Migrant Workers and Malaria - Dr Win Maung.compressed

Myanmar Artemisinin Monotherapy Replacement Project (AMTR)

Independent Evaluation

1 April 2015 Dissemination Workshop

Dr Myat Phone KyawDr Myo Min

Dr Win Maung

Working Paper 3 - June 2014Situation of Mobile Migrant Workers and Malaria at Vulnerable

Sites in Myanmar: A Qualitative Research Paper

Research Objectives

• Discover the mobility dynamics of migrant workers at four different sites and their group decisions to solve common health problems including malaria

• Identify the workers understanding of malaria illness, treatment seeking practices for suspected malaria, and personal protective measures

• Find out their sources of information related to malaria and preferences of media channels.

Research Design and Sites

• A cross-sectional, exploratory, qualitative research using FGD and pre-tested question guides

• Study sites and population covered mobile/migrant workers with three areas of economic likelihood: fishing, gold panning and mining.

Sample Size

Township Activity Mobility No. FGDNo. participants

(M/F)

Kawthaung Fishing low 2 17 (17/0)

Kawthaung Fishing high 2 15 (15/0)

Kawthaung Various low 3 22 (16/6)

Kawthaung Various high 2 18 (8/10)

Shwe Kyin Mining high 10 91 (60/31)

Shwe Kyin Mining/Plantation low 2 8 (5/3)

Dawei Various high 5 53 (27/26)

Dawei Mining high 3 25 (13/12)

Ye Phyu Plantation high 2 26 (18/8)

Total 31 275 (179/96)

Results 1 – Mobility Dynamics

• Movement frequency varied from < 1 to 2-3 per year

• Movements influenced by:– nature of work– financial status– family ties, health (especially when afflicted by malaria)

and socio-cultural reasons – special events/festive periods include water festival

(Thingyan); lighting festival (Thadingyut) & pagoda festival.

• Migrant groups on rubber and palm oil plantations = low mobility, fishing sites = higher level of mobility.

• Cross-border migrant movements from fishing sites a likely factor in the spread of drug resistant parasites

Results 2- Common Health Problems

• Common health problems other than malaria included:– diarrhoea, flu and dengue (seasonal)

• Other health problems included:– chronic/non-infectious illness - hypertension, diabetes

– Acute - abdominal pain, dizziness, headaches, muscle and joint pain, nausea and fatigue.

• Care seeking and group decisions:– Reported practices

• Self-medication

• approaching drug-sellers

• unlicensed practitioners (‘quacks’ or retired health staff)

• Malaria not generally perceived as a serious problem and self-medication favoured.

• Respondents did not seek early diagnosis and prompt treatment when suffering from acute undifferentiated fever.

Results 3 – Understanding Malaria

• Knowledge of Malaria Symptoms– Symptoms reasonably well understood across all sites but

revealed misconceptions.– Discussants often defined malaria fever based upon

traditional beliefs, cultural perceptions and personal experience, symptoms included: • fever with chills• abdominal pain• headache, • dizziness, nausea and vomiting• cold and clammy extremities • alternate hot and cold sensations• loss of appetite • muscle spasms.

Results 3 – Understanding Malaria (Cont.)

• Knowledge of causes and modes of transmission included:– Mosquito bites a major cause of malaria transmission. – Intensity of mosquito bites linked to seasonality e.g. early part

of the rainy season coincides with month of Warso; and late part of the dry season - Tabaung and Tagoo.

– Misconceptions on malaria transmission included:• drinking stream / contaminated water• eating contaminated food, bananas, cold / sour food, fatty /

oily meals; • taking a bath in a stream at the wrong time.

– Ideas that stemmed from others’ experiences included:• seasonal illnesses like flu, • weather changes, • physical stress and strain, • sleeplessness, tiredness, weakness, and fatigue.

Results 4 - Malaria Experience, Diagnosis and Seeking Treatment

• Malaria experience and first responses included:– Seeking advice from people within the migrant group that

previously had malaria and shared their experience.

– Some people with fever, self diagnosed malaria based on previous experience and did not seek confirmation from a diagnostic test.

– In some cases, medication was obtained following a proper diagnostic procedure by a doctor:

“ I think I should check my health status. If I checked, I would know my condition. I live in the forest so I do not know what the cause of last illness was. At that time, I doubted that it was due to getting cold or working in rain”.

– Other first response was to seek treatment from local health care providers if available.

Results 4 - Malaria Experience, Diagnosis and Seeking Treatment (Cont.)

• Malaria Diagnosis

– Knowledge was good, most participants were aware of rapid diagnostic tests (RDT).

– Sources for awareness included CHW, malaria team, radio, hearsay, clinics, NGOs including IOM and UNICEF.

Results 4 - Malaria Experience, Diagnosis and Seeking Treatment (Cont.)

• Medical Check-ups

– Most participants did not know the importance of having malaria check-ups done before leaving for another destination (including home).

– The motivation to test for malaria in their hometowns was linked to experiencing fever and its seriousness and to accessibility to testing.

Results 4 - Malaria Experience, Diagnosis and Seeking Treatment (Cont.)

• Antimalarial awareness– Familiar with Chloroquine, Quinine, Fansidar and Artesunate– Combinations of antimalarials, including ACT available at RHCs

and midwives spread information.– Artemisinin related compounds sold by drug sellers without

prescription. – Familiar with ‘Padonmar’ as a trade name, not as ACT quality

seal. – Other medicines used for treatment of malaria included

analgesics (Novalgin, paracetamol) & indigenous medicineand herbs.

– Participants from non-endemic areas unaware of ACTs (e.gworkers at Shwe Kyin gold mine), but just follow doctors’ prescriptions.

– Some misperceptions resulted in antimalarial tablets being crushed in water to prevent malaria

• Treatment Seeking from:– Unlicensed practitioners most easily accessible (majority of

consultations). – HW’s and midwives from nearby rural health centres (fishing &

gold mining sites). – Self-medication is common but if it becomes serious they

usually go to the hospital. Quotes: • “If health conditions are in crisis, one of the health care

providers from Aung-Bar sub-centre comes to treat”.• “We get treatment from the clinic, but there is no

screening”.• “The retired mid-wife, Daw Mar Nyo, treats patients

suspected to have malaria but she does not conduct malaria tests”.

Results 4 - Malaria Experience, Diagnosis and Seeking Treatment (Cont.)

• Cost of Malaria Illness– Reported cost of treating an acute episode of malaria

illness ranged from 1,000 to 100,000 Kyats dependent on :• number of visits• the health care provider, and • the type of treatment given.

– Affordability was a major determining factor the type of treatment sought.

– In Kawthaung, treatment costs were up to 500,000 kyats.• Those who could not afford opted for traditional /

indigenous medicines. • Reported needing to borrow money from their

employers.• Similar situation noted for workers at gold panning sites

and in Heindar mines.

Results 4 - Malaria Experience, Diagnosis and Seeking Treatment (Cont.)

• Major constraints reported for seeking diagnosis and treatment were:

• high transportation charges• difficulty in reaching health facilities during the rainy

season• lack of health care providers at the worksite especially

during health emergencies• long waiting time to see healthcare professionals• lack of good information on malaria interventions

• Suggestions for increase centred on:• Location/nearness of health clinic• Availability of health care providers for early diagnosis

especially during the transmission season• Availability of information on malaria diagnosis and

treatment

Results 4 - Malaria Experience, Diagnosis and Seeking Treatment (Cont.)

Results 5 – Protection from Malaria

• Perceptions about malaria prevention

– Fishing and gold panning sites - not well-informed.

– Some still believe that it is not possible to protect against malaria, it can only be treated once infected.

• Awareness of Specific Mosquito Bite Prevention Measures

– Common awareness on protective measures included:

• sleeping under a bed-net

• wearing long sleeved clothing

• using mosquito repellents and coils

– But also some incorrect views

• drinking boiled water; and

• keeping the environment clean

Results 5 – Protection from Malaria (Cont.)

• Awareness of ITNs/LLINs and preferences

– Awareness of free distribution of LLINs/ITNs at fishing and gold panning sites.

– Some knew about insecticide kits but did no see them anywhere.

– LLIN/ITN usage varied due to multiple personal reasons.

– Some express preference for simple bed nets over LLIN/ITN:

• LLIN smell and skin reactions to insecticide

• LLIN rough surface sometimes causing abrasion

• LLIN thickness (durability).

– Insufficient distribution of ITN/LLIN has hampered regular use.

– The majority reported willingness to use LLIN/ITN.

• Perceptions towards sustainable use of ITNs/LLINs– Majority interviewed, recognised challenges in the sustainability

of LLINs/ITNs use:

• Unable to use when out fishing

• Personal health problems (breathing difficulties & allergies)

• Irregular supply of the nets

• No replacements when the nets get torn or lost.

– “We are not accustomed to using bed nets so we cannot sleep under them. Many have difficulties breathing when using LLINs/ITNs”.

– “I cannot sleep under bed nets when I am on the boat because the wind is so strong and there are no mosquitoes”.

– “There should be more health education about malaria so that people understand the advantages of sleeping under bed nets”.

Results 5 – Protection from Malaria (Cont.)

Results 6 – Information and Media Channels

Type of Malaria Information

– Cause of malaria

– Mode of transmission

– Prevention

– Diagnosis

– Treatment

Format and delivery

– Leaflets

– Posters

– TV discussion

and adverts

– Radio

discussions

and adverts

– Village/town

meetings

Source of Malaria Information

– Health care

providers

– LHV

– Midwives

– NGOs on health

education

sessions for

cross-border

migrants

Summary of Findings

• Major factors identified that influence migrant workers’ decisions on seeking diagnosis and/or care for fever:1. The perceived cause and severity of the illness:

• Few hospitalizations or deaths due to malaria. • Severe illness, they went to hospital for treatment.

2. The availability of services in the vicinity:• Perceived better quality services from trained public

providers in rural health centres and hospitals• Availability an issue.

3. The affordability of mitigation and treatment i.e. the cost in relation to availability of funds:• Ultimate decisive factor to treatment outcome.• Workers were willing to spend what they had and

borrow money.

Summary of findings

• Prevention and BCC– Knowledge of prevention of mosquito bites – sleeping

under a net/ ITN.– Almost all had heard of treated nets and many owned

LLINs distributed by the Health Department, UNICEF, World Vision or IOM.

– Some expressed preferences for simple bed nets over LLINs/ITNs, based on perceived side effects such as smell and skin reactions

– Many saw added advantages of better protection by LLINs/ITNs.

– General health and malaria relevant messages reached groups through a variety of channels, and that they appreciated the information.

– Preferred information source were radio programmes, especially at night time, due to their high mobility.

General Recommendations

• Enhance existing knowledge on malaria transmission, prevention, diagnosis and treatment using high quality and target-oriented BCC programmes taking into account the specific working situation of the migrants.

• Bring subsidized (or reasonably priced RDT and QA-ACT) closer to the work sites through an extension of mobile public workers (volunteers), and stronger engagement of the informal private sector, to ensure affordable diagnosis and treatment is within easy reach migrant workers at all times of the year even when weather conditions are unfavourable.

• Emphasize the need for malaria check-ups before movement between work sites and villages of origin, or when moving on to another work site, and make these services more widely available.

Specific Recommendations for the AMTR Project

• The great importance of migrant populations in the containment of the spread of artemisinin resistance in Plasmodium falciparum, a specific recommendation for the AMTR project is:– As the AMTR project rolls out its strategy to introduce

Rapid Diagnostic Tests in the private sector, PSI should focus its BCC activities on migrant populations in Tier 1 of the Resistance Containment areas and strengthen awareness and knowledge about RDTs, and also the treatment practices of private sector providers in these areas and ensure the availability of QA-ACT.

ConclusionFind out the mobility dynamics of migrant workers at four different sites and their group decisions to solve common

health problems including malaria;

• Mobility dynamics

– Varied level of movement across the 4 study sites.

– Commonly low mobility of migrant groups in bi-directional movements (plantation and mining sites).

– Frequent cross-border movements from fishing sites. Islanders identified as high risk to potentially spread resistant parasites.

• Decisions solving common health problems on malaria

– Subsidized health commodities

– Bring mobile health workers

– Strong emphasis on the need for malaria check-ups before movement between work sites and villages of origin

• There is general knowledge to seek for health; need to situate mobile health posts instead of seeking for local unlicensed workers.

• Train local health workers and distribute free RDTs to encourage check ups and reduced OPE.

• Availability of information on malaria diagnosis and treatment

• Adequate awareness of the importance of LLINs as a protective measures.

• Continuous distribution and/or replacement of LLINs

ConclusionIdentify the workers understanding of malaria

illness, treatment seeking practices for suspected malaria, and personal protective measures

• Preferred information sources – radio programmes, especially at night time, due to their high mobility.

• Others are:

• Night time village/community meetings and video shows

• Leaflets

• Posters

ConclusionFind out their sources of information related to

malaria and preferences of media channels.

Myanmar Artemisinin Monotherapy Replacement Project (AMTR) Independent Evaluation

is implemented by

In partnership with

Thank you for listening!