Giving birth on the way to the clinic: undocumented migrant women's perceptions and experiences of maternal healthcare accessibility along the Thailand-Myanmar border.

BACKGROUND: Millions of women give birth annually without the support of a trained birth attendant. Generally and globally, countries provide maternal health services for their citizens but there is a coverage gap for undocumented migrant women who often can't access the same care due to their legal status. The objective of this investigation is to explore undocumented migrants' experiences and perceptions of maternal healthcare accessibility. METHODS: We held focus groups discussions with 64 pregnant women at 3 migrant health clinics on the Thailand-Myanmar border and asked how they learned about the clinic, their health care options, travel and past experiences with birth services. In this context undocumented women could sign up for migrant health insurance at the clinic that would allow them to be referred for tertiary care at government hospitals if needed. RESULTS: Women learned about care options through a network approach often relying on information from community members and trusted care providers. For many, choice of alternate care was limited by lack of antenatal care services close to their homes, limited knowledge of other services and inability to pay fees associated with hospital care. Women travelled up to 4 h to get to the clinic by foot, bicycle, tractor, motorcycle or car, sometimes using multiple modes of transport. Journeys from the Myanmar side of the border were sometimes complicated by nighttime border crossing closures, limited transport and heavy rain. CONCLUSIONS: Undocumented migrant women in our study experienced a type of conditional or variable accessibility where time of day, transport and weather needed to align with the onset of labour to ensure that they could get to the migrant clinic on time to give birth. We anticipate that undocumented migrants in other countries may also experience conditional accessibility to birth care, especially where travel is necessary due to limited local services. Care providers may improve opportunities for undocumented pregnant women to access maternal care by disseminating information on available services through informal networks and addressing travel barriers through mobile services and other travel supports. Trial registration The research project was approved by Research Ethics Committee at the Faculty of Medicine, Chiang Mai University (FAM-2560-05204), and the Department of Community Medicine and Global Health at the University of Oslo-Norwegian Centre for Research Data (58542).

Undocumented pregnant migrants have difficulties and limitations in accessing maternal health care services. Although the governments have tried to provide maternal health care services to all, there is still a gap in coverage among this population. This study explores how undocumented pregnant migrants perceive their ability to access maternal health care and share their experiences when utilizing it. We used focus groups to interview 64 pregnant women at three migrant health clinics on the Thailand­Myanmar border. We asked how they learned about the clinic, their health care options, travel, and past experiences with birth services. The results showed that they usually knew about care options from community members and trusted care providers. The limitations for the choice of alternate care were due to a lack of services close to their homes, limited knowledge of other services, inability to pay hospital fees, and difficulty traveling from their residence to the clinic. Therefore, we anticipate that undocumented migrants in other countries may also experience difficulties in accessibility to birth care, especially where travel is necessary due to limited local services. Care providers may improve opportunities for these migrants to access maternal care by disseminating information on available services through informal networks and addressing travel barriers through mobile services and other travel supports.

Utilizing community InfoSpots for health education: perspectives and experiences in Migoli and Izazi, Tanzania.

Limited access to health education can be a barrier for reaching the Sustainable Development Goals, especially in rural communities in sub-Saharan Africa. We addressed this gap by installing community information spots (InfoSpots) with access to the internet and a locally stored digital health education platform (the platform) in Migoli and Izazi, Tanzania. The objective of this case study was to explore the perspectives and experiences of InfoSpot users and non-users in these communities. We conducted 35 semi-structured interviews with participants living, working or studying in Migoli or Izazi in February 2020 and subsequently analysed the data using content analysis. The 25 InfoSpot users reported variations in use patterns. Users with more education utilized the platform for their own health education and that of others, in addition to internet surfing. High school students also used the platform for practicing English, in addition to health education. Most InfoSpot users found the platform easy to use; however, those with less education received guidance from other users. Non-users reported that they would have used the InfoSpot with the platform if they had been aware of its existence. All participants reported a positive view of the digital health messages, especially animations as a health knowledge transfer tool. In conclusion, different and unintended use of the platform shows that the communities are creative in ways of utilizing the InfoSpots and gaining knowledge. The platform could have been used by more people if it had been promoted better in the communities.

Access to good-quality health education is crucial for reaching the Sustainable Development Goals. We installed community information spots (InfoSpots) with access to the internet and a locally stored digital health education platform (the platform) in two rural villages in Tanzania in November 2019. This qualitative case study was conducted in Migoli and Izazi in February 2020, and 35 people participated in semi-structured interviews. Content analysis was performed with the software NVivo, and quotations were used to illustrate the themes. Twenty-five participants were classified as InfoSpot users. Variations and creativity in use patterns were reported. Less educated users were guided by others, while users with more education used the platform for their own and for the education of others, in addition to internet surfing. The students who used the InfoSpot for health education and for practicing English demonstrated unintended use of the platform. All non-users reported that they would have used the InfoSpots if they had been aware of their existence. All participants, users and non-users, reported a positive view of the digital health messages, especially animations as a health knowledge transfer tool. The use of such platforms can be an important factor in disease prevention.

Including undocumented migrants in universal health coverage: a maternal health case study from the Thailand-Myanmar border.

BACKGROUND: Many countries aspiring to achieve universal health coverage struggle with how to ensure health coverage for undocumented migrants. Using a case study of maternal health care in a Thailand-Myanmar border region this article explores coverage for migrants, service provision challenges and the contribution of a voluntary health insurance program. METHODS: In 2018 we interviewed 18 key informants who provided, oversaw or contributed to maternal healthcare services for migrant women in the border region of Tak province, Thailand. RESULTS: In this region, we found that public and non-profit providers helped increase healthcare coverage beyond undocumented migrants' official entitlements. Interview participants explained that Free and low-cost antenatal care (ANC) is provided to undocumented migrants through migrant specific clinics, outreach programs and health posts. Hospitals offer emergency birth care, although uninsured migrant patients are subsequently billed for the services. Care providers identified sustainability, institutional debt from unpaid obstetric hospital bills, cross border logistical difficulties and the late arrival of patients requiring emergency lifesaving interventions as challenges when providing care to undocumented migrants. An insurance fund was developed to provide coverage for costly emergency interventions at Thai government hospitals. The insurance fund, along with existing free and low-cost services, helped increase population coverage, range of services and financial protection for undocumented migrants. CONCLUSIONS: This case study offers considerations for extending health coverage to undocumented populations. Non-profit insurance funds can help to improve healthcare entitlements, provide financial protection and reduce service providers' debt. However, there are limits to programs that offer voluntary coverage for undocumented migrants. High costs associated with emergency interventions along with gaps in insurance coverage challenge the sustainability for NGO, non-profit and government health providers and may be financially disastrous for patients. Finally, in international border regions with high mobility, it may be valuable to implement and strengthen cross border referrals and health insurance for migrants.

Choosing where to give birth: Factors influencing migrant women's decision making in two regions of Thailand.

BACKGROUND: Choosing where to give birth can be a matter of life and death for both mother and child. Migrants, registered or unregistered, may face different choices and challenges than non-migrants. Despite this, previous research on the factors migrant women consider when deciding where to give birth is very limited. This paper addresses this gap by examining women's decision making in a respective border and urban locale in Thailand. METHODS: We held focus group discussions [13] with 72 non-Thai pregnant migrant women at non-government clinics in a rural border area and at two hospitals in Chiang Mai, a large city in Northern Thailand in 2018. We asked women where they will go to give birth and to explain the factors that influenced their decision. RESULTS: Women identified getting the relevant documentation necessary to register their child's birth, safe birth and medical advice/quality care, as the top three factors that influenced their care seeking decision making. Language of service, free or low cost care, language of services, proximity to home, and limited alternate options for care were also identified as important considerations. CONCLUSION: Understanding factors that migrant women value when choosing where to deliver can help health care providers to create services that are responsive to migrants' preferences and encourage provision of relevant information which may influence patient decision making. The desire to obtain birth documentation for their child appears to be important for migrants who understand the importance of personal documentation for the lives of their children. Healthcare institutions may wish to introduce processes to facilitate obtaining documentation for pregnant migrant women and their newborns.

PROTOCOL: When and how to replicate systematic reviews.

This is a protocol for a co-registered Cochrane and Campbell Review (Methodology). The objectives are as follows: To identify, describe and assess methods for: when to replicate a systematic review; how to replicate a systematic review.

"Living like I am in Thailand": stress and coping strategies among Thai migrant masseuses in Oslo, Norway.

BACKGROUND: Migrants experience stress before, during and after migrating to a new country, all of which influences their mental wellbeing. In Norway, migration from Thailand is highly gendered as most Thai migrants are women who migrate to live with their Norwegian spouse. Massage shops, often owned by Thai entrepreneurs, are a locale where women use their cultural knowledge to bridge into the local economy. There is little knowledge about Thai migrant masseuses' experience of stress in daily life and associated coping strategies. The objective of this inquiry was to examine stressors and coping strategies among Thai migrant masseuses in Oslo, Norway. METHODS: We conducted in-depth interviews with 14 Thai migrants who were working as masseuses in Oslo, Norway. We asked participants about their health, experiences of stress, and coping strategies and subsequently analyzed the data using thematic analysis. RESULTS: Stress in participants' lives related to settling in, loneliness, finances and spousal relationships. Of these, relationship conflict was the largest source of stress. Women largely embraced self-coping strategies and utilized Thai cultural practices and Buddhist cognitive thinking. Once relationship conflict became untenable, participants fought to change their situation. Limited fluency in Norwegian, Thai stigma about mental health and limited knowledge of the Norwegian health system were barriers to seeking healthcare. CONCLUSIONS: Migrants in our study often adopted "Thainess", the use of Thai cultural practices and Buddhist cognitive thinking, as a strategy for coping with stress. Preferences for self-coping, mental health stigma, and linguistic competency are important considerations when designing mental wellbeing interventions for Thai women. Use of an interpreter or systems navigator can help overcome language barriers. Clinicians can take detailed case histories to better understand Thai patients' stress, coping strategies and wellbeing. Health policy makers could consider network approaches, including using Thai health systems navigators to bridge the health system and Thai communities.

Accessing public healthcare in Oslo, Norway: the experiences of Thai immigrant masseuses.

BACKGROUND: Thai massage is a highly gendered and culturally specific occupation. Many female Thai masseuses migrate to Norway as marriage migrants and as such are entitled to the same public healthcare as Norwegian citizens. Additionally, anyone who is not fluent in Norwegian is entitled to have an interpreter provided by the public healthcare system. Norway and most other countries aspire to universal health coverage, but certain immigrant populations continue to experience difficulties accessing appropriate healthcare. This study examined healthcare access among Thai migrant masseuses in Oslo. METHODS: Guided by access to healthcare theory, we conducted a qualitative exploratory study in 2018 with Thai women working as masseuses in Oslo, Norway. Through semi-structured in-depth interviews with 14 Thai women, we explored access to healthcare, health system navigation and care experiences. We analyzed the data using thematic analysis and grouped the information into themes relevant to healthcare access. RESULTS: Participants did not perceive that their occupation limited their access to healthcare. Most of the barriers participants experienced when accessing care were related to persistent language challenges. Women who presented at healthcare facilities with their Norwegian spouse were rarely offered interpreters, despite their husband's limited capacity to translate effectively. Cultural values inhibit women from demanding the interpretation services to which they are entitled. In seeking healthcare, women sought information about health services from their Thai network and relied on family members, friends and contacts to act as informal interpreters. Some addressed their healthcare needs through self-treatment using imported medication or sought healthcare abroad. CONCLUSIONS: Despite having the same entitlements to public healthcare as Norwegian citizens, Thai migrants experience difficulties accessing healthcare due to pervasive language barriers. A significant gap exists between the official policy that professional interpreters should be provided and the reality experienced by study participants. To improve communication and equitable access to healthcare for Thai immigrant women in Norway, health personnel should offer professional interpreters and not rely on Norwegian spouses to translate. Use of community health workers and outreach through Thai networks, may also improve Thai immigrants' knowledge and ability to navigate the Norwegian healthcare system.

Migrant tuberculosis patient needs and health system response along the Thailand-Myanmar border.

This article aims to identify how the health system in Tak province, Thailand has responded to migrants' barriers to tuberculosis (TB) treatment. Our qualitatively driven multi-methods project utilized focus group discussions, key informant interviews, and a survey of community health volunteers to collect data in 2014 from multiple perspectives. Migrants identified legal status and transportation difficulties as the primary barriers to seeking TB treatment. Lack of financial resources and difficulties locating appropriate and affordable health services in other Thai provinces or across the border in Myanmar further contributed to migrants' challenges. TB care providers responded to barriers to treatment by bringing care out into the community, enhancing patient mobility, providing supportive services, and reaching out to potential patients. Interventions to improve migrant access and adherence to TB treatment necessarily extend outside of the health system and require significant resources to expand equitable access to treatment. Although this research is specific to the Thailand-Myanmar border, we anticipate that the findings will contribute to broader conversations around the inputs that are necessary to address disparities and inequities. Our study suggests that migrants need to be provided with resources that help stabilize their financial situation and overcome difficulties associated with their legal status in order to access and continue TB treatment.

Treating the invisible: Gaps and opportunities for enhanced TB control along the Thailand-Myanmar border.

BACKGROUND: In Thailand's northwestern Tak province, contextual conditions along the border with Myanmar pose difficulties for TB control among migrant populations. Incomplete surveillance data, migrant patient mobility, and loss to follow-up make it difficult to estimate the TB burden and implement effective TB control measures. This multi-methods study examined tuberculosis, tuberculosis and human immunodeficiency virus co-infection, and multidrug-resistant tuberculosis treatment accessibility for migrants and refugees in Tak province, health system response, and public health surveillance. METHODS: In this study we conducted 13 interviews with key informants working in public health or TB treatment provision to elicit information on TB treatment availability and TB surveillance practices. In addition we organized 15 focus group discussions with refugee and migrant TB, TB/HIV, and MDR-TB patients and non-patients to discuss treatment access. We analyzed the data using thematic analysis and created treatment availability maps with Google maps. RESULTS: The study identified surveillance, treatment, and funding gaps. Migrant TB cases are underreported in the provincial statistics due to jurisdictional interpretations and resource barriers. Our results suggest that TB/HIV and MDR-TB treatment options are limited for migrants and a heavy reliance on donor funding may lead to potential funding gaps for migrant TB services. We identified several opportunities that positively contribute to TB control in Tak province: improved diagnostics, comprehensive care, and collaboration through data sharing, planning, and patient referrals. The various organizations providing TB treatment to migrant and refugee populations along the border and the Tak Provincial Public Health Office are highly collaborative which offers a strong foundation for future TB control initiatives. CONCLUSIONS: Our findings suggest the need to enhance the surveillance system to include all migrant TB patients who seek treatment in Tak province and support efforts by stakeholders on both sides of the border to continue to share data and engage in collaborative planning on TB, TB/HIV, and MDR-TB treatment provision for migrant populations.

Migrant and Refugee Patient Perspectives on Travel and Tuberculosis along the Thailand-Myanmar Border: A Qualitative Study.

BACKGROUND: The Thailand-Myanmar border separates two very different health systems. The healthcare system in eastern Myanmar remains underdeveloped as a result of decades of instability. Comparatively, Tak province, Thailand has more healthcare resources. In this Thai border province government hospitals and non-governmental organizations provide tuberculosis (TB) treatment to migrants and refugees. OBJECTIVES: Our overall study aimed to explore accessibility of TB treatment, TB surveillance and health system responsiveness specific to migrant and refugee populations in Tak province. In this paper, we focus on the perspectives of migrant and refugee TB patients with respect to travel and treatment in Tak province. METHODS: In 2014 we conducted focus group discussions with 61 TB, Tuberculosis and Human Immunodeficiency Virus co-infection, and multidrug-resistant TB patients in Tak province. We analyzed the data for content and themes and documented individual travel trajectories. RESULTS AND DISCUSSION: Migrants are travelling with active TB within the country and between Thailand and Myanmar. Migrants primarily travelled to obtain treatment but two participants reported travelling home to seek family care in Myanmar before returning to Thailand for treatment. Travel, while expensive and arduous, is an adaptive strategy that migrants use to access healthcare. CONCLUSIONS: Migrant's need for travel points to larger difficulties associated with healthcare access in the border region. Long distance travel with an infectious disease can be seen as an indicator that local healthcare is not available or affordable. These findings suggest that public health officials from both sides of the border should discuss the factors that contribute to travel with active TB and explore potential solutions to mitigate disease transmission in migrant populations.

Access to free or low-cost tuberculosis treatment for migrants and refugees along the Thailand-Myanmar border in Tak province, Thailand.

BACKGROUND: In Tak province, Thailand migrants and refugees from Myanmar navigate a pluralistic healthcare system to seek Tuberculosis (TB) care from a variety of government and non-governmental providers. This multi-methods qualitative study examined access to TB, TB/HIV and multidrug-resistant tuberculosis (MDR-TB) treatment with an emphasis on barriers to care and enabling factors. METHODS: In the summer and fall of 2014, we conducted 12 key informant interviews with public health officials and TB treatment providers. We also conducted 11 focus group discussions with migrants and refugees who were receiving TB, TB/HIV and MDR-TB treatment in Tak province as well as non-TB patients. We analyzed these data through thematic analysis using both predetermined and emergent codes. As a second step in the qualitative analysis, we explored the barriers and enabling factors separately for migrants and refugees. RESULTS: We found that refugees face fewer barriers to accessing TB treatment than migrants. For both migrants and refugees, legal status plays an important intermediary role in influencing the population's ability to access care and eligibility for treatment. Our results suggest that there is a large geographical catchment area for migrants who seek TB treatment in Tak province that extends beyond provincial boundaries. Migrant participants described their ability to seek care as linked to the financial and non-financial resources required to travel and undergo treatment. Patients identified language of health services, availability of free or low cost services, and psychosocial support as important health system characteristics that affect accessibility. CONCLUSION: Access to TB treatment for migrants and refugees occurs at the interface of health system accessibility, population ability and legal status. In Tak province, migrant patients draw upon their social networks and financial resources to navigate a pathway to treatment. We revised a conceptual framework for access to healthcare to incorporate legal status and the cyclical pathways through which migrants access TB treatment in this region. We recommend that organizations continue to collaborate to provide supportive services that help migrants to access and continue TB treatment.

The convergence of HIV/AIDS and customary tenure on women's access to land in rural Malawi.

This paper examines the convergence of HIV/AIDS and the social processes through which women access customary land in rural Malawi. Data were collected from focus group discussions with women in patrilineal and matrilineal communities. Women's land tenure is primarily determined through kinship group membership, customary inheritance practices and location of residence. In patrilineal communities, land is inherited through the male lineage and women access land through relationships with male members who are the rightful heirs. Conversely in matrilineal matrilocal communities, women as daughters directly inherit the land. This research found that in patrilineal communities, HIV/AIDS, gendered inequalities embedded in customary inheritance practices and resource shortages combine to affect women's access to land. HIV/AIDS may cause the termination of a woman's relationship with the access individual due to stigma or the individual's death. Termination of such relationships increases tenure insecurity for women accessing land in a community where they do not have inheritance rights. In contrast to the patrilineal patrilocal experience, research on matrilineal matrilocal communities demonstrates that where women are the inheritors of the land and have robust land tenure rights, they are not at risk of losing their access to land due to HIV/AIDS.