The Thai Government 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 migrant 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,912 it was important to identify context-specific barriers to inform the planning and delivery of migrant immunization programmes in Tak province, Thailand.
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 research 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 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 languages; two of them spoke the Myanmar language 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 vaccine 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.
Participants considered that vaccinating their children was a good thing. They were able to identify several benefits that immunization 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 immunization, 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 previous research identified in the international literature.912 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).
This report presents the first exploration of the barriers to immunization among children of migrant workers from Myanmar 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 opportunities for developing an acceptable and accessible immunization programme. In the light of these findings, we decided 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 20092010 mass immunization campaign. 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 immunization campaign were over the threshold of 8090% 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.
We would like to thank the Tak provincial health department for their invaluable support, the SMRU vaccination team for their hard work and the Burmese Migrant Workers Education Committee and Help without Frontiers for offering us constant support. Likewise, 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 Research 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, Mahidol University. The vaccination campaign was funded by the Sherpa Foundation and the European Union.
Competing interests: None declared.
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(Submitted: 6 December 2010 Revised version received: 1 April 2011 Accepted: 10 April 2011 Published online: 20 May 2011)