How Changing Behaviour is Beating Malaria in Thailand
IOM Thailand, with the support of the Global Fund, is implementing a malaria Behaviour Change Communication campaign to reach migrants and their host communities with malaria and personal protection messages. This includes multilingual comic books, posters, flip charts, board games and radio broadcasts which together have reached almost 170,000 beneficiaries over the first two years of the campaign.
IOM teams visit beneficiaries at their homes or workplaces, with an emphasis on areas bordering Myanmar and Cambodia. The teams faced many challenges, including reaching communities in remote and hard-to-reach locations, addressing the many different languages and dialects spoken and the low literacy level of beneficiaries. IOM’s malaria control efforts in Thailand have played an important part in helping the country reach the targets for the Millennium Development Goals (MDG) and the Global Malaria Action Plan (GMAP).
Protecting migrants from the disease was one of the targets assigned to IOM because the national government was already working with the Thai population. Symptoms do not show during the incubation period of the disease so infected, mobile individuals who cross the borders can spread the disease if they don’t know the proper preventative and treatment measures. It is for this reason that attending to the migrant population is one of the keys to reducing the malaria burden in the region.
How do you teach migrant workers about malaria and achieve changes in their behaviour to protect themselves from the disease? That is the question IOM Thailand faced three years ago when they started implementing the Global Fund malaria project.
IOM Thailand had three main challenges. To begin with, migrant populations and their employers didn’t know who IOM was and they were afraid that Thai authorities could arrest them or return them to their countries if they didn’t have official documentation. Also, IOM needed to know where the target population lived and how many people there were. The second difficulty was language. Most of the migrant workers come from Cambodia and Myanmar and they speak three different languages (Khmer, Burmese and Karen).
The last big challenge was the educational level and cultural beliefs of the target population. For example: “Ethnic groups believe in herbal remedies and spiritual healing. They conduct sacrifices of chickens, because the malaria symptoms are shivering and fever, and they think that a ghost or spirit possesses the person and this is causing the disease,” explained the IOM field coordinator for Chiang Mai and Chiang Rai provinces, Amaralak Khamhong.
The IOM Thailand project manager, Warin Choomsai Na Ayudhaya, and her work team faced this situation when they started the project. Recently, field coordinators from 11 provinces met in Bangkok and discussed the project achievements and explored best practices and useful approaches to help strengthen the programme. After three years of working with the community they have not just saved incalculable numbers of lives, they have also created a model of work with the migrant worker population in Thailand that could serve as an example for future health projects.
Where are the migrants? Where do they come from? Are they seasonal or permanent? To solve these questions, the household mapping of migrant clusters in 20 provinces was implemented in 2012-2013. After identifying the target population, the medical unit started providing blood tests, and directly observing treatment and following up on the infected patients. These activities were part of the case management pillars of the project. To act on prevention, the work team created a behavior change communication campaign.
To solve the problem of the language barrier IOM Thailand hired bilingual staff with work permits that could speak the communities’ languages. Finding personnel who matched these criteria, however, was not so easy, and due to the low literacy levels of the beneficiaries so the team designed visual materials to explain to the migrants the importance of sleeping under the long lasting insecticide nets (LLIN), using repellents and how the disease is spread.
Flip charts with drawings and text in different languages, comic books, posters and bilingual radio broadcast were produced to address the obstacle of the language and literacy barrier. The IOM staff also designed a board game and conducted workshops in factories and plantations to explain to the migrants the benefits of personal protection against mosquito bites and, consequently, malaria, in a straightforward and simple manner.
Regarding cultural behavior and practices, the staff realized it would be impossible, or inappropriate, to attempt to change their beliefs, so they adopted a bilateral advocacy approach to support the use of both modern medicine and spiritual healing. “I think they can see the difference, because sometimes they have to kill a lot of chickens and it still doesn’t help, has no effect and they don’t get better, but at the same time when they take the medicine they get better, so they learn from experiences…and then they talk to each other,” shared Ms. Khamhong in the workshop.
The number of migrant workers infected with malaria in Thailand has decreased over the last few years. Paradoxically, the number of malaria cases in the Thai population has risen over the same period.
“I see the success being that people use bed nets more. Also, when we distributed the repellents, everyone came and asked ‘Can I get some? Because I want to use it when I go to the forest’. They know that when they go to the forest they have to protect themselves from mosquito bites,” said Wero Eckert, Field Coordinator in Tak Province.
Another ‘best practice’ identified was the training of local leaders about malaria prevention. This meant that the message was better understood, and that people changed their risky behaviors. The coordinator concluded in the workshop that working in the field could be successful when all parties are involved and do their job, and cooperation is the key to the success.
The field coordinators also saw the gap in not working on the other side of the border, given the high population mobility between countries in this region. In the case of the Thai-Myanmar border the Ministries of Public Health of both countries are trying to have a meeting and want to train people – the health staff on the Burma side – but they cannot find the funding right now. However, they have already mapped out the plan and who is responsible for health issues on that side.
This Global Fund-supported malaria project is a five-year programme. There are still two more years of work ahead, but the lessons already learnt will help strengthen it, and could also start being applied to other projects involving migrants.
“Now people know who IOM is and they trust us. This is the first time that IOM has applied a behavior change communication strategy in Thailand and the results are visible. Projects like this one could also be applied in Mother and Child Health Care or Disaster Risk Reduction programs for the migrants,” concluded Ms. Choomsai Na Ayudhaya.
See pictures at: https://www.flickr.com/photos/iomasiapacific/sets/72157647998003002/