Barriers to accessing TB clinics among Myanmar TB patients attending a Thailand-Myanmar border hospital: a qualitative approach

Purpose – This qualitative approach study aimed to understand the barriers to accessing a tuberculosis (TB) clinic in a Thai hospital as experienced by TB patients fromMyanmar living on the Thailand-Myanmar border. Design/methodology/approach – Twenty-two participants were asked to provide information. In-depth interviews were used to gather the information. Each interview lasted 40 min. Findings – TB patients from Myanmar experience several barriers to accessing TB treatment and care at Mae Sai Hospital, such as language and economic problems, although they are very satisfied with the quality of service and positive attitude of the health care providers. A long waiting time and lack of explanation of the pathogenesis of TB were noted as negative aspects by the patients and their relatives. The medical staff at the TB clinic were negatively affected by the excessive workload and unsuitability of some methods or technologies. Using budgetary subsidies from agencies to fund TB care and treatment was not sustainable. Foreign TB patients are not subsidized by the national universal insurance scheme of Thailand, and sending TB patients back to their home country is sometimes unavoidable. Originality/value –Thailand and Myanmar should strengthen their collaboration and develop a system to improve the quality of TB patient care and management for those who are living in poverty and lack education, by focusing on reducing language and economic barriers to accessing health care services including support for medicines and laboratory materials related to TB case management among these populations.


Introduction
Tuberculosis (TB) is one of the most important human bacterial infections, and health care systems worldwide invest large sums to address the problem [1]. In 2019, the World Health Organization (WHO) estimated that 10.4 million and 558,000 individuals suffered from TB and drug-resistant TB, respectively [1]. TB is prioritized as a first-line human threat in many countries, particularly in the developing world, including Thailand and Myanmar [2]. WHO also reported that approximately 5,000 of 32,000 TB deaths in 2017 were of individuals infected with TB and HIV in Myanmar [3]. However, there is no information available on TB and HIV specific to the Shan State. People who live in rural areas with poor education and low economic status are at a relatively much greater risk of TB infection [4]. Early detection and prompt treatment with a standard regimen are needed to eliminate the disease [5]. The accessibility of health care services is the most important factor in the reduction of TB in all populations. The WHO defines accessibility according to three dimensions: physical accessibility, economic accessibility (affordability) and information accessibility [6]. These barriers were supported by Dhavan et al. [7], particularly in the significance of feasibility and effectiveness of the process and treatment outcomes among migrant workers who live in at a poor socioeconomic status.
In 2019, the Chiang Rai Public Health Office reported more than 1,300 confirmed new TB cases in Chiang Rai Province, and 20% of the cases were identified in foreigners [8]. Among the foreigners with TB, 80% were from Myanmar [8]. People from Myanmar who live along the border, especially in Shan State, face challenges in receiving treatment for TB from their local hospitals, and hence sometimes they cross the border to receive treatment at Mae Sai Hospital in Thailand, which is located less than 3 km from the border [8]. The hospital provides services based on the standard of care for all people, including TB care and treatment [5]. Mae Sai Hospital, according to its primary mission and function, provides health care services for the Thai population [9].
Providing medical care for a person regardless of their race, color, language and nationality is the primary mode of operation of the standard health care service in Thailand. Mae Sai Hospital has more than 200 outpatient visits every day [10]. Approximately 30-50% of the outpatients are from Myanmar [10], and some of them are diagnosed with active TB; 150-200 new TB cases are detected every year [11,12]. Under the agreement that has been made by hospitals in Thailand and Myanmar, there are three main options for the management of TB patients from Myanmar at Mae Sai hospital [8]: referred back to their local hospital, admission as inpatients to start an intensive treatment regimen or patients from Myanmar who are diagnosed with TB can be asked to stay somewhere in Thailand to undergo follow-up at a TB clinic. TB treatment and care is a generally lengthy process and is expensive. To achieve the stated goal of the United Nations regarding the elimination of TB by 2030 [13], all stakeholders need to make improvements, including hospitals located on borders where there is a high prevalence of TB.
This study aimed to identify barriers to accessing TB diagnosis and treatment at a Thai hospital experienced by foreign TB patients living along the border between Thailand and Myanmar.

Methodology
A qualitative approach was used to elicit information from the participants, who were purposively selected from three groups: TB patients, patients' relatives and health care providers at Mae Sai Hospital. Mae Sai Hospital is located in East Chiang Rai Province, which borders Tachileik City, Shan State, Myanmar. A 17-item questionnaire was developed based on information obtained from a literature review. The validity of the questionnaire was assessed via the item objective congruence (IOC) method [14,15] and the validity was determined by 3 experts in the field: a medical doctor, a nurse working in a TB clinic and an epidemiologist. The questionnaire was tested for feasibility in a pilot study with 10 foreign TB patients at Mae Chan Hospital in April 2019.
Approval for access to Mae Sai Hospital was granted by the hospital director. All relevant medical staff received explanations of study. All participants were purposively selected for interviews, which were conducted in private and confidential rooms by two researchers who were experts in qualitative research: one Thai researcher and medical doctor from Myanmar who was a research team member. The selection of the TB patients for the study was preliminarily based on having been diagnosed with TB disease from a medical doctor and receiving treatment and care in Mae Sai Hospital. All Myanmar TB patients (participants) were selected based on having made at least two visits to a TB clinic at the hospital and a willingness to provide information. Researchers approached patients who attended the TB clinic every Thursday between May to August 2019 until they completed gathering information.
Appointments were made one week in advance, and participants were asked to sign the informed consent form before the interview. The TB patients and their relatives from Myanmar who could not communicate in Thai were interviewed by the researcher from Myanmar. Interviews were conducted from May to August 2019. All interviews were audiotaped after obtaining approval from the participants. Brief notes or field notes were also taken during the interview. Each interview lasted 40 min.
All tapes were transcribed and translated into English. The completeness of each interview was ascertained before the data were subjected to the next step. The interviews were reviewed by all research team members and compared with the notes taken during the interviews. Typed interview transcripts were sent back to the interviewee who was asked to validate the accuracy of the content before further analysis. Data were extracted and analyzed by themes using the NVivo program (NVivo, qualitative data analysis software; QSR International Pty Ltd., version 11,2015). After the thematic analysis was completed, the information was discussed among the members of the research team who determined the findings and drew conclusions.

Ethical issue
This study was approved by the Mae Fah Luang University Research Ethics Committee on Human Research (No. REH-61215).

Results
A total of 22 participants provided information for the study (10 TB patients from Myanmar, 5 of their relatives and 7 health care providers). Ten TB patients from Myanmar (five females and five males) were from rural areas in Tachileik District, Shan State, Myanmar, and none of them had health insurance. They were aged between 19 and 64 years, were married and had a primary level of education. Five relatives who participated in the study were middle-aged and employed. Seven health care providers from the Thai hospital participated in the study (one administrator: a hospital director; five individuals who provided direct patients care: two physicians, one public health professional, one nurse, one pharmacist; and one support staff member: medical laboratory technician).
Reasons for obtaining TB treatment at a Thai hospital Several reasons for obtaining treatment from a Thai hospital were indicated by the TB patients from Myanmar: a lack of satisfaction with the medical services in hospitals in Myanmar, a lack of medical doctors in hospitals in Myanmar and confidence in the quality of medical services provided by Thai hospitals.
A 64-year-old female said the following: Approximately three weeks before we had to go to the Mae Sai Hospital, I was admitted to Tachileik Hospital for 2 weeks. The hospital could not give me a diagnosis or treatment, and I was not feeling better. Moreover, I had to wait too long to get test results in Tachileik  A 59-year-old health care provider said the following: We have a strong and clear policy regarding providing all services to all people in the same way that is not affected by their race, nationality, or economic status. However, given the overcrowding of clients on some days or in some clinics, the patients may need to wait in a long queue before seeing a doctor; we have tried to improve this matter. (HCP#1) A 47-year-old health care provider said the following: I have worked for this clinic for almost 17 years, and we have enough drugs and materials to provide care in our TB clinic; however, the most important issue is that we need more staff to make sure that we have worked through the standard guidelines for TB treatment and control. And it would be helpful to have occasional training sessions. Then we can provide most effective care for our patients. (HCP#4) Barriers to accessing TB treatment in Mae Sai hospital Two factors were found to be significant barriers to accessing care at this Thai hospital: language and economic barriers. Mae Sai Hospital has hired many support staff in different departments, including TB clinics, to help with communication between health care providers and patients. However, given the large volume of patients each day, the language was found to be the major barrier to accessing medical services at this Thai hospital. The hospital has several options with regard to providing support to patients who have a financial problem, such as waiving all or some medical expenses, allowing them to pay later and offsetting costs with support from nonprofit organizations. However, all Thai TB patients do not face this issue because they are supported by the government through the universal insurance scheme.
Language barriers are common among Myanmar TB patients attending Thai hospitals. A 47-year-old health care provider said the following: We have hired staff who are fluent in both Thai and Burmese to help our TB clinic staff communicate with the patients. It is really helpful! However, TB patients do not only come from Myanmar. TB patients of other ethnicities also come, which is a problem because we could not find people for hire who could speak many languages. (HCP#4) Economic barriers are also common among TB patients from Myanmar who access Thai hospitals, due to the loss of daily income, the inability to pay for transportation expenses and medical costs A 64-year-old female TB patient said the following: Language was mentioned as a major barrier to accessing Thai hospitals by TB patients from Myanmar. This was supported by several studies in different settings. Nakiwala et al. [16] reported that a language barrier was found in TB clinics in many countries, including developed and developing countries, and posed a major challenge to eliminating TB globally. A systematic review in sub-Saharan Africa also reported that language was identified as one of the major barriers to accessing TB clinics [17]. Moreover, a qualitative study demonstrated the presence of a language barrier in TB clinics in Mozambique [18]. Additionally, it has been demonstrated that language was defined as one of the significant barriers to accessing medical care by TB patients who lived in Thailand-Myanmar border areas [19].
Most TB patients from Myanmar and their relatives reported that economic status was a significant concern when attending Thai hospitals. Due to the long treatment course for TB and transportation costs, financial concerns constituted one of the major barriers to accessing TB clinics, particularly with regard to adherence to completing the course of treatment. This is supported by a study in Uganda that reported that financial problems were a significant barrier for patients attending the TB clinics [20]. A qualitative study in China also showed that economic factors were identified as a barrier to attending the TB clinics [21]. A systematic review also showed that the financial problems of TB patients posed a major barrier to accessing TB clinics [22]. However, in the study setting, it would be suitable to have a health insurance program that is possible to buy in one country but that can be used in another country.
A long waiting time and the lack of information about the pathogenesis of the disease were mentioned as points for improvement by patients and relatives who attended this hospital in Thailand. To improve the quality of and satisfaction with the service, the hospital needs to develop a concrete plan, taking into account the limited health resources of the hospital. The continuous improvement of services and encouragement of health care providers to regularly obtain training to update their skills and knowledge related to TB care and treatment should be priorities for the executive manager of the hospital. Overcrowding of patients and long waiting times significantly affect patient satisfaction, and improvements of these issues would lead to increased positive TB treatment outcome rates [17]. A study in China demonstrated that treatment and prevention and control measures at the family and community levels had greater impacts on reducing TB problems, in particular providing information about the pathogenesis of the disease to patients and their relatives [23].
Some limitations to this study were found when validating details of the typed documents with the Myanmar participants, because some of them had returned to their home country, making it difficult to contact them after the process of typing up the audio tapes was completed. This made the period of completing the study four months (May to August 2019) when the confirmation of the information was received from the participants before further analysis. Furthermore, two of the Myanmar TB patients were not Burmese but were from the Akha minority living on the Myanmar side, but because they could speak Thai, the process of interview and confirmation of information was completed in the Thai language.

Conclusion
The number of TB cases is increasing, particularly in this hospital located along the Thailand-Myanmar border. People who are living in poverty and have a poor education are very vulnerable to TB. However, their access to health care services is affected by several barriers, including language and economic barriers. To eliminate TB, both the Thailand and Myanmar health agencies should develop a concrete plan to work together, such as by providing adequate financial supporting to this particular clinic. These health care providers also need to receive regular training with regard to the updated technology and guidelines to work effectively in this setting. Hiring additional staff who can speak the local languages would help improve the effectiveness of care and treatment. A proper education method for improving knowledge on TB prevention and care at family-and community levels is highly significant, particularly regarding in the use of local languages that is comprehnsible for TB patients from Myanmar.