The Beliefs and Practices on Sexual Health and Sexual Transmitted Infection Prevention of Myanmar Migrant Workers in Thailand

The qualitative research method was applied in this research. The data collection covered observation, field note takings, in-depth interviews, and secondary data derived from literature reviews of various sources. The participants consisted of 22 Myanmar migrant workers who could communicate in Thai and live in Thailand for at least one year. The data was analyzed by using the method of content analysis.


INTRODUCTION
Thailand has been well-reputed as a country in Southeast Asia that can attract a number of migrant workers from her neighbouring countries, owing to an increasing demand for labours to work in various factories and industries [1]. The Chiang Mai and Surat Thani [3]. Once in Thailand, they have unavoidably encountered various issues, i.e., a number of migrant workers have had health problems, hiding from Thai authority owing to their illegal entry; no work permit and inability to communicate to promote the Myanmar migrant workers' healthcare [4]. Obviously, the issue of migrant's health has been a serious concern for Thai authorities relating to transnational migrant worker's policy [5].
Given the migrant workers' inability to access the public healthcare system, the disease control and prevention have, to a greater extent, been unduly delayed and affected national public healthcare services [6]. Besides, some groups of migrant workers are still ignorant about healthcare and have unhealthy behavior [4,7]. The evidence indicated that the Myanmar migrant workers with sexual transmitted infection, HIV infection, did not go to the hospital for treatment or use condom to protect themselves. So, this could easily be the cause for HIV to spread widely and consequently, more people would be infected [8]. It was also found that these Myanmar migrant workers have had sexual and reproductive health problems, for example, wrong attitude, inadequate knowledge and misconception about family planning and disease prevention, STIs prevention, unwanted pregnancy, language barrier, abortion, as well as postpartum care [4, 8 -11].
Since the related health and sexual reproductive health issues have increased and caused concerns for governments in Southeast Asian nations, policy planners have come up with necessary measures regarding sexual and reproductive health in order to tackle these issues, apart from controlling and decreasing the number of illegal migrant workers, as well as preventing sexual transmitted infection [12]. So the policies reflect the government's focus not only on the migrant workers who are sexually active but the possible impacts on social structure and welfare of the people in the country, including negative health control and preventative measures [13,14].
Owing to the extensively sexual and reproductive health issues of migrant workers in Southeast Asia, many countries of this region all launched preventative measures to control migrant workers and map out related sexual and reproductive health policies [14,15]. Efforts were made to reduce the number of illegal migrant workers and, at the same time, to decrease sexually transmitted infection prevention [13]. The above-mentioned measures and policy boiled down to the fact that those governments were very anxious about the illegal migrant workers who are mostly at reproductive age and, if uncontrollable, the country's social structure, public social welfare and healthcare system can be, to a greater extent, inadvertently affected [16].
Therefore, the researchers have realized the importance of the Myanmar migrant worker's issues as earlier mentioned, thus collaboratively conducted the research on the perspectives and experiences of sexual practice on sexually transmitted infection prevention among Myanmar migrant workers in Thailand. Upon completion, the findings can be used as foundation data to inform and propose to the society and health organizations concerned, especially those responsible for coming up with the effectiveness of migrant's health policy.

MATERIALS AND METHODS
The qualitative research approach was applied in this research to explain the sexual beliefs and practices of sexually transmitted infection prevention among Myanmar migrant workers in Thailand.

Participants and Setting
The participants covered 22 males and females Myanmar migrant workers at latex rubber factory and rubber tapping in Surat Thani province, able to communicate in Thai language and lived in Thailand for more than one year. Their job and responsibility included working with rubber related products ranging from rubber tapping, latex storage, making rubber sheet and rubber product processing. Those rubber tappers had to work on night shifts and continued working till day shift, whereas workers at latex rubber factory worked on a shift basis. This research included three districts of Surat Thani province, i.e. Muang district, Poon Pin district and Kanjanadith district, respectively.

Data Collection
In gathering data required, the research team employed a qualitative approach by using in-depth interviews technique, based on interview guidelines derived from literature reviews, experience and expertise of the researchers themselves, in addition to observation, field note takings together with such secondary data as literature reviews from various sources. The interview guidelines were validated by three professors who are experts in the field of study. The questions were followed by three open-ended questions: (a) "Could you please tell me about your experience in looking after your sexual health, for example, what have you done and how?" (b) "What is the meaning of sexually transmitted infection?" (c) "How do you protect yourself from STIs/ and what methods do you use, how?" During the interview, all participants were interviewed by the research team individually in a private room to maintain privacy and minimize any distractions that might occur.

Data Analysis and Rigor
In this regard, the research team had applied a qualitative research analytical technique used by van Manen [17]; all data collected were analyzed accordingly. The collection of data was systematically administered and once each interview session ended, verbatim transcription of data was executed to ensure its precision; besides, the team scrutinized the trustworthiness of the transcripts while carried on with the data analysis. The rigor of this research was that it was conducted according to Guba and Lincoln [18]'s approach by (a) credibility, this refers to finding out about the data's trustworthiness and correctness which all boiled down to the fact that whether or not the research was systematically conducted;(b) transferability, this refers to an ability to transfer the findings to other population of any other studies. Briefly, those informants in this research were specifically selected; the research team had no intention to transfer the outcomes of the study to other population; instead, the team intended to describe quality data covering 3 dimensions: detailed and reliable information; insightful phenomenon and, last but not least comprehensive coverage;(c) dependability, this refers to the testing and verification regarding the reliability of data collected. To achieve the objectives, the research team had to prove that there was a reasonable linkage between interviewing data and field note takings while administering the interviews, including the availability of supportive evidences to the extent that a better understanding of the immediate phenomenon occurred;(d) conformability, this refers to the ability to objectively confirm the findings through repetitive examinations of the data available. Theoretically and practically speaking, the research data systematically collected must be audited and examined to provide an audit trail.

RESULTS
The findings of this research consisted of two major themes and four subthemes as follows: 1.

Theme 1: The Meaning of Sexual Transmitted Infection
The majority of Myanmar migrant workers said that the sexually transmitted infection (STI) related to HIV infections or AIDS, those who got infected would be treated as shameful persons; nobody wanted to associate with, and disdained by their society. Above all, nobody wanted to get close to them for fear of being infected. Those interviewed stated the following: "Is it HIV/AIDS? I suppose it's a kind of disease we got infected after often sleeping with those having diseases. If friends or neighbors know we have the disease, they will have contempt for us or keep their distance, surely they're afraid to get infections from us and don't want to be near us" (IDM3) "Not quite sure about it, but I feel that AIDS is frightening. If anybody got infected, then it is recommended to stay away from them, because we would get that kind of disease, too. So I am scared and have to keep my distance" (IDM9)

Theme 2: The Sexual Health and Sexual Transmitted Infection Prevention
The experiences of sexual transmitted infections prevention among Myanmar migrant workers fell into four subthemes as follow:

Sub-theme 2.1: Males and Females: Equality to STI's Prevention
As for most Myanmar migrant workers, the research findings found that men and women had equal rights; they could lead their life as they wished, having equal freedom and no job or responsibility discrimination regardless of gender. However, men always had more rights, power and privilege than women when taking family status into consideration. Interviews extracted were as follows: "We're equal, I think; women have to work and earn money as men. But at home or anything to do with family issues, I let my husband to be a decision maker, I am a woman, he, as a man, got to be stronger and smarter" (IDM7) "Oh, we are equal and have the same rights, she can go wherever she wants, she's working to earn money, so am I; but when coming to family issues, I think men are more authoritative and have to play a role of decision maker, wife has to listen and follow us as family leaders" (IDM11)

Sub-theme 2.2: Sexual Risk Behaviors: No Prostitute Service, No Sexual Risk
The majority of Myanmar male and female workers talked about their sexual risk behaviors in such a way that they did not have sexual risk behaviors, owing to the fact that they had to stay with their spouses all the time; no night out or changing partners. They felt that it was not worth it and that inappropriate to spend money on parties or prostitutes. Details of the interviews are as follows: "I never go for prostitute service, only drink alcohol occasionally. I and my wife are together all the time and try to save up money earned from our job; it's a waste of money to go out at night or buy woman's services" (IDM3) "I've never been out to parties at night, my husband hasn't, either; though he sometimes drinks alcohol, but he's always with me; both of us don't sleep around" (IDM7)

Sub-theme 2.3: Condom Usage: Unaffordable and The Symbol of Promiscuity and Untrustworthiness
Both male and female Myanmar migrant workers interviewed said that they had never bought and used condom; they viewed that using condom was disgusting and condoms were dirty stuff whereby the users deemed promiscuous, polygamy, which is contradictory to their customs and tradition. Some said that condoms were expensive and they had only one wife/husband, so it was not necessary to use a condom, as the following interview excerpts went: "We Myanmar people normally don't use condom; my husband hasn't used it. Though never seen it, rumor has it that those using condoms are very promiscuous or they must have some sort of STIs. Besides, condoms are expensive, too" (IDM12)

Sub-theme 2.4: Abortion: UnavoidableSolutions of Unwanted Pregnancy
Most Myanmar migrant workers said that unwanted pregnancy was leading to an abortion. Having an abortion was acceptable if the mother thought that she was incapable of bringing up her child or did not have enough money to raise her child. In that case, a mother-to-be could decide to have an abortion, which could be done by taking medicine or getting the abortion service from some healthcare clinics. They also stated that no condom usage may be the cause of unwanted pregnancy and end up with abortion. Details of the interviews were as follows:

DISCUSSION
The findings of this research indicated that the meaning of sexually transmitted infection is an infection that can be inflicted through having unprotected sex, changing partners and sharing common syringes [19]. The symptoms of sexually transmitted infection are similar to having been infected by HIV/AIDS. It is unfortunate that those infected by these kinds of diseases would be disdained and treated as contemptuous persons [20]. They would publicly shun and certainly be avoided and isolated; above all, they would be treated as disassociated persons in their society as people fear of being inflicted.
The sexually transmitted infection prevention experiences of Myanmar migrant workers as far as Myanmar migrant workers' perspectives on gender equality were concerned, men and women are not different in terms of how to live their life; both having full control and able to independently decide by themselves; including equal responsibility of their job [21,22]. Nonetheless, regarding gender status in the family, women are always inferior to men treated as more privileged and powerful, having more rights and, as a breadwinner, will always have the final say. Unsurprisingly, both Myanmar and Thai workers at Surat Thani province had identical ideas about gender equality, given that both nationalities shared comparable socio-cultural beliefs and similarities [16,23,24].
The sexual risk behavior related to alcohol consumption, going night outs, having several sex partners, including occasionally using call girls' services [25]. The research findings also found that information given by Myanmar male and female informants, saying that they did not have such risk behavior, either, as they were not promiscuous, and that all of them would stay close and stick to their job and spouses all the time. They also stated that it would be a waste of time and money to go out at night having fun or use prostitute services [26].
Obviously, this kind of attitude of Myanmar migrant workers could be attributable to their embedded tradition and social values passing down from their ancestors [27]. Arguably, their negative attitudes towards using condoms could stem from the lacking of proper birth control knowledge and information among public health staff or their negative perception through mass media since the early days [28]. Obviously, condom usage has been related to affective measures of anti-sexually transmitted infections and HIVs over the past three decades [29]. Therefore, using condoms can be viewed as an efficient method in preventing sexually transmitted infections [30,31], which corresponded to an interview in Myanmar newspaper that Myanmar people strongly believed that condoms should never be used with their spouse, and that contraceptive pills for birth control were being used, instead. One of the studies found that using condoms in Myanmar was not popular since it was related to unethical issues, i.e., having affairs or sleeping with prostitutes. Contraceptive condom was regarded as a shameful product because it was used by people wanting prostitutes' services [29].
As for Myanmar, undergoing and performing an abortion is also illegal. Based on Thailand Abortion Surveillance Information's data in 2011, it was found that 2.3% of Myanmar patients being treated at hospitals owing to abortion implications [3]. According to this research findings, the Myanmar migrant workers said during an interview that having and performing an abortion is illegal and immoral, except for such good reason as low economic income resulting in their inability to carry out raising a child; in other words, having an abortion is socially and morally acceptable in Myanmar if the couples having sound economic-related reasons [32]. Worth mentioning is that the research team found none of those interviewed had any abortion while working in Thailand, but the Myanmar migrant workers gave the example of their friends getting an abortion from some abortion service providers in Surat Thani province. The providers performing an abortion consisted of Thai and Myanmar nationalities living in Thailand. The women's reason for having an illegal abortion was that they already had enough children and if they had one more, then it would be tough for them financially and emotionally (normally, Myanmar people have a maximum of 3 children) [33].
To put things into perspective, though the research team did not find abortion issue among Myanmar migrant workers at Surat Thani province, one of the critical scenarios in Thailand was about Myanmar migrant workers' having an abortion [32]. Clearly, this problem was caused by not having effective family planning leading to unwanted pregnancies and abortions. Besides, some of them decided to have an illegal abortion to fear being dismissed from their job if found pregnant by their employer [4]. It is suggested and recommended that the public and private organizations concerned should earnestly attempt and put more efforts to effectively deal with this issue accordingly.

STRENGTHS AND LIMITATIONS OF THE STUDY
The findings of this research might not be generalized beyond the participants because of less number of participants. Furthermore, most participants had worked in a latex rubber factory and rubber tapping in Surat Thani province, which might affect their perceptions and attitudes. Additionally, the study results could, to some degree, vary depending on working location and the types of industry for which Myanmar migrant workers were employed. However, the auditability of this research occurred from the homogenous participants.

IMPLICATIONS OF THE FINDINGS
The findings of this research have several significant implications for nursing and healthcare practice, i.e. the public health nursing, sexual health nursing, including nursing administration. In the public health and sexual health practice implications, attitudes toward sexually transmitted infection and condom usage of Myanmar migrant workers, the public health officers or nurses should provide effective communication or sexual health education for them about the benefits of using condoms, since they can be informed and educated to prevent them from getting sexually transmitted infection. That aside, it can help them to succeed in birth control and reduce the rate of abortion. By the same token, public health or nursing administrators should provide relevant training programs to nurses taking care of Myanmar migrant workers, focusing on the workers' attitudes, health beliefs, health behaviors and communicative aspects. As a result, that would certainly contribute to enhancing the nurses' perspectives, knowledge and understanding of their Myanmar migrant workers so much so that they are well and fully equipped to provide effective nursing services to those visiting workers.

CONCLUSION
Based on the research findings, Myanmar migrant workers, regardless of gender, have had insufficient knowledge and information of sexually transmitted infection. It is vital that concerned parties, both public and private ones, need to cooperate and access those laborers to disseminate information on various types of sexually transmitted infection, their implications, guidelines and preventative measures. More importantly, the concerned parties are required to initiate relevant activities or educational programs through a computer or mobile phone applications widely used by those workers. For attitudes toward sexually transmitted infection and condom usage, though it is rather difficult to change Myanmar migrant workers' attitudes towards condom usage, the concerned health organizations or physicians and nurses should find some effective communicative channels to inform and educate them about the benefits of using condoms that can better prevent them from sexually transmitted infection and help them to succeed in birth control. By the same token, trying to gradually alter their attitudes that using a contraceptive condom is actually not a shameful behavior is also necessary. In brief, concerned health centers and individuals, especially nurses, must put efforts to search this kind of attitude and find the best approach as to how to correct their belief and understanding. Admittedly, it might take time to adjust Myanmar migrant workers' attitudes that, in fact, using condom is not at all a symbol of a promiscuous person, dirty guys or immoral behavior. Instead, those using condoms properly would be regarded as wisely modernized people with birth control knowledge and, above all, keep themselves safe from sexually transmitted diseases.

AUTHORS' CONTRIBUTION
All of the authors in this research approved this manuscript to be published in TOPHJ. Nuchanad Hounnaklang, principle investigator and first author conceptualized the idea of research, contributed to research design, data collection and data analysis, drafted and revised of this manuscript, Chawapon Sarnkhaowkhom, co-researcher and corresponding author, involved in conceptualized the idea of research, contributed to research design, data collection and data analysis, initial drafting of this manuscript, essentially intellectual contribution and Rattana Bannatham, coresearcher, involved in revised of this manuscript.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE
The ethics review committee for research involving human research subjects, health science group, Chulalongkorn University, Thailand had approved this research. (IRB Code: 099.1/60).

HUMAN AND ANIMAL RIGHTS
This research has no animal usage in this research. The procedures of this human research followed the standards of ethics and The Ethics Review Committee for Research involving human research subjects,Chulalongkorn University, Thailand.

CONSENT FOR PUBLICATION
The participants of this research gave consent and participated willingly. Anonymity and confidentiality were ensured by not revealing the participants' names in the data collection process, interviews, and also research report.