**1. Introduction**

As of 2019, the estimated number of migrants internationally amounted to 272 million, equivalent to about 3.5% of the world's population [1]. In 2019, there were 79.5 million forcedly displaced people around the world. Among these, 26 million were refugees, and 3.5 million were asylum seekers [2]. The volume of refugees worldwide has greatly increased from 10 million to 26 million in the last decade. Approximately 68% of refugees globally originated from five countries, including Afghanistan, Myanmar, South Sudan, Syria, and Venezuela. The major refugee crises that contributed to massive displacement of people were the exodus of the Rohingya people from Myanmar to Bangladesh and the conflict in Arab countries that caused the unprecedented outflow of refugees from countries including Syria, Iraq, and Libya into Europe [2].

Refugees and asylum seekers usually face many health threats, including infectious diseases, non-communicable diseases, and mental health [3]. For infectious diseases, refugee and asylum seekers are likely to be more vulnerable to serious outbreak because of poor living conditions, poor sanitization, and lack of access to healthcare [4–7]. Kondilis et al. demonstrated that, during the coronavirus disease 2019 (COVID-19) pandemic, refugees and asylum seekers in Greece faced numerous events of outbreaks. The

**Citation:** Julchoo, S.; Phaiyarom, M.; Sinam, P.; Kunpeuk, W.; Pudpong, N.; Suphanchaimat, R. Analysis of Policies to Protect the Health of Urban Refugees and Asylum Seekers in Thailand: A Qualitative Study and Delphi Survey. *Int. J. Environ. Res. Public Health* **2021**, *18*, 10566. https://doi.org/10.3390/ ijerph182010566

Academic Editor: Kevin Pottie

Received: 8 July 2021 Accepted: 6 October 2021 Published: 9 October 2021

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overall 9-month incidence of COVID-19 amongst refugees and asylum seekers in Greece was relatively high (about 2000 cases per 100,000 population) [8].

Thailand is among the most common destination for cross-border migration in Southeast Asia. The majority of migrants in Thailand came from its neighboring countries, namely, Cambodia, Lao PDR, Myanmar, and Vietnam (so-called CLMV nations). At present, there are more than 3 million migrants living in Thailand [9].

In addition, Thailand is also a residence for refugees and asylum seekers [10]. The country has hosted refugees along the Thai–Myanmar border for more than four decades. During the 1980s and 1990s, Thailand faced a huge influx of refugees from Myanmar because of the conflict between ethnic groups and the Myanmar government. To date, there are nine temporary shelters for almost 100,000 refugees [10]. Apart from sheltering refugees along the border, Thailand is a host country for urban refugees and asylum seekers (URAS). The majority of URAS live in the capital city, Bangkok, approximately 5000. The well-being of sheltered refugees shows tangible advancement as it is relatively straightforward to implement a policy in a well-defined geographical space. The United Nations High Commissioner for Refugees (UNHCR) and international non-governmental organizations (NGOs), such as Médecins Sans Frontières and the International Rescue Committee, provide additional humanitarian assistance in the shelters. In contrast, the health of URAS in Thailand has not been widely discussed in most policy dialogues [11]. In addition, almost all URAS live scattered across the city, creating difficulty in identifying a main responsible agency to take a pivotal role to protect the health of URAS at the utmost. A greater understanding about necessary health policies that support the health of URAS has important public health implications as URAS are necessarily involved with Thailand's quest to achieve universal health coverage (UHC). The Thai government has set a clear direction for UHC where 'all people' on Thai soil must have their health protected. This is stipulated in many policy documents such as the Border Health Plan of the Ministry of Public Health (MOPH) (2017-2521) [12] and Strategies for National Health Insurance Development of the National Health Security Office (2017-2521) [13].

Therefore, the main objective of this study was to explore views of stakeholders engaged with policies that are related to or have influenced the health and well-being of URAS in Thailand. We also investigated the views of URAS themselves to complement the stakeholders' perspectives.

#### **2. Methods**

#### *2.1. Study Design and Setting*

This study employed a mixed-methods approach, comprising both qualitative and quantitative data collection, and focusing on URAS in Greater Bangkok only (*N*~5000).

#### *2.2. Data Collection Methods*

For the qualitative strand, we used in-depth interviews. Prior to and right after the fieldwork, we arranged a meeting among the team members to finetune the understanding on the interview topics and data from the interviewees. Each interview took approximately 45–60 minutes per informant. For Thai interviewees, the interviews either took place face-to-face in the workplace of the informant, or, during a telephone interview, in a private room. For URAS informants, we used face to face interview at the office of Bangkok Refugee Center (BRC). BRC is the main NGO under the patronage of UNHCR. The main function of the BRC is to provide legal support and counselling for URAS. The BRC staff also assisted the research team to recruit URAS who could serve as the informant for the study. However, the BRC staff did not present themselves during the interview with URAS. Only the researchers and URAS informants presented during the interview in BRC private room. A purposive sampling was used to identify key informants and additional informants were identified by snowball selection. The sampling of Thai informants focused on those who had been involved in the policies for URAS or had ever dealt with the research on URAS.

The interviews were audio-recorded and transcribed verbatim, with consent from the interviewees. Key information from the interviews was used to guide the Delphi survey's questions. The total number of 37 interviewees consisted of nine representatives from NGOs with work experience on URAS, five representatives from the MOPH, five independent academics, four healthcare providers in public health facilities where URAS usually visited, four policymakers from the National Health Security Office (NHSO), Ministry of Labor (MOL), Ministry of Foreign Affairs (MFA), and Ministry of Interior (MOI), three representatives from international development agencies, and seven URAS from six nationalities (Afghani, Iraqi, Pakistani, Somali, Sri Lankan, and Vietnamese), Table 1.

**Table 1.** Characteristics of key informants' interviews.


For the quantitative strand, a Delphi survey was exercised. We invited the informants from the prior in-depth interviews to take part in the Delphi survey. However, only thirteen informants agreed to participate (four NGO staff, three policymakers, two representatives from international development agencies, one academic, and one healthcare provider). The survey began by circulating the questionnaire via an electronic mail to these thirteen participants. We then collected their responses and sent the questionnaire back to them for another two rounds. In the later rounds, the participants were able to view the group's responses. Two participants dropped out in the later rounds. This meant, finally, eleven participants completed the three-round survey. Once the survey was completed, we then re-interviewed or had an informal discussion with some interviewees to triangulate the survey results against the survey responses (and vice versa) and to assess if any additional themes would emerge. The data were collected in the office computer with password protection. Only the principal investigator could access the interview data. The linkage between the interview and the Delphi survey is visualized in Figure 1.
