Developing primary care occupational health services for informal sector workers in Thailand

Abstract

This study demonstrates action research’s emancipatory traditions in enabling community stakeholders in rural Thai settings to increase self-reliance and collaboration in improving primary care occupational health services. Most of the Thai workforce are informal sector workers outside Thai labor law protections, health and safety regulatory frameworks, and without specific occupational health services to provide for work-related health needs. This project brought together community leader teams, village health volunteers and informal workers themselves to collaboratively develop community services for this underserved group. Significant changes were effected at community team level, with improvements in networking and community nurses’ health care for the workers and in their oversight and supervision of village health volunteers (VHVs) in the community. Most notably, VHVs’ self-confidence improved at providing illness prevention and health promotion support in workers’ homes and work settings congruent with their daily lifestyle and work schedules. Informal workers’ health self-care behaviors improved.

Keywords

Action research informal sector workers primary occupational health care services village health volunteers

Introduction

The global informal sector workforce has grown rapidly in recent decades, exacerbated in low- and middle-income countries by rural workers migrating to towns and cities for work (Manothum & Rukijkanpanich, 2010; Thanachaisethavut, Charoenlert, & Saeng-Ging, 2008). Informal sector workers include self-employed or home-based and workers in small enterprises with no formal employment contracts. The Thai workforce was estimated at 39 million in 2012, with the majority 25 million (64.2%) in the unregulated informal worker economy (National Statistics Office, 2013). Thai informal workers work mostly in the agricultural sector (62.5%), with lesser numbers in trading 28.3%, and production 9.2%. Although they constitute the majority of the workforce, and make significant contributions to the Thai economy and society, they are a marginalized group, who work outside Thai Labor Law protection, health and safety regulatory frameworks, and without occupational health services to provide for work-related health needs.

Informal sector workers face many work-related health risks. The Thai National Statistics Office (2013) showed that 66.8% of informal sector workers were exposed to toxic chemicals and 20% worked with dangerous equipment. Nilvarangkul et al. (2006) found that 93.5% of women weavers had posture-related back, neck, arm or hand pain. Formal sector workers with work-related injuries can access compensation under the Thai Workmen’s Compensation Act 1994 (Thanachaisethavut et al., 2008), however, informal sector workers are outside this provision.

Informal sector workers can now access free health care due to significant health services policy improvements in Thailand over the past two decades. Free state-provided healthcare first became available for poor and disabled people in 1994, alongside a variety of government, or employer-based, health schemes for government or private sector employees. However, by 2001, around 30% of Thai people still had no health insurance (Suraratdecha, Saithanu, & Tangcharoensathien, 2005; Tangcharoensathien & Jongudomsuk, 2004). From 2001, the government launched a series of universal health coverage insurance schemes culminating in 2006 with the introduction of a universal free medical access card for all Thai citizens (Mee-Udon, 2014).

Primary care health centers are the basic service units in Thailand. Located in all sub-districts, and described as health promotion hospitals, they are staffed by community nurses, public health staff, oral health therapists, and visiting physicians, though only the latter available in a small number of hospitals. There is a secondary care referral system from sub-district health promoting hospitals, to district and provincial hospitals, on through to tertiary care at regional or university hospitals. Although health-promoting hospitals’ roles are to provide basic treatment, disease prevention and health promotion services (Sriwanitchakorn, Surasuk, Bumroong, Thasanee, & Natthaporn, 2002), most are primarily treatment focused, with support services for chronic illness, such as diabetes mellitus and hypertension, and care for older persons (Nilvarangkul, Adler-Collins, Thaewnongiew & Klunglang, 2009). Although informal sector workers have free access to these primary health centers, none provide specific health services for work-related illness/injuries, or education, or health promotion to reduce work related illness/accident risk (Nilvarangkul et al., 2006, 2009).

Research on occupational health services for informal sector workers is limited in Thailand. The Thai Bureau of Occupational and Environmental Diseases (TBOED) (2010) has an occupational health care services model for primary care for informal sector workers for training health personnel responsible for community care of informal sector workers. However, their own research found that while some primary care units were able to provide services for the informal sector workers, some did not since the proposed service methods were not congruent with the care culture in the units. In addition, some units did not have enough staff with occupational health knowledge or skills, and staff perceived these services as outside their responsibility (Office of Disease Prevention and Control, Region 4, 2009). Other studies have focused on assessing health risks of informal sector workers (Chanthawutthinan, 2012), or specific groups such as dress makers (Arreeruk, 2009), using “top-down” approaches to develop informal sector workers’ care protocols rather than engaging the workers themselves as partners in the study. Manothum and Rukijkanpanich (2010) is one example of participatory action research (PAR) with micro-enterprise informal workers; weavers, blanket, and ceramic workers from four regions of Thailand. They found that occupational safety knowledge, attitudes, and safety risk identification improved, as did worker-initiated action to address safety measures.

Action research is “a participatory, democratic process concerned with developing practical knowing in the pursuit of worthwhile human purposes, grounded in a participatory worldview…” (Reason & Bardbury, 2006, p. 1). In healthcare, action research’s collaborative approach enables close community and researcher engagement through all stages of the research process to improve health and well-being, from definition of the issues through to intitiating action, including social change (Viswanathan et al., 2004). Its aims are to produce knowledge from the world-views of marginalized, deprived, and oppressed groups to contribute to transforming social realities (de Koning & Martin, 1996). Our study used action research to investigate the potential for developing primary care occupational health services, by engaging community leader teams, VHVs, and the economically and educationally marginalized informal sector workers. These groups, although previously familiar with each other, had never before come together to talk about primary care occupational health services. The project allowed all stakeholders to have free dialogue amongst themselves within their own community context to share their understandings of problems and service needs. This chance for voicing “what moves and hurts them” (Brookfield, 1993, p. 234), raised a critical consciousness and agreement to address the issues for their mutual benefit. Our research was driven by the assumptions that “action researchers can trust that, what should arise from the community will arise, that power is already present, and that the answers to identified problems will become clear through exploration and dialogue, as will necessary actions to remedy the situation” (Pavlish & Pharris, 2011, p. 14).

Methodology

This study used a four phase action research spiral process; developing understanding of the problem, collaborative action planning, plan implementation, and evaluation and reflection on plans’ impacts (Lewin, 1946; Moule & Goodman, 2014).

This project grew out of earlier collaborations between university researchers and local health and government units and the growing awareness of informal sector work-related health service needs. The research team comprised one academic from community nursing, three from public health, one from medicine and one from the pharmaceutical sciences faculty of a large regional university. All had prior rural community action research experience and commitment to enable marginalized communities to flourish and enhance their well-being.

Research setting

The settings were four health-promoting hospitals and surrounding villages based in Kalasin and Udon Thani Provinces in the North East, and Phayao Province in Northern Thailand.

Participants

There were three groups made up of 183 purposively recruited community participants. The first group, community leaders’ teams, consisted of 33 persons with various care responsibilities for informal sector workers who accepted invitations to join the project, including community health center personnel, members of local sub-district administration organizations (SAO), community leaders, VHV leaders, and informal sector workers’ leaders. Another group was comprised of 30 VHVs who provided support and basic care for the workers. The third group was made up of 120 informal sector workers, including mortar and pestle production workers, cotton weavers, knitting and sewing workers, and sugarcane and monkey apple farmers.

Research instrument

A questionnaire covering work-related health problems and perceived health/safety risks was developed by the research team, with sections on general health and safety, and specific areas on agricultural chemical use, respiratory and musculo-skeletal problems. Three occupational health experienced academics, two from public health and one from community medicine, critically reviewed the draft questionnaire and revisons were made based on their feedback to improve its validity (Polit & Beck, 2008). It was pretested with 30 informal sector workers from similar work contexts to the participants. Reliability was assessed using Kuder-Richardson with a reliability co-efficient of .78, which was judged acceptable (Lobiondo-Wood & Haber, 2010).

Data collection

Quantitative data

Questionnaire data was collected via face to face interviews by trained VHVs with all 120 informal sector worker participants.

Qualitative data

VHVs and research team members conducted a series of 36 focus group discussions (FGDs). The first 12 FGDs (3 in each of the four research settings) investigated informal sector workers’ perception of work-related illness, their views on access to occupational health services, their health service needs and elicited their suggestions on future service provision as basis for action planning. Further FGD meetings were also held with VHVs (4) and the community “teams” (4) for in-depth coverage of issues around current services, organization, training, perception of service need, etc. The 16 remaining FGDs included VHVs, community team and workers together, to engage in development and implementation of action plans and formative and eventually summative evaluation. All FGDs were audiotaped for later transcription and written notes were taken.

Comprehensive field notes recorded incidental information and reflections from planning meetings, FGDs, participant observations and ongoing informal interviews among researchers and participants. This constituted a reflective journal and audit trail for monitoring the rigor of the study, using Lincoln and Guba’s (1985) four criteria of credibility, transferability, dependability and confirmability. We used triangulation to confirm information (Patton, 2002) with transcribed data returned to participants for confirmation and clarification.

Data analysis

Quantitative questionnaire data were entered into spreadsheets for validation, coding, and analyses using SPSS (version 15). Descriptive statistics, including frequencies, means and standard deviations, were calculated for sociodemographic data, and work-related illness, health-risk, and self-care behaviors for preventing work-related illness.

Qualitative data from FGDs were transcribed verbatim from audiotapes and content analysis used for the analysis (Elo & Kyngas, 2008). The research team read and re-read the transcribed information to become familiar with it. Data were open-coded and clustered into groups and categories and connections across categories eventually collapsed into main themes. The analysis was ongoing from the outset following the spiral process of action research back and forth throughout the phases of the project.

Ethical review

Ethical approval for this study was obtained from the Human Research Ethics Committee of Khon Kaen University (HE 542393).

Findings

Research findings are presented in an interactive sequence reflecting the iterative action research process.

Phase one: developing understanding of current situation

At the project’s outset, four community teams (14–16 persons each) established themselves in their respective communities. From initial FGDs with the community teams and researchers, it was clear that there were no specific occupational health services in the respective primary care units for informal sector workers and health workers admitted limited capability and confidence for doing such work. Only one primary care unit monitored blood cholinesterase for exposure levels to organophosphate pesticides, and then only occasionally dependent on Ministry of Public Health project funding.

Community nurses and health personnel had received no specific training in work-related health problems and had never provided specific services for work-related illness, nor pro-active work safety or accident prevention information. They typically provided symptom-focused individual health without clarifying if the problems were work-related. One community nurse commented:

I admit I have never provided occupational health care services for informal sector workers since I focus on provide care for chronic patients such as diabetes mellitus and hypertension since it is government policy to care for the chronic illness group.

Another, a VHV, indicated: “I was trained about chronic illness such as diabetes mellitus many times, but I have never trained about how to prevent illness related to work.”

As the community health team members came to realize that many work-related health problems were preventable, they requested education on occupational health particularly for promoting work safety and risk prevention. Informal sector workers also had little prior knowledge about work safety risks and links between work and illness and as their consciousness grew, they also shared their concerns with community team members. This built a common grassroots understanding and health worker/VHVs commitment to strategize to address this gap in their knowledge and skills. As one community health nurse commented:

I do not want the workers to have illness related to work, but (with) only me it is difficult since I have (big) work load but if we help each other it is possible to provide care for the workers.

Phase two: collaborating to develop action plans

The community teams and researchers collaborated to develop action plans to respond to needs identified in the phase one round of FGDs. Table 1 presents summary outlines of the priority problems and ensuing action plans focused on occupational health care services, work and safety risk prevention for community health and volunteer health workers, capacity and confidence building for health workers, and relationship building with the informal workers.

Table 1.

Problems, corresponding action plans, implementation, and findings.

Problems	Corresponding action plans	Implementation	Findings
No community health education services related to work and safety for the informal sector workers	To provide health and safety education to community health workers and VHVs	Establish teams to provide occupational health services Team workers and VHVs trained to be academic moderators, on human behavior and ways to empower people to change their health behaviors, on work-related illness, musculoskeletal disorders and appropriate work posture, respiratory diseases, agricultural chemical toxicity and work and safety issues VHVs trained to provide specific health education relevant to informal sector worker groups as follows: mortar production workers, cotton weavers, knitting and sewing dressmakers, sugarcane farmers and monkey apple farmers	About 14–16 team workers were responsible for care of the informal sector workers in each setting Community team workers and health personnel easily learned about the topics. VHVs had difficulty in learning some content. VHVs provided health education for informal workers 3–4 times per month but most lacked confidence to provide health education as planned. Some informal sector workers did not welcome or value the VHVs
Workers had poor knowledge about work and safety issues	To provide education about work and safety to the workers	The VHVs began providing health information relevant to each group.	Some workers learned more easily than others. Initial worker mistrust of VHVs capacity and role
Non-specific health-care for work-related illness. No symptom investigation for work-related causes or issues	To teach health personnel about work-related illness and health and safety	Health personnel began investigating work-related health issues of informal sector workers and specifically noting this in case records	Health personnel learned to investigate and provide care for basic work-related illness, e.g. investigate about musculo-skeletal pain from poor work posture, and provide health education on exercise and posture

A survey questionnaire was used to investigate the informal workers’ health needs and work safety risks. Trained VHVs carried out survey interviews with all informal workers and results confirmed a variety of work-related health problems; musculoskeletal pain 46.7%, dermatitis from agricultural chemicals 56.3%, and 20% with respiratory effects from dust. The workers also had risky work behaviors, e.g. poor posture 79.2%, and prolonged hours per day 79.2%. Seventy percent used chemical pesticides, and 71.9% used them without appropriate protective clothing and equipment. Almost 36% never read product directions before using chemicals.

After the survey had been carried out and informal worker feedback obtained on the initial draft action plans, revisions were made and final action plans were decided on. Table 2 presents additional action plan details, including importance of adjusting VHV time availability to suit informal workers’ daily schedules and need for educational materials.

Table 2.

Needs, corresponding action plans, implementation, and findings.

Needs	Corresponding action plans	Implementation	Findings
VHVs lack of knowledge on worker health and safety and own lack of confidence as community educators	To increase VHVs’ knowledge and self-confidence	Team members especially health personnel trained VHVs how to change workers’ behavior. They also made 2–3 supervision visits with VHVs when they visited the workers at their homes VHVs read and reread researcher provided training materials to increase their knowledge. VHVs visited workers in their homes in pairs to improve their confidence	Most VHVs learned how to change human behavior VHVs confidence providing work and safety health education increased
Informal sector workers skepticism about VHVs’ capacity and role	To increase the informal sector workers’ trust and confidence in VHVs	Community health personnel guaranteed VHVs health education skills and knowledge. Community leaders joined with VHVs on visits to workers’ homes to confirm VHVs had knowledge and training about work and safety	Informal sector workers revalued their relationships with VHVs and came to welcome them into their houses
		Leaders also supported VHVs’ activities over village public broadcasting tower. VHVs demonstrated their knowledge and training about work and safety on home visits
Mismatch between workers’ availability and VHVs regular work schedules	To develop more flexible work and time management strategies	VHVs met to discuss mismatch in time availabilities. VHVs re-arranged visit schedules to suit VHV and worker schedules. They sometimes met in the evenings or during day at the work site, e.g. fields, gardens	VHVs visit schedules much more successful for providing work and safety education to the workers
Require education materials on work and safety designed for literacy level of informal workers	To produce informative handbook about work and safety designed for informal sector workers	Researchers produce education materials relevant to workers health and safety needs and their educational levels. VHVs distribute education materials during home visits to workers	Most workers made large improvements in work and safety knowledge. Workers also increased appropriate work-related self-care behavior

A series of five occupational health education booklets and a supplementary video were then prepared in Thai to assist training with VHVs. One VHV reflected several worker’s concerns about their literacy levels; “We have low education and cannot remember all about the work and safety. Could you (researchers) please make a handbook which does not use technical terms and has a lot of pictures for us.”

The booklets covered musculo-skeletal problems, strategies for reducing work-place posture risks, use of protective clothing and equipment in dusty settings, proper use and protective methods when using agricultural chemicals, identifying accident risks, and so on. They were used as teaching aids for VHV training groups and also for education of, and distribution to, informal workers.

Phase three: empowering to take action

Community nurses and VHVs worked closely in training sessions using the occupational health and preventive education booklets to improve their work-related health knowledge and capacity. From the training also came an increasing sense of ownership of the action plans and empowerment for implementing them. One community leader said, “I am proud that this was team work and VHVs were able to set action plans.”

Community nurses and VHVs changed the way they responded to presenting complaints. They actively moved to a more holistic “symptom in context” model, e.g. investigating presenting musculoskeletal symptoms for any work-related aspects and similarly considering the potential role of acute agricultural chemical allergy/toxicity in other cases. One community nurse’s positive comments reflected the views of the bulk of her colleagues, “I now investigated work related illness when the workers were ill. I had never done it before. This was good because I now knew the cause of their illness and was able to provide proper suggestions.”

Health education and preventive support activities began with a one-month trial of VHVs visiting informal sector workers at their homes three to four times a month. Initially, VHVs lacked confidence in their own abilities to be educators. As recounted by a VHV:

To tell you (researchers) the truth, I talked to a community nurse that I wanted to stop joining this project since I found that I lack confidence to provide health education for the workers… but I thought that this was my responsibility and it has benefit for the workers. So I decided to join the project.

Although providing health education for people in the community was part of the VHVs responsibilities, the mismatch between health center regular duty hours and free time of many informal sector workers made this problematic. VHVs adapted by home-visiting outside regular work hours, in evenings and on worker’s days off, initially to discuss the proposed action plans, and, as the project progressed, for health education support.

As the initial implementation phase got underway, the VHVs discussed problems they had found and made revisions to the action plans. For example, instead of visiting the workers alone, they paired up for home visits for support and to consult each other on the spot. Researchers retrained the teams and VHVs and encouraged role playing of health education sessions to improve confidence. Team members, especially community nurses, also visited workers' homes with VHVs to provide supervision feedback to further improve their confidence.

Phase four: evaluating actions taken

There were many changes perceived by stakeholder groups in this project.

Community teams

Although community health personnel had understood, in principle, the importance of community networking and working collaboratively, their prior reality had been different. As action plans were implemented, one community nurse’s comment reflected the common view of others, “In the past I had never joined with community leaders since I had not seen any benefit. But now I learn to work with the leaders since they help us to get with the workers and gain participation. They also help us to advertise our activities to the workers.” Community leaders and SAO staff also praised the new opportunities and benefits from working more collaboratively to help the workers in their communities.

Community nursing personnel also revalued the importance of monitoring VHVs’ work. Several indicated they had never monitored or supervised VHVs work before. “When I train them in the past I just let them do it without evaluating their work or monitoring if they were able to do it or not. When I participated in this project, I really saw benefit of monitoring VHVs’ work.”

Village health volunteers

VHVs had previously provided care for informal sector workers under instructions from community health center staff such as supporting diabetes mellitus patients and providing relevant health education information. They had never been involved in any specific occupational health activities. As the project progressed, they became enthusiastic about their improved occupational health knowledge and especially increased confidence and job motivation. The training had also focused on relationship building with the workers with positive effects.

The VHVs’ confidence grew as their relationships with the workers were transformed. For example, one VHV commented, “Now I have much confidence when I provide information to the monkey apple farmers. At first they did not believe me and said ‘how dare I suggest (to) them?’ But after I provide information about their health problems very often, they now listen to me. They say it matches with their problems.”

Another VHV reiterated the empowering effect of her new work requirements. “At first when I visited, after only five minutes, they asked me do you have any more to say since we have to go to work. Now I visit them for 30 minutes. They listen and ask many questions about my suggestions. I feel confident and very proud of myself.”

Some VHVs adapted their schedules to visit workers’ homes in the evening, or night, when workers had free time. One VHV said “I rode my motorcycle around their houses every day and kept an eye when they were available. If they were busy, I would go home, but if they were available, I provided knowledge for them.”

Another VHV mentioned persistence in overcoming her work doubts, “At the start I was scared about providing knowledge for the workers in this project. But it really made me learn about patience… At first, I visited them and they did not welcome me and said that they did not have free time to talk. But I kept doing it continuously. They later turned to listen and admitted that my suggestion was very important to them and now welcome me.”

Finally, VHVs learned to empower informal sector workers themselves to prevent work-related illness. They used a variety of methods to encourage the workers’ learning. For example, they encouraged family members’ support for the workers and also used critical questioning to develop workers’ self-reflective learning. One VHV said: “When I visited them at their homes, I listened to them. I convinced them to think about their health, as, if they were ill, could they still work and earn money for their family members?”

Another VHV reflected, “I talk to stone mortar workers (crushing rocks to produce mortar and pestles) that VHVs were concerned about their health and gave their time (as volunteers) for the best interests of the workers. And ask them what do you think you can do for yourselves?”

Informal sector workers

Many workers responded positively as the project progressed and became much more concerned about their health and altered their work practices. For example, at follow-up survey with all workers (10 months post-project), those reporting working with appropriate posture had increased from 16.7% to 82.5%. Those using face masks to prevent dust exposure rose from 52.5% to 91.3%. Again, those reading agricultural chemical instructions before use rose from 71.9% to 96.9 %, although many still did not read them carefully, or fully understand the safety steps and dilution instructions.

From observations and discussion with the workers, unsafe storage of diluted pesticides, e.g. in soft drink bottles, had ceased as the workers realized the dangers of children and others mistakenly drinking from them. Greater understanding of severe health effects of chemical exposure also led to elimination of practices like blowing directly into the spray head to clean the filter with consequent spray blow-back over hands, face, and neck.

Some workers did not welcome VHVs visits initially, as they felt VHVs were lay people like themselves so did not have any more work and safety knowledge than they did. One VHV reported, “The monkey apple farmers did not trust me… they perceived that I had never planted monkey apple so how could I know about their work illness.” This mistrust was eventually alleviated, as one worker attested “In the past, I wanted to finish my work quickly. I lifted things heavier than 25 kilograms. After work, in the evenings I always had low back pain. After VHVs provided information to me about work and safety, now, I do not lift heavy things. I divide things up before I lift. The VHVs told us if we work properly, we will work until we become old.”

Discussion

This research investigated the potential for enhancing work-related primary care services for informal sector workers through engaging community stakeholders, including the workers themselves, in the action research process. Changes were evident at community team level, with improved networking, and improved community nurses’ clinical care for the workers and their supervision and monitoring of VHVs work in the community. VHVs were enabled to provide work-related illness prevention and health promotion support for the informal workers in their home and work settings congruent with their lifestyles and culture. Not only did VHVs increase knowledge and skill capacity, but there were major changes in work motivation and spiritual commitment to this new area of work for them, best exemplified by the poignant comment by one VHV: “I was not a sugarcane farmer, but I wanted to provide information for them with the hope the farmers would eventually die from aging and with dignity, rather than die with respiratory problems due to work or agricultural chemical toxicity.”

Informal workers’ awareness of health and safety risks and work practice changes and self-care clearly improved. For example, they stopped storing chemical pesticides in coke bottles and changed towards more appropriate working postures. Notably, informal workers also changed their views about VHVs’ competence. After initial skepticism, they became increasingly positive as they realized the health benefits of following the VHVs advice, e.g. reduced back pain from improved work posture. The workers revaluing of the VHVs role acted synergistically to bolster the VHVs’ own work self-confidence and commitment.

These findings are different from other studies TBOED (2010) whose “top-down” focus was on health personnel and VHVs in routine health services work. Our study focused on community collaboration to ensure health practice changes that dovetailed with the workers daily lifestyle and working routines.

A transformative action research process of trust and confidence building began with the researchers’ careful relationship building with community teams at the project’s outset. Although community nurses and health personnel working with VHVs had previously worked together, they had never engaged local political and community leaders and workers in their discussions. Engaging with this leadership allowed community health priorities to emerge and the community teams’ realization of the paucity of health services for informal workers. This facilitation of free self-reflective dialogue within participants’ own communities to learn about their situations and difficulties reflected Freire’s (1974) concept of critical thinking through dialogue. The ensuing shared awareness drove collaborative planning to develop action plans to address these issues. Collaborative implementation of the action plans built belief in their own efforts and self-confidence and increasing sense of ownership and empowerment (Honey, 1999; Minkler, 1990). They were able to overcome obstacles, going well beyond development of group consciousness to effective mobilization for practical solutions for their priority health issues (Park, 1999; Reason & Bradbury, 2008; Small, 1995).

In summary, it was clear at the study’s outset that community health expertise for specific work-related health services were very limited, almost non-existent. Action research’s emancipatory tradition made it a very apt approach for bringing all relevant community actors together to develop a shared consciousness and commitment to action to address these concerns. The process allowed co-creation of knowledge and practical strategies for improving health care support for this socially and economically vulnerable group with high work-related health risks and needs.

Conclusion

This action research process brought relevant local community stakeholders together to dialogue, understand situation, plan, and evaluate strategies for addressing priority informal worker health and safety problems. The outcome of our study has important implications for community nursing practice and service delivery systems providing for informal sector workers. Policy makers at national level should consider this approach when considering providing health services for informal sector workers.

Footnotes

Acknowledgements

The authors extend sincere gratitude to all the community participants who contributed to this project. They also wish to thank the Research and Training Center for Enhancing Quality of Life of Working-Age People, Khon Kaen University for providing support facilities to conduct the project. The authors would like to thank Dr. Annabel DSouza Sekar for leading the review process of this article. Should there be any comments/reactions you wish to share, please bring them to the interactive portion (Reader Responses column) of the website: .

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by funding from the Thai Health Promotion Foundation Grant # 53-00-0312-2.

Author biographies

Kessarawan Nilvarangkul is an Associate Professor in the Faculty of Nursing and Director of Research and Training Centre for Enhancing Quality of Life of Working-Age People, Khon Kaen University, Khon Kaen, Thailand. She has academic interests in community health nursing and occupational health and safety, and extensive action research and community development experience particularly with marginalized rural informal sector workers.

Sara Arphorn is an Associate Professor in the Department of Occupational Health and Safety, Faculty of Public Health, Mahidol University, Bangkok, Thailand. She has specialist interests in occupational toxicology, occupational safety and health, ergonomics, participatory action oriented training and extensive research and support network building experience within the Thai informal workforce sector.

John F Smith is an Associate Professor in the Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. He has academic interests in community/public health, health policy and medical and health workforce capacity building, mainly in S-E Asia.

Teerasak Phajan is a lecturer at Sirindhorn College of Public Health, Khon Kaen, Thailand with academic interests in community health research, public health administration and statistics and research methodologies.

Nusaraporn Kessomboon is Associate Professor of Social and Administrative Pharmacy at the Faculty of Pharmaceutical Sciences, Khon Kaen University. She has been principal investigator and co-investigator of several research projects related to drug system and policy, health impact assessment and international trade and health.

Kesorn Thawenonngiew is a senior public health technical officer in the Khon Kaen Provincial Office of Disease Prevention and Control, Thailand. She has extensive epidemiology and community nursing practice and research experience especially related to surveillance and detection of infectious disease and health system outbreak responses in the North East Thailand region.

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