1. Myanmar Artemisinin Monotherapy
Replacement Project (AMTR)
Independent Evaluation
1 April 2015
Dissemination Workshop
Dr Myat Phone Kyaw
Dr Myo Min
Dr Win Maung
Working Paper 3 - June 2014
Situation of Mobile Migrant Workers and Malaria at Vulnerable
Sites in Myanmar: A Qualitative Research Paper

2. 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.

3. 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.

4. Sample Size
Township Activity Mobility No. FGD
No. 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)

5. 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

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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 medicine
and herbs.
– Participants from non-endemic areas unaware of ACTs (e.g
workers at Shwe Kyin gold mine), but just follow doctors’
prescriptions.
– Some misperceptions resulted in antimalarial tablets being
crushed in water to prevent malaria

13. • 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.)

14. • 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.)

15. • 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.)

16. 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

17. 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.

18. • 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.)

19. 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

20. 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.

21. 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.

22. 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.

23. 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.

24. Conclusion
Find 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

25. • 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
Conclusion
Identify the workers understanding of malaria
illness, treatment seeking practices for suspected
malaria, and personal protective measures

26. • 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
Conclusion
Find out their sources of information related to
malaria and preferences of media channels.

27. Myanmar Artemisinin Monotherapy Replacement
Project (AMTR) Independent Evaluation
is implemented by
In partnership with
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