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Health-seeking behaviour of male foreign migrant workers living in a dormitory in Singapore
© Lee et al.; licensee BioMed Central Ltd. 2014
Received: 5 June 2014
Accepted: 27 June 2014
Published: 10 July 2014
Foreign workers’ migrant status may hinder their utilisation of health services. This study describes the health-seeking behaviour and beliefs of a group of male migrant workers in Singapore and the barriers limiting their access to primary healthcare.
A cross-sectional study of 525 male migrant workers, ≥21 years old and of Indian, Bangladeshi or Myanmar nationality, was conducted at a dormitory via self-administered questionnaires covering demographics, prevalence of medical conditions and health-seeking behaviours through hypothetical scenarios and personal experience.
71% (95%CI: 67 to 75%) of participants did not have or were not aware if they had healthcare insurance. 53% (95%CI: 48 to 57%) reported ever having had an illness episode while in Singapore, of whom 87% (95%CI: 82 to 91%) saw a doctor. The number of rest days was significantly associated with higher probability of having consulted a doctor for their last illness episode (p = 0.026), and higher basic monthly salary was associated with seeing a doctor within 3 days of illness (p = 0.002). Of those who saw a doctor, 84% (95%CI: 79 to 89%) responded that they did so because they felt medical care would help them to work better. While 55% (95%CI: 36 to 73%) said they did not see a doctor because the illness was not serious, those with lower salaries were significantly more likely to cite inadequate finances (55% of those earning < S$500/month). In hypothetical injury or illness scenarios, most responded that they would see the doctor, but a sizeable proportion (15% 95%CI: 12 to 18%) said they would continue to work even in a work-related injury scenario that caused severe pain and functional impairment. Those with lower salaries were significantly more likely to believe they would have to pay for their own healthcare or be uncertain about who would pay.
The majority of foreign workers in this study sought healthcare when they fell ill. However, knowledge about health-related insurance was poor and a sizeable minority, in particular those earning < S$500 per month, may face significant issues in accessing care.
International movement of migrant labour is an increasing global phenomenon, with approximately half of about 175 million migrants around the world being migrant workers . In Southeast Asia, Singapore is a major receiving country for migrant labour. As of December 2010, there were an estimated 1,113,200 migrant workers (35% of Singapore’s workforce) in Singapore. Of these, 685,400 were semi-skilled or unskilled workers, including 293,400 in construction  and 131,000 in the shipyard sector,  and come largely from South East Asia (Malaysia, Thailand, Indonesia, the Philippines and Myanmar), South Asia (India and Bangladesh) and China [4, 5].
The increasing number of migrant workers in high risk occupations in Singapore,  and their long working hours may elevate the risk of occupational accidents . They are also at risk from occupational skin and lung diseases, and work-related musculoskeletal disorders. Additionally, outbreaks of infectious diseases such as typhus, dengue and pneumonia have been documented, possibly due to the high-density living conditions and occasionally less than satisfactory sanitary living conditions [8–10]. The high risk of health related problems may be compounded by issues with adequate and timely access to healthcare, particular in lower income workers. While Singapore has a highly accessible primary care network, migrant workers in Singapore were no longer eligible for government subsidized medical care since 2007,  and fees at private sector primary care clinics range from S$18 to S$50 per consult (S$1 = 0.8 US dollars as of May 2014), which may be costly to some migrant workers.
Singapore’s Employment of Foreign Manpower Act (Chapter 91A) does mandate employers to procure medical insurance for the foreign employee’s medical expenses, with coverage of at least $15,000 per 12-month period of the foreign employee’s employment . The Work Injury Compensation Act (WICA) provides injured employees with a means to claim compensation for injuries sustained during work; the worker only has to prove that he suffered an accident or incurred any diseases due to work for the employer . However, there have been media reports of instances where medical treatment and sick leave have not been commensurate with the severity of workplace accidents,  and anecdotal accounts of workers not wanting to report sick due to fear of losing a day’s pay for missing work or even of being laid off if they take too many sick days . However, it is unclear how widespread such issues may be, whether migrant workers are sufficiently aware of their rights to medical care and compensation, and how this might or might not affect their health-seeking behaviour.
Other research has documented utilization patterns of migrant workers at the emergency department, [16–18] but there is a dearth of information on their health-seeking behaviour, and what factors may predispose to inadequate or delayed access to healthcare in Singapore. In collaboration with a non-governmental organisation (NGO), HealthServe, which has outreach activities in a large dormitory for migrant workers and an offsite clinic nearby, we conducted a cross-sectional survey to ascertain health-seeking behaviour, describe reasons for and possible barriers to seeking care, as well as identify any potential vulnerable groups within this population of migrant workers.
Research site and study population
The research was conducted at an all-male dormitory for migrant workers in Jurong, Singapore, near a major industrial area. The dormitory housed approximately 7000 migrant workers from shipyard and construction industries under various companies, and had residents of several nationalities with a significant representation in the migrant work force in Singapore, including mainly Indians (45%) and Bangladeshis (35%), and a significant number of Myanmars (10%).
Selection of participants and data collection
We first observed the dormitory on 2 weekday evenings to establish patterns of human traffic, and identify key sites and timeframes to conduct the survey. The gantry point where all the residents pass through when entering and leaving the dormitory was identified as the ideal location for recruitment of survey participants. We observed that, from 5 pm to 10 pm, 5334 out of the estimated 7000 residents (76%) returned from work, with the peak flow (2257 (32%)) occurring from 7 to 8 pm. About 60% returned between 7 pm to 10 pm, which were the opening hours of the function room made available to us by our NGO partner HealthServe for conducting our survey.
We then conducted the survey over 3 weekday evenings. We systematically approached one in ten men as they were about to enter the dormitory gantry to invite them to participate, with inclusion criteria being: male; 21 years old and above; Non-Singaporean and non-permanent resident; having a valid work permit for 3 months or more; being of Indian, Bangladeshi and Myanmar ethnicity; and being able to understand English, Bangladeshi, Myanmar, Hindi, Tamil, or Telugu. Verbal consent was obtained and those who agreed undertook the survey in a quiet room. Small tokens of appreciation (biscuits and drinks) were handed out to those who completed the questionnaire. No identification was taken, but participants who reported that they had already taken part once were excluded to prevent repeat participation.
Questionnaire design, translation and administration
Insights from a qualitative research study involving in-depth interviews with 16 migrant workers from the same dormitory  were used to aid the design of a questionnaire comprising three major sections. The first covered personal and socio-demographical information like age, nationality, marital status, education, salary and working conditions. Another section covered previous health-seeking experience based on participants’ response to a previous illness or injury, and their reasons for and against seeking medical attention. A final section covered how they would respond to four hypothetical illness or injury scenarios: (A) an upper respiratory tract infection (URTI), (B) an URTI lasting three days and complicated by high fever (38°C), (C) a worksite injury to the foot with some pain but no functional impairment, and (D) the same worksite injury but with pain so severe as to cause functional impairment. The self-administered questionnaire was translated into Bangladeshi, Myanmar, English, Hindi, Tamil, and Telugu, reflecting the linguistic backgrounds of our study population, with accuracy of translation verified through back-translation to English. Facilitators underwent half a day of training on questionnaire administration, and were assisted by volunteer translators from amongst the workers at the survey site to answer participants’ queries.
Sample size calculation and statistical analysis
We calculated our target sample size of 500 to give confidence intervals within ±5% of an estimate on the proportion who seek healthcare, which was assumed to lie between 30% to 90% for a given scenario or condition. Chi-squared tests were used when comparing differences in health-seeking behaviour by various socio-demographic factors, with a p-value of less than 0.05 indicating a statistically significant result. We also evaluated predictors of inadequate or delayed access to healthcare for two outcomes of interest – seeing a doctor, and seeing a doctor within 3 days during their most recent illness episode. Odd ratios (ORs) from multivariate logistic regression incorporating all variables significant at a level of p < 0.10 on univariate analysis are also presented. Analyses were performed using Stata for Windows, version 11 (Stata Corporation, College Station, Texas, USA).
The study was approved on 22/1/2013 by the ethics review board of the National University of Singapore (IRB reference 12-503).
Socio-demographics and healthcare insurance characteristics of participants (N = 525)
Characteristic (No. of valid responses)
Language used in survey (N = 525)
Age in years (N = 525)
21 to 29
30 to 39
40 and above
Nationality (N = 525)
Marital status (N = 521)
No. of people supported (N = 505)
3 or less
4 to 6
7 or more
Industry (N = 518)
Highest education (N = 523)
Primary or less
Basic monthly salary (N = 520)
S$499 or less
$500 to $999
$1,000 or more
Average working hrs/wk (N = 516)
Less than 45 hours
45 to 65 hours
More than 65 hours
No. of rest days/mth (N = 517)
2 days or less
3 to 4 days
5 or more days
Duration in Singapore (N = 516)
2 years or less
3 to 4 years
5 or more years
Healthcare insurance plan (N = 525)
Do not know
Association between selected factors and seeking medical care, and seeking medical care within 3 days based on valid responses to most recent illness episode while working in Singapore
No. who fell sick
No. who saw a doctor (%*)
No. who saw a doctor within 3 days (%*)
Age in years
21 to 29
30 to 39
40 and above
No. of people supported
3 or less
4 to 6
7 or more
Primary or less
Basic monthly salary
S$499 or less
$500 to $999
$1,000 or more
Average working hrs/wk
Less than 45 hours
45 to 65 hours
More than 65 hours
No. of rest days/mth
2 days or less
3 to 4 days
5 or more days
Duration in Singapore
2 years or less
3 to 4 years
5 or more years
Healthcare insurance plan
Do not know
Type of symptoms
Body aches/joint pains
Severity of symptoms
Not serious at all
A little serious
While there have been hospital-based studies describing patterns of health-services utilisation by migrant workers [16, 18], this is the first attempt to document health-seeking behaviour in this often neglected population outside of the healthcare setting in Singapore. While utilisation of health services by this migrant population was relatively high, we noted potentially vulnerable groups which may either delay or avoid accessing medical care altogether. Lower income workers, in particular, also had financial concerns about affordability of care, and had the least confidence that their company would be responsible for their medical expenses.
In our study population, the proportion which saw a doctor was consistently high for all conditions and symptoms including injuries, musculoskeletal symptoms, skin problems, febrile illness and respiratory symptoms. The consistently high access to care may have been supported by an onsite private sector clinic within the dormitory compound and a volunteer-run clinic by our NGO partner which was within 15 minutes walking distance. In contrast, a study in Songkhla province, Thailand, found that the proportion who sought care varied widely by type of symptoms, with health-seeking for respiratory symptoms being particularly low (less than 3% of the workers surveyed) . In that study, the perception that symptoms were not serious was cited as a major reason for not seeking medical care . Incidentally, our study also found "illness not serious" as the most important factor for not seeing a doctor (Figure 2B), although there was no association between severity of symptoms and seeking medical care. The overall proportion which saw a doctor for their most recent illness (87%) also compares favourably with a similar study in Beijing where only 36% did so. However, it must be noted that the study in Beijing referred to illnesses in East Asian migrants over a two week period , and the health-seeking behaviour of that population and the predominantly South Asian population of our study may be very different. Authors from that study suggest their findings could be attributed to low levels of healthcare insurance and the healthcare policy in China, where migrants from rural communities are classified as temporary residents while in the city, leading to difficulties in accessing care. In our case, although less than a third reported knowing that they had a healthcare insurance plan, 38 to 46% expect their company to pay across the various scenarios in Figure 3. While substantially better than the situation described in Beijing where 94% of the workers denied having healthcare insurance, Singapore’s Employment of Foreign Manpower Act (Chapter 91A) actually mandates that all such expenses be borne by the employer for all foreign workers . As such, there is clearly a gap between the law and either what is practiced or the worker’s knowledge of their entitlement.
Like the other two studies, [20, 21] we identified some potentially vulnerable groups. The study from Thailand demonstrated how undocumented workers were far less likely to seek care. Our study, which only included documented workers, found that the only independent predictor of not seeing a doctor was having less rest days per month. However, we did find that lower income was significantly associated with delayed access to care (i.e. not seeing a doctor within 3 days, or not at all); notably, lower monthly per capita household income was also identified as a risk factor for poorer access in the study from Beijing . Furthermore, we showed that in those who did not see a doctor, lower income participants were much more likely to cite financial concerns, and also that such participants were much less likely to notify their supervisors of their condition, and more likely to believe they were responsible for their own healthcare costs in our hypothetical illness/injury scenarios. Moreover, a substantial minority would not notify their supervisor of a serious work-related injury (17%), and not see a doctor despite running a high fever with prolonged respiratory symptoms (12%). Therefore, while financial concerns may not be a barrier to eventual access to healthcare in most of those surveyed, it may be affecting timely access, which would exacerbate conditions like pneumonia and make them harder to treat. In addition, the reluctance to notify supervisors, particularly in lower income workers, may reflect possible communication issues between supervisors and workers that could compromise work-site safety.In terms of policy implications, the most commonly cited reasons for seeking care were the need to "take care of themselves" and to "help them do their work better" (Figure 2A). We believe this suggests most migrant workers would be motivated to seek care when required, as well as adopt other practices important for their health and safety. What is therefore important is to sufficiently educate them on the issues identified, including their entitlement to medical care paid for by their employers, and situations which warrant timely medical attention. The Ministry of Manpower has in recent years included an educational programme highlighting to incoming migrant workers some of their rights alongside key messages on work safety, and what could be done would be to emphasize some of the above points, as well as focus on the vulnerable groups, in particular lower income workers. In addition, these programmes may have to be supplemented by working with large private sector healthcare chains which service migrant workers, peer educators, and access to a course for redress in the event they are treated unfairly, such as designated hotlines for counselling and advocacy services like those provided through our NGO partner HealthServe, or through government channels by the Ministry of Manpower, with provisions made for those only conversant in their native languages.
Our work has several limitations. The survey was restricted to only one dormitory which housed only documented male migrant workers due to the logistical difficulties of accessing migrant workers without prior outreach work, which in this case had been done by our NGO partner. Workers in this dormitory were primarily of three nationalities, and predominantly from the shipyard industry, which would affect the generalisability of our findings. Prior work by our NGO partner may also have made this group more knowledgeable or even improved health seeking behaviour in these migrant workers. Notably, the Ministry of Manpower lists about 30 such migrant worker dormitories around Singapore, and there are also migrant workers not housed in dormitories, and undocumented workers which are difficult to access due to their illegal status. A more detailed study involving a wider range of living quarters, nationalities and industries is hence needed. We also acknowledge that our study suffered from possible biases from a high non-response rate. Better response rates would require alternative recruitment strategies, such as going room-to-room to perform surveys or working through employers. Finally, we were unable to assess migrant workers’ perceptions of healthcare services given the wide diversity of private, government and NGO options which might be accessed by these workers.
In conclusion, while the majority of the workers we surveyed were able to access care, we identified possible delays in access in a vulnerable group of lower income workers, inadequate knowledge about healthcare insurance plans, and the presence of a sizeable minority who would not seek care when presented with potentially serious health problems. While more representative studies are needed, these are important insights amenable to improvements through appropriate agencies working to provide better education and access to information among migrant workers.
Acknowledgements and funding
The authors wish to acknowledge all members of the 2012/2013 Community Health Project Group 7 of NUS Yong Loo Lin School of Medicine for their contribution to making this study possible. The authors also would like to extend their gratitude to the staff of HealthServe for their advice and experience. We also thank Ms Ng Pei Yi for editorial support in revising the manuscript. Finally, the authors would like to express heartfelt thanks to all foreign migrant workers for their kind and patient participation during visits to their dormitory. The Dean’s office of the Yong Loo Lin School of Medicine at National University of Singapore is gratefully acknowledged for their funding and support. The funding organisation had no role in the design, conduct, analysis and interpretation or preparation of the report of this study.
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