Health seeking behaviour and access to care for mobile and migrant populations in Cambodia

Abstract

Background: Malaria elimination campaigns are making huge strides in Cambodia with a target of malaria elimination by 2025. However, pockets of transmission remain. Predominately in border forested areas in Western Cambodia, the populations residing here are often part of mobile and migrant populations (MMPs). Moreover, the rise of drug resistance makes the goal of malaria elimination ever more urgent. Materials and methods: The Cambodia Mobile and Migrant Population Survey was a cross-sectional survey aimed to gain further insight into MMPs to inform malaria control and elimination interventions. A purposive sampling technique was used to identify study participants, given the difficulty of identifying and accessing MMPs. The survey was conducted across ten malaria endemic health districts in 2017. Separation of MMPs into four main occupational subgroups; construction workers, seasonal workers, forest goers and security personnel, was used for analysis. Results: The results from this study confirm MMPs are a key group at higher risk of malaria due to their associated risky behaviours. MMPs have a significantly different risk of suffering from fever between subgroups with forest goers and seasonal workers far more likely to report suffering from fever within the last three months. However, the willingness to seek healthcare because of fever was remarkably good, and similar among subgroups. A concerning finding was the low numbers of suspected malaria cases being diagnosed with parasitological blood testing and just under half of MMPs were not aware that malaria should be confirmed by parasitological blood test. Conclusion: MMPs are at an elevated risk of malaria compared to the general population, and this risk varies within MMPs depending on the subgroup. Although health seeking behaviour was reportedly good for all MMP subgroups to public health facilities and volunteers, barriers in access to care were significantly different. This highlights that MMPs can no longer be treated as a homogenous group when targeted by malaria interventions. *Correspondence to: Soy Ty Kheang, University Research Co., LLC, Phnom Penh, Cambodia, Tel: +855 17 988 388; E-mail: ksoyty@urc-chs.com Received: June 10, 2019; Accepted: June 24, 2019; Published: June 27, 2019 Background The past decade has seen impressive improvements in malaria control, presenting the possibility for renewed attempts for elimination [1]. Cambodia made huge strides in reducing malaria, and over the last decade, cases caused by Plasmodium falciparum have reduced by 81% [2]. As a result, Cambodia aims to completely eliminate malaria by 2025 [3]. However, the emergence and spread of P. falciparum artemisinin drug resistance poses major challenges to achieving these goals as treatment failure becomes increasingly common [4,5]. Resistance was first reported on the Thai-Cambodia border in 2008 and has since spread to several more countries in the Greater Mekong Sub-region (GMS) causing increasing concern for global malaria mortality rates [6,7]. Features of the current social landscape in Cambodia, including having a highly mobile population with reduced access to public healthcare, and the high utilisation of unregulated private healthcare, may further exacerbate the existing problems of resistance [8]. In the setting of elimination, the remaining cases often cluster in particular groups, generally those who are most vulnerable and marginalised, who engage in high risk behaviours [9,10]. It is these foci which therefore need to be understood best to achieve elimination. In Cambodia, malaria transmission tends to be concentrated in Mobile and Migrant Populations (MMPs). MMPs have been found to be three times more likely to have clinical malaria episodes compared to the general population, and in the Thailand-Cambodia border regions, areas with greater numbers of migrants also had correspondingly higher rates of malaria [11,12]. Due to the high mobility of MMPs, they often do not have access to routine surveillance or health promotion initiatives and they are more likely to seek more accessible unlicensed private healthcare, as was found to be the case in MMPs in Myanmar [13-16]. Thus the characteristics of this population are suggested to be one of the main drivers for malaria transmission and spread of drug resistance [5,16,17]. It is feared that this could lead to the reintroduction of malaria into previously malaria-free zones, especially as cases are often reported when migrants have returned to their home residence for treatment [17,18]. Migration poses significant challenges to the elimination of malaria and this will not be effectively dealt with until MMPs are better understood. Kheang ST (2019) Health seeking behaviour and access to care for mobile and migrant populations in Cambodia Volume 2: 2-7 Prev Med Commun Health , 2019 doi: 10.15761/PMCH.1000126 In Cambodia, the generally accepted definition of MMPs are that mobile individuals have been residing in the area for less than six months and migrant individuals have been there for more than six months, but less than a year [17,19]. MMPs are at greater risk of malaria than the general population for several key reasons; one of the main reasons is that their work is related to the forest, putting them at high risk of coming into contact with malaria vectors, and this forestrelated transmission is the most common form of transmission in Cambodia [15,17,20]. Multiple studies have shown that significantly higher parasite rates have been found in migrants and villagers living near forest areas compared to the general population [21,22]. Other key reasons include the health seeking behaviour of MMPs and the barriers they face when accessing care. A study focusing on migrants working on the Thailand-Cambodia border found that between 15-27% (depending on the migrant subgroup) would not seek treatment for suspected malaria [23]. If MMPs do seek healthcare, they are likely to seek private healthcare providers, potentially increasing their exposure to poor quality drugs and treatment regimens [14,20]. The most important determinants for MMPs to seek care were the proximity of services and the cost, including cost of treatment and also transport to get there [8,23]. Furthermore, they often have poor access to healthcare as they work in remote areas, making them more likely to have late diagnosis and they are often difficult to follow up to ensure treatment compliance and clearance of parasites [5,18]. Key factors influencing MMP access to healthcare in the GMS included geographical constraints, barriers to do with culture or language, financial constraints and potential eligibility or legal restrictions for migrant health [5,24]. Although the general characteristics of MMPs are understood, interventions often target them as a homogenous group; however, without understanding the unique behaviours of each subgroup within MMPs, they will never be effectively targeted. Health seeking behaviour and barriers to healthcare access were identified as key research priorities to develop malaria control interventions [4,18]. Therefore, the aim of this study is to create a detailed picture of the health seeking behaviour of the key MMP subgroups at risk of malaria in Cambodia. Materials and methods