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Bulletin of the World Health Organization

Print version ISSN 0042-9686






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

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



Local setting












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.9–12 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).


Lessons learnt











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)



* Correspondence to Sara Canavati (e-mail: