Socio-ecological barriers to access COVID-19 vaccination among Burmese irregular migrant workers in Thailand

Hightlight

• •The finding reveals 90% (n = 361) of 398 participants were fully unvaccinated.
• •Exclusion from vaccine distribution and the high cost of the vaccine is a significant challenge to accessing vaccination.
• •Perceived low quality due to the spread of rumour and lack of access to proper vaccine side effects in their spoken languages.
• •Geographical challenges and unfamiliar online registration system.
• •Public discrimination and fear of being arrested when going out to get a vaccination.

Abstract

Thailand is a migration hub in ASEAN (Association of Southeast Asian Nations), with more than 3.9 million migrant workers, accounting for 10% of the country's workforce. The government of Thailand has moved from a pandemic to an endemic state of living with the SAR-CoV2 virus as a new normal since over half of the population has been vaccinated. There is, however, an estimated 1.3 million irregular migrant workers in Thailand who are not covered by Social Security Schemes (SSS) and are likely to have not been vaccinated. This study examines the socio-ecological barriers to accessing vaccination among Burmese irregular migrant workers in Thailand. Qualitative and quantitative data were collected from NGO (Non-Government Organizations) workers and Burmese irregular migrants through an online survey and in-depth interviews. The study reported that over 90% of Burmese irregular migrants were unvaccinated. The main reasons for the low vaccination rate include exclusion from the vaccine distribution program, high cost of the vaccine, perceived low quality of vaccine, language barriers, lack of vaccine information, private and public discrimination against migrants, fear of being detained and deported, and difficulties in finding time and transportation to go to vaccination centres. The Thai government should employ culturally competent interpreters to disseminate vaccine information and potential side effects to encourage vaccinations in order to prevent further casualties and curb the global health crisis. Moreover, it is imperative that the Thai government provide free vaccines to all immigrants regardless of their status and amnesty from deportation and detention during the vaccination period.

1. Background

Over the last two years, the world has witnessed an unprecedented global health catastrophe caused by COVID-19, which has significantly impacted the lives of millions of people. Approximately 6.17 million people have died due to COVID-19, and over 494 million infections have been confirmed as of 5 Apr 2022 (Worldometer, 2022a). Globally, migrant workers are vulnerable to poor health due to precarious working conditions and overcrowded living conditions (Lassale et al., 2020; Lewis et al., 2020), limited social distancing or self-isolation capacity (De Vito et al., 2017), and are at a higher risk of contracting COVID-19 than the host population in their destination (European Centre for Disease Prevention and Control, 2021). For example, during the early outbreak of COVID-19 in Singapore, 90% of the cases were found among migrant workers living in dormitories (Singapore Ministry of Health, 2021). Additionally, even before the COVID-19 pandemic, access to healthcare and vaccinations was a barrier for them due to an inability to pay out of pocket, discrimination, language and cultural barriers, and concerns about one's legal status (Chuah et al., 2018; European Centre for Disease Prevention and Control, 2018; Kohlenberger et al., 2019; Lebano et al., 2020; Pocock et al., 2020; Rivenbark and Ichou, 2020). In particular, this pandemic has exposed vulnerabilities among those of irregular status (World Health Organization, 2021a).

As a regional migration hub in ASEAN (Association of Southeast Asian Nations), Thailand hosts more than 3.9 million migrant workers, representing 10% of the country's workforce. Most come from Myanmar (Burma), Cambodia, Laos, and Vietnam, contributing between 4.3 and 6.6% of the country's gross domestic product. Only approximately 1.97 million migrant workers were enrolled in public health insurance (United Nations Thematic Working Group on Migration in Thailand, 2019). An estimated 1 to 2.5 million were irregular status conditions (International Organization for Migration, 2021b), and this number seems higher following the COVID-19 disruption due to loss of employment and work permit expiration. Moreover, this unprecedented COVID-19 virus has negatively impacted global health and the economy (International Monetary Fund, 2020). To recover the country's economy from COVID-19, Thailand has transited to an endemic condition or to adapt to living with the virus as a new normal (Bangkok Post, 2022). To address this issue, the Thai government has vaccinated more than 60% of its population against COVID-19 (Ritchie et al., 2022) and announced vaccination for migrant workers who are insured with Social Security Scheme (SSS) (Boonwara Sumano and Naneksomboonph, 2021). As part of a new agreement to mitigate labour shortages and strengthen economic recovery, the government has allocated 500,000 vaccines to new migrant workers from neighbouring countries (Reuters, 2021b).

However, an estimated 1.3 million irregular migrants uninsured by SSS do not receive any vaccinations in Thailand (Bangkok Post, 2021b), despite the Thai government's commitment to living with a virus in the long term. In the meantime, the COVID-19 infection rate in Thailand remains high daily. As of April 2022, there were 3757,575 infections detected and 25,603 deaths. A total of 21,088 additional confirmed cases were reported, of which 20,995 were transmitted locally (Worldometer, 2022b). Furthermore, an analysis revealed that the COVID-19 fatality rate is higher among unvaccinated populations across the globe (Our World in Data, 2021). In comparison with the general population, migrant workers demonstrate a lower level of vaccination acceptance or higher levels of vaccine hesitancy globally (Loiacono et al., 2020; Noori et al., 2021). Therefore, it is extremely important to include all immigrants in vaccination campaigns, regardless of their immigration status, to enable a healthy labour force and to minimize the risk of severe disease and further casualties caused by COVID-19. The purpose of this article was to explore the barriers that Burmese irregular migrant workers (BIMWs) encounter when it comes to accessing COVID-19 vaccination in Thailand.

2. Theoretical framework

This study adapted McLeroy's Socio-Ecological Model (SEM) to understand the barriers to accessing COVID-19 vaccination among BIMWs in Thailand. The model described the multifactored interrelationship between intrapersonal, interpersonal, organisational, community, and policy environments and how they affect the population's well-being (McLeroy et al., 1988). In this study, participants were NGO (Non-Governmental Organizations) workers and BIMWs who lacked legal documents and were uninsured for health insurance and social security. Several variables may affect their willingness to get and access vaccination. Therefore, to improve access to vaccination among BIMWs, interventions should consider all five levels of the SME model. This model guides interview questions to explore the participant's experiences and barriers to getting vaccination that is not attainable from the quantitative data. Moreover, Glanz et al. (2015) stated that this model is the most relevant for investigating factors that influence health behaviour within a population and can formulate interventions strategically. The model has also been utilised in many existing studies to explore the barriers to accessing healthcare services among the migrant population in various countries and contexts (Gany et al., 2006; Barker and Horton, 2008; Greves et al., 2007; Shtarkshall et al., 2009; Pitkin Derose et al., 2009; Reininger et al., 2014; Viken et al., 2015; Yu et al., 2019).

3. Material and methods

3.1. Study setting and study method

This study used a convergent mixed-method design to explore the factors that prevent BIMWs from accessing the COVID-19 vaccine in Thailand. Both qualitative and quantitative data were collected between September 2021 to January 2022. In total, 23 BIMWs and 17 NGO workers participated in qualitative interviews (see Table 1), while 398 completed the online questionnaire (see Table 2). The rationale behind using a convergent mixed-method study is that it enables both qualitative and quantitative data to be collected concurrently, analysed separately, and interpreted to support and compare the results (Creswell, 2018).

Table 1.

Demographic characteristics of the qualitative participants (N = 40).

Characteristics	Number
BIMWs (N = 23)
Gender
Male	11
Female	12
Current Employment Status
Unemployed	15
Employed	6
Vaccination status
Fully vaccinated (two doses)	1
One dose	0
None	22
An average year in Thailand	5
NGO participants (N = 17)
Gender
Male	8
Female	9
Nationality
Burmese	11
Thai	5
USA	1
Employment sector
Health sector	6
Labour protection sector	6
Local journalist on the migrant issue	1
Both labour protection and the health sector	3
Legal officer	1

Table 2.

Demographic characteristics of the quantitative participants among irregular migrant workers (N = 398).

Sample characteristic	Frequency	Percentage
Gender
Male	188	47.2
Female	210	52.8
Age
18–29	139	34.9
30–39	145	36.4
40–49	80	20.1
50 above	34	8.5
Current employment status
Unemployed	156	39.2
Employ	242	60.8
Current employment sector (Top 5 answer only)
Construction	56	23.1
Agriculture sector	49	20.2
Domestic work	34	14.0
Factory/ garment production	26	10.7
Retail trade and vendor	14	4.8
Vaccination status
Fully vaccinated (two doses)	12	3.0
One does	25	5.3
None	361	90.7
Able to speak Thai
Yes	36	9
No	362	91.0

The inclusion criteria for this study included irregular migrant workers who were originally from Burmese and had migrated to Thailand before the COVID-19 pandemic or had been in Thailand for at least two years. The BIMWs were chosen specifically because the Burmese migrant workers population accounts for 68% of Thailand's entire migrant worker population, with at least 1 million were estimated to be in irregular status (United Nations Thematic Working Group on Migration in Thailand, 2019). The selection for NGO (Non-Govermnent Organization) participants includes individuals currently engaged in the healthcare, legal rights, and labour-protection sectors for migrant populations in Thailand.

3.2. Data collection procedure

This study employed a multistage sampling procedure for data collection. The study employed an online data collection approach considering travel restrictions enforcement and the rising number of COVID-19 infections in Thailand during the data collection period. Initially, the researcher sent invitations for interview participation and online questionnaires to several organisations that provide healthcare and protection for migrants, as well as community-based organisations led by migrants, to help distribute the survey on their respective platforms to obtain voluntary responses. Moreover, the researcher distributed the Burmese language online questionnaires survey (multiple-choice questions) to several migrant communities in Thailand via social media (Facebook groups, messenger chat groups, WhatsApp groups). As a last step in the online survey, the respondents were asked to share it with their community and provide their contact information if they were interested in voluntarily participating in an in-depth interview.

BIMW's online survey respondents who indicated a willingness to participate were conducted in-depth interviews (IDIs) individually based on their availability. Interview questions were based on survey questionnaires, with some modifications and follow-ups based on the respondents' responses.  NGO workers who responded to the invitation for voluntary participation were interviewed regarding their experiences and perceptions of the major challenges faced by BIMWs in obtaining vaccinations. A separate focus group discussion (FDG) interview was conducted for BIMWs and NGOs whose schedules were concurrent.

The study adopted an online interview approach through Zoom or WhatsApp based on the participants' preferences; both provide end-to-end encryption to ensure that the participants' stories are secure and data remain confidential. During the interview, the researcher also took some notes. The Burmese language was primarily used to communicate with the migrant participants. An English-language interview was conducted with participants from Thai NGOs. The participants were encouraged to share the online survey with others and recruit more members who meet the selection criteria. For each participant, the interview lasted between 25 and 35 min. Upon repetition of narratives or data saturation, the interview was concluded as suggested by (Saunders et al., 2018). To cover internet access costs, the researcher provided each participant with a mobile phone card credited with 100 Thai Bath.

3.3. Ethical consideration

Before the interview, the researcher explained the purpose of the study and the interview procedure. This included the participants' right to withdraw from the interview without hesitation. As part of the interview procedure, the researcher obtained either verbal or written consent from the participant, depending on their preferences for participation and the interview audio recording. Research Ethics Sub-Committee approved the research ethical protocol, Postgraduate Student Committee (PSC) of Lingnan University in Hong Kong, China.

4. Data analysis procedure

4.1. Quantitative data

Quantitative data analysis was performed using IBM SPSS Statistic for Windows, Version 26. Online questionnaires were converted into Microsoft Excel, assigning numbers to variables. For example, vaccination status (completely vaccinated = 1, one does vaccinate = 2, none = 3), and data were exported into SPSS. Descriptive statistics were used rather than regression analysis to understand vaccination rates and the significant barriers to accessing vaccination. The quantitative data are presented in percentages and frequencies to describe sociodemographic characteristics, barriers to vaccination, and willingness to receive vaccination.

4.2. Qualitative data

The researcher listened to the audio recording several times before transcribing and translating it to gain a deeper understanding of the qualitative data. After the audio interview recording was transcribed verbatim, it was translated into English. In order to clarify any transcription errors that may have occurred, the transcribed transcripts were read aloud, and the audio tape was played several times. To increase the credibility of the study's findings, the transcription was returned to the NGO participants for confirmation that the researcher's translation accurately reflected their experiences and perceptions. The transcriptions were not returned to the migrant participants as they were occupied with their jobs and had no computer access. The researcher read the field notes and transcribed data line by line, merging similar data into consolidated data and analysing them thematically using the methodology provided by (Clarke et al., 2015), and the socio-ecological model. Inductive analysis was performed, with codes and themes derived from the data rather than the socio-ecological framework.

5. Results

5.1. Participants' demographic characteristics

A total of 40 individuals participated in this study. Among the participants, there were 23 BIMWs and 17 NGO workers. Tables 1 and 2 below provide an overview of the demographic characteristics of all participants.

5.2. Quantitative findings

5.2.1. Vaccination status

According to the quantitative findings, only 3.0% (n = 12) of 398 survey participants received a full vaccination, 5.3% (n = 25) received one dose, and 90.7% (n = 361) were unvaccinated due to numerous barriers. To understand the significant barriers hindering BIMWs from accessing vaccinations, this study utilised thematic qualitative analysis using a socio-ecological model, emphasizing factors relating to intrapersonal, interpersonal, institutional, community, and policy issues. These major themes are further subdivided into 11 sub-themes, as illustrated in (Fig. 1).

Fig. 1.

Socio-ecological barriers to access COVID-19 vaccination among Burmese irregular migrant workers in Thailand. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.).

5.3. Qualitative findings

5.3.1. Individual-level

5.3.1.1. Financial burden due to free vaccine delivery is not accessible throughout the country

Participants reported that the Thai government only provides the COVID-19 vaccine to residents in certain districts regardless of immigration status, including irregular migrants. Some areas, however, offer free vaccinations to migrant workers, while others charge a fee, and others do not offer any vaccinations at all. The study found that 39.2% (n = 156) of participants were unemployed or became unemployed due to the disruption caused by COVID-19. Others were fired by their employers after testing positive for COVID-19. As a result, the financial burden was one of the significant hurdles to COVID-19 vaccination among the BIMWs due to a lack of income to pay the vaccine fee.

5.3.1.2. The employer's reluctance to cover the vaccination cost

The employer's reluctance to cover the costs of COVID-19 tests, vaccines, and registration is another barrier to vaccination among the currently employed. Participants reported that most multinational companies or factories cover all costs of hiring migrant workers, including vaccinations. There are, however, a relatively small number of such factories located primarily in major metropolitan areas. Most participants work in low- and middle-income industries in remote locations.

My employer informed me that the cost would be deducted from my salary if I wanted to receive the COVID-19 vaccine. Therefore, I must refuse to accept the vaccine since I am more concerned with food and housing costs for my daily survival. P10 (Female)

5.3.1.3. Rumours and unavailability of vaccine side effects in the migrant's mother tongue language

Additionally, 79.4% (n = 316) of the participants did not receive or have access to information regarding the side effects of the COVID-19 vaccine in their native languages. Several factors contribute to migrant workers' unwillingness to receive vaccination, such as a lack of access to adequate information and rumours about the vaccine spreading among them.

One of the challenges among the Burmese immigrant population is living with rumours regarding vaccines. (P8, Executive Director)

Several participants from NGO organisations indicated that Burmese migrant workers believe rumours stating that vaccinations from China or India are ineffective and that someone had died because of the vaccination. In Mae Sot City, where the Thai population and the migrant population are almost equal, a group of community-based organisations distributed Sinopharm vaccines to migrant workers. As an example, one of the NGO participants shared his experience in mobilizing migrant workers for vaccination due to vaccine rumours:

It is extremely difficult to communicate about the vaccine with migrant workers. They repeatedly asked what type of vaccine they would receive. It was challenging to gather a list of names willing to receive vaccinations when we mentioned vaccine names such as Sinopharm. (P4, Health officer)

5.3.2. Interpersonal level

5.3.2.1. Language barriers

The language barrier is one major obstacle to getting vaccination among participants. More than 91.0% (n = 362) of participants indicated they did not understand Thai and had difficulty understanding the announcement about the COVID-19 vaccination procedure.

There has been a high rate of migrant workers who have failed to receive the COVID-19 vaccination due to language barriers and a lack of knowledge regarding whether the vaccine is free, where to obtain it, or how to register. (P2, healthcare workers)

5.3.2.2. Factory lockdowns

On the other hand, the lockdown of factories presents another challenge for migrant workers who wish to receive a vaccination. Participants mentioned employers are concerned about the factory closing during a disease outbreak or infection among migrant workers. Consequently, some employers prohibit workers from leaving their manufacturing sites, including seeking medication or vaccination.

Although I have learned that my local district government offers free vaccinations, it is difficult for me to obtain vaccinations because I cannot take time off work or off days. (P7, Male)

Aside from factories being locked down, NGO participants reported that most workplaces prohibited them from entering, making it difficult for them to distribute vaccines and for many migrant workers to obtain vaccinations.

Many employers did not provide their workers with the COVID-19 test and vaccination. Furthermore, it was also difficult for NGO workers to access the workplace to deliver vaccination. (P4, labour rights officer).

5.3.3. Organization level

5.3.3.1. Inaccessibility of vaccination centres

More than half, 76.9% (n = 306) of the participants indicated that geographical challenges in reaching free COVID-19 vaccination centres posed a barrier to vaccination.

The cost of transportation is a concern for some migrant workers due to geographical challenges. In addition, some of them must take a ferry or a boat to the designated vaccination center for COVID-19 even though the vaccination would be free. (P5, health officer)

The participants also mentioned that some NGO health clinics, such as "Mae Taw Clinic" in Mae Sot City, offer free health care and vaccination services to all Burmese migrants. However, migrant workers from other areas, such as those working in rural agriculture sector, have difficulty accessing the program due to travel restrictions, lack of legal documentation, and transportation issues.

5.3.3.2. Unfamiliarity with the registration process and experiences of discrimination

An unfamiliar registration process and a complex vaccination booking system hinder migrant workers from receiving vaccinations. Many participants, 81.4% (n = 325), expressed concerns about contacting the provincial administration health office for vaccinations due to a lack of social support for interpretation services. Also, 63.8% (n = 254) of the participants indicated they would resent approaching a government healthcare facility for vaccination even though it would be free of charge because of discriminatory treatment experiences and being labelled as viral spreaders following the COVID-19 outbreak in Thailand.

5.3.4. Community-level

5.3.4.1. Fear of arrest and deportation

A total of 91.2% (n = 363) participants stated that the fear of being arrested on their way to getting vaccinated and being deported back to their home countries are impediments to getting vaccinated. Similarly, most NGO participants reported that migrant workers have little trust in the Thai government's announcement that they can receive vaccinations at a nearby public health facility due to the lack of legal documents and ongoing arrest and deportation among irregular migration workers.

Irregular migrants do not trust government announcements and are concerned about being arrested. (P1, Head of the Labour)

Some participants expressed scepticism regarding the Thai government's announcement that vaccinations would be administered in the community. The Thai government has not announced any safety measures, and the police are positioned at every street corner monitoring irregular migrants to extort money. Participants described that police are similar to money robbers.

The police will likely demand money of at least 2000 to 5000 baht if they apprehend us. We were threatened with deportation back to Burmese if we did not pay. If we do not have any money, the police will take whatever we possess, such as watches, rings, and jewellery. The police's behaviour is reminiscent of a robbery. (P9, Female)

5.3.4.2. Discrimination in public spaces

Furthermore, over three-quarters of participants, 86.4% (n = 344), reported discrimination experiences in the workplace, public areas, and transportation following an infection among migrant workers in the seafood processing industry.

The public has begun to blame migrant workers from Burmese for spreading the disease, despite the fact that positive COVID-19 cases have also been detected among Thai citizens. (P3, Labour protection officer)

The participants reported that discrimination against Burmese migrant workers was high and that it was difficult for them to obtain even a taxi. For example, one participant described her experiences with the taxi driver in this way:

The taxi driver told me that I did not need your money. It is quite challenging to get even a taxi for transportation" " (P5, Female)

5.3.5. Public policy level

5.3.5.1. Documentation requirements and vaccine combinations

Nearly half of the participants, 46.5% (n = 185), indicated that the complicated announcement about combining Sinovac and AstraZeneca vaccines confuses and decreases their willingness to vaccinate. Aside from the issue of mixed vaccines, migrant workers must possess a legal document or registration card to make an appointment for vaccination.

For irregular migrants, it is challenging to schedule vaccination appointments due to a lack of legal documentation and the inability to afford registration to obtain legal status. (P2, Female)

This requirement poses a significant challenge because many migrant workers have found themselves in irregular conditions because of the loss of employment since the COVID-19 disruption and the financial hardships associated with completing the Thai cabinet resolution registration to obtain a legal work permit.

6. Discussion

The study's findings indicate that participants face several barriers to accessing vaccination. This study found that 90.7% (n = 361) of participants were unvaccinated. This finding is similar to a previous rapid assessment of migrant workers from a construction site in the Bangkok Metropolitan Region in early 2021 (International Organization for Migration, 2021a). The primary barriers factors are discussed below:

6.1. Individual-level

The study revealed that a significant number (39.2%) of participants were unemployed due to the COVID-19 pandemic disruption. A similar finding was found in a previous assessment of Burmese migrant workers' vulnerability in Thailand in March 2021(International Organization for Migration, 2021c). A significant number of Burmese migrant workers were trapped in Thailand due to the closure of the border and travel restrictions. Most of these individuals live in precarious living conditions and cannot cover the cost of extending their work visas or registering for work permits. The findings reveal that one of the most significant barriers to vaccination is the inability to afford out-of-pocket expenses resulting from financial challenges faced by low-income migrant workers (Ang et al., 2017; Han et al., 2021; World Health Organization, 2021c).

Similarly, this study indicates that employers' reluctance to cover health insurance and vaccination costs, as well as factory lockdowns and difficulties accessing the outdoors are barriers to vaccinations for workers currently employed as found in previous studies (Kunpeuk et al., 2020; United Nations Thematic Working Group on Migration in Thailand, 2019). Moreover, the study reported that the COVID-19 pandemic exacerbated the hardships of millions of migrant workers and refugees in Thailand. These hardships included a lack of access to medical care related to the coronavirus and a loss of employment and essential income that adversely affected their mental health and well-being (Quinley, 2021). Therefore, it is likely that irregular migrants in Thailand will continue to face barriers to vaccination unless vaccines are freely distributed, as they cannot afford vaccinations. Their primary concern is to obtain food and shelter daily. In light of this, the Thai government should consider including all migrant populations in the national health plans and distributing free COVID-19 vaccines as part of the global call to reduce the global health crisis (Al-Oraibi et al., 2021).

Furthermore, migrants are not included in the COVID-19 national response and do not have global access to COVID-19-related precaution information in their mother tongues (Kondilis et al., 2021; Maldonado et al., 2020). The study also found that (79.4%) of participants did not receive information about the side effects of the COVID-19 vaccine in the language of their community. A recent study of Burmese migrant workers in July 2021 also revealed that 53% could not obtain information about COVID-19 precautions in their native language (International Organization for Migration, 2021c). The present study's findings are consistent with previous studies conducted in different countries, which have found that some participants were not confident in the effectiveness of the COVID-19 vaccine. This was due to a lack of information about vaccination side effects in their native languages and the manipulation of rumours that some people died due to vaccination. However, some participants said the vaccine had no side effects (Abba-Aji et al., 2022; Han et al., 2021). Therefore, an explicit and accessible vaccine information campaign in their native language is essential to increase the vaccination rate among irregular migrant workers. The Thai government could implement this in conjunction with other diaspora organisations and by recruiting migrant workers themselves to disseminate the side effects.

6.2. Interpersonal level

Additionally, participants face a significant language barrier that makes accessing information on COVID-19 precautions and vaccine side effects difficult. About 91.0% of participants in this study did not understand the COVID-19 vaccine announcement, the registration process for making reservations, or where to obtain the vaccine. Further, the study revealed that (81.4%) of participants were unfamiliar with the registration process, such as contacting the district health office or registering online. According to a study conducted in the United Kingdom, the digitization of healthcare services has reduced access to information and the COVID-19 vaccine for minority migrant populations owing to language barriers (Knights et al., 2021). In this respect, the Thai government should consider recruiting more volunteers in collaboration with various diaspora organisations, including cultural competence interpreter volunteers from within the migrant community to assist in delivering COVID-19 vaccine information and facilitating the vaccination booking process, as implemented by UNICEF in Thailand (UNICEF, 2022).

6.3. Organisational level

According to the study, 76.9% of participants had difficulty accessing vaccination sites due to geographical barriers, and 81.4% cited unfamiliarity with the booking process as a barrier. Similarly, these barriers have been identified as substantial impediments to receiving vaccines among the migrant population globally (Deal et al., 2021; Williams et al., 2021; World Health Organization, 2021a). Moreover, this study found that over half (63.3%) are unwilling to accept vaccinations even if they are free of charge due to discrimination experiences such as virus spreaders and the fear of being detained. On the contrary, a recent 2021 survey conducted by the International Organization for Migration (IOM) among construction migrant workers revealed that 77% were unvaccinated, while only 23% had received at least one vaccination. When asked whether they would take a vaccine if it were free of charge and available in the community, only 12% of those surveyed were reluctant to receive immunisations due to worries about interaction with other medicine, side effects, and though the vaccine is unnecessary (International Organization for Migration, 2021a).

Nevertheless, the participants in this study are regular migrant workers who have no fear of going to the doctor to have a vaccination or vaccination is conducted in the factory. The situation of irregular migrants differs from that of regular workers. The restricted travel restrictions and their lack of legal status prevent some of them from accessing even free NGO vaccine clinics within their communities. On the other hand, only a few NGO clinics and the Thai Red Cross Society provide free vaccinations to immigrant populations regardless of their status in Thailand (Reuters, 2021a).

6.4. Community-level

The majority (91.2%) of those who participated in this study expressed concerns about being detained at a vaccination clinic, imprisoned, and deported due to the lack of legal documentation. These concerns have been cited as barriers to accessing vaccination among irregular migrants worldwide (Khai, 2021; World Health Organization, 2021b). In particular, the Thai government continues raids and crackdowns on irregular migrant communities (Khmer Times, 2021) and has deported over 30,000 irregular migrant workers, primarily from Burma, by 2021 (Bangkok Post, 2021a). When fighting the COVID-19 pandemic, the Thai government should prioritize vaccine distribution to those irregular immigrant populations through transparent procedures and protocols that respect human rights, gender, and cultural perspectives, while following the World Health Organization (WHO) vaccine guidelines to ensure maximum success (World Health Organization & United Nations Children's Fund, 2021). The study also found that (86.4%) of participants were concerned about public discrimination regarding going to medical facilities and getting outside of their community for health care, as reported (Wongsamuth, 2021; Khai and Asaduzzaman, 2022). These factors make it difficult for the migrant population to access vaccinations, even though they are free of charge in some areas.

6.5. Public policy level

In contrast to other countries, the Thai government introduced a vaccine combination to combat the COVID-19 pandemic, particularly during the fifth wave. Due to this policy introduction, the Thai population has also become more hesitant to receive vaccines (Bangkok Post, 2021c). Consequently, nearly half of the participants (46.5%) reported being unwilling to accept free vaccines because of the combination. In addition to requiring proper documentation, such as a passport and a pin card, the Thai government has announced the availability of walk-in vaccinations and reservations for residents, including foreign workers. Meanwhile, the Thai government offers registration to irregular migrant workers to obtain pin cards and work permits until 2023, but they must undergo a health examination that costs more than 7200 baths (240 dollars) (Wongsamuth, 2020). These offers are unaffordable and inaccessible to the migrant population considering COVID-19 due to the loss of employment and livelihoods. As WHO recommended, the Thai government should consider the distribution of free vaccines in partnership with diaspora organisations and introducing an amnesty period to encourage vaccination (World Health Organization, 2021d).

7. Policy implications

Firstly, to prevent further casualties and halt the pandemic, vaccination of all populations, regardless of nationality or immigration status, would be crucial if living with a virus condition became the new norm. As such, the Thai government should promote vaccine awareness in the migrant's language in collaboration with diaspora organisations and community-based health workers and employ linguistically and culturally competent interpreters. Secondly, to motivate and increase vaccination rates among irregular migrant workers, the government should launch a vaccination campaign with a specific amnesty period from arrest and detention. This is because irregular migrants are most concerned about arrest and deportation as they lack legal documentation and the ongoing deportation of those detained by the Thai authorities. Additionally, the livelihood opportunities in their home country have been exacerbated by political turmoil following the military coup in 2021.

8. Strengths and limitations

To the author's knowledge, this is the first study to examine factors that hinder or prevent Burmese irregular migrant workers from accessing vaccinations in Thailand and Southeast Asia countries. There is a lack of studies, although Burmese migrant workers constitute more than half of Thailand's migrant worker population. The study presents several novel insights and practical implications that can be incorporated into policy and interventions to address the factors preventing irregular migrants and asylum seekers from receiving COVID-19 vaccinations. A further strength of this study is the participation of NGO workers, Thai citizens, and BIMWs, which allows for capturing different perspectives and experiences, thereby enhancing the research findings for policy implications.  Using a mixed-method case study design enabled the identification of key barriers preventing vaccination among BIMWs. In addition, the socio-ecological model employed in this study provides a framework for interpreting the findings and guiding interventions to address vaccination barriers among irregular migrants in Thailand.

However, given the travel restrictions during this research, the study relied on online interviews and could only interview individuals who had access to the internet. Thus, this study uncovered the experiences and concerns of migrants who could not access the internet or did not access the survey questions. It would be ideal to conduct a survey and interview in person to understand better the various barriers that hinder the BIMWs from getting vaccinated. As a result, this study cannot generalize barriers to BIMWs' access to COVID-19 vaccination across Thailand. It is necessary to conduct further research in remote areas using the same method of collecting fieldwork data to fully understand the research problem and identify a practical route to counter this unprecedented pandemic in Thailand or other countries by addressing vaccine barriers among migrant workers.

9. Conclusion

Thailand has a high rate of irregular migrant workers who are marginalised and vulnerable to healthcare access. COVID-19 has exacerbated this situation, and the Thai government has taken advantage of the moment control order to enforce more raids and arrests of irregular migrants.  The study identified some of the most significant barriers that BIMWs face when it comes to obtaining COVID-19 vaccinations, which can be applied to other irregular migrants around the world as well. The absence of vaccination provision, excessive costs associated with vaccinations, geographical barriers, factory lockdowns, and inaccessible and unavailable in all districts of free vaccination distribution from NGOs are major barriers to vaccination for irregular migrant workers. Other significant barriers to vaccination for irregular migrants are rumours, language barriers, complex registration procedures, public discrimination, and fear of arrest. The findings of this study suggest that providing free vaccinations to all individuals regardless of their immigrant status and protecting them from detention and arrest will increase vaccination among irregular migrants and may contribute to the success of the effort to combat COVID-19.

Ethical approval and consent to participate

Ethical approval was obtained from the Postgraduate Student Committee (PSC) of the research ethics committee of Lingnan University in Hong Kong. Oral informed consent from all participants was obtained before conducting an interview and audio recording aligned with the research ethics. All the participants' names were assigned pseudonyms. All methods are well carried out according to relevant guidelines and regulations.

Consent to publication

Not applicable.

Availability of data and material

All data generated or analysed during this study are included in this published article.

Funding

This research received no funding.

Declaration of Competing Interest

The author declares that he has no known completing financial interests or personal relationships that could have influenced the work reported in this paper.