Maternal and child health (MCH) is crucial to the well-being of mothers and children. Stigma regarding access to MCH services is a major challenge, especially for hill tribe people in Thailand. The study aimed to understand the components of stigma and its impact on MCH service and outcomes including experiences and expectations to address the stigma in perspective of Akha hill tribe women in Thailand.
A phenomenological qualitative approach was used to gather information from Akha women who had attended MCH service one year prior and had an experience with stigma. A validated question guide was used in the study. The interview was conducted in private and confidential rooms in the Akha hill tribe villages between June and September 2021. A thematic analysis was used to extract the major and minor themes and develop the findings.
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In Thailand, MCH services are provided to all reproductive groups and children, including those who do not hold Thai identification (ID) cards, which are used for access to all public services [19]. Commonly, all health institutes provide an MCH service every Tuesday, including a small, so-called health-promoting hospital located in the hill tribe villages [20]. At the health-promoting hospital, pregnant women are cared for under the guidelines of the Thai Ministry of Public Health, including an assessment of general health and detection of potential risks [21]. However, one study in Chiang Rai, Thailand, reported that only 7.1% received three doses of tetanus toxoid during pregnancy, and less than 50% of pregnant hill tribe women accessed MCH services properly [22].Moreover, 64.3% of Akha pregnant women gave birth at home by untrained midwives, and only 30% of Akha children received vaccines based on Thailand expanded program on immunization (EPI) program [23].
The presence of stigma when attending a clinic exerts the greatest impact on certain populations with specific characteristics [24,25,26]. The hill tribe people in Thailand have moved down from South China over several centuries [27]. There are six main tribes: Akah, Lahu, Hmong, Yao, Karen, and Lisu [27]. Akha people comprise the largest group, with their own culture, lifestyle, and language [27] which is different from Thai people [28]. Most Akha in Thailand live under the national poverty line [29] and have poor education [24]. Inaddition, Akha people are very limited in their use of the Thai language [30]. While all health caregivers are Thai then it is difficult to Akha people to access the services [31].
The study aimed to understand the components of stigma and its impact on MCH service and outcomes including experience and expectation to address the stigma in perspective of Akha hill tribe women in Thailand.
A phenomenological qualitative approach [34] was used to elicit information from participants who were Akha hill tribe women living in seven hill tribe villages located along the Thailand-Myanmar border who experienced stigma while accessing MCH services. Akha women who were pregnant or had delivered their child one year prior to data collection and had accessed an MCH service at least once were invited to participate in the study.
The questions were developed from a review of the literature, information obtained from health care providers who worked in the hill tribe villages, and from some pregnant women who had experienced stigma while attending an MCH service. The validity and reliability of the questions were tested before use in the field. Three external experts who were public health professional, medical anthropologist, and nurse working at MCH services were invited to validate the question information and the research context and content. The objective of the validity test was to confirm that the contents of the questions covered the context required in the study. The questions were piloted among six postdelivery women who lived in two hill tribe villages in Mae Chan District, Chiang Rai Province, Thailand. The main objective of the pilot test was to ensure that both the researchers and participants understood the same meaning and sense of the questions provided. Ultimately, seven questions were finalized for use in the study: (1) Which hospital did you attend for MCH services? (2) Did you experience any discomfort or stigma when attending MCH services? (3) Can you provide information in terms of frequency, who displayed stigmatizing behaviors, and in what form? (4) How did you feel about this experience? (5) How did you respond to these behaviors? (6) What is your expectation about accessing MCH services? (7) Did you experience other barriers to accessing MCH services?
Village headmen were informed about the study and asked to select participants five days in advance according to the inclusion criteria. The participants were purposively selected from seven hill tribe villages. Hill tribe women who were postdelivery one year prior who had experienced stigma when attending an MCH clinic and who able to use Thai met the inclusion criteria. Women who met the criteria were informed by the village headman and asked to participate in the study. At the date of the interview, women who met the criteria and intended to provide information to the researcher were screened again to determine whether they had evidence according to the criteria. Only those who had a strong experience with stigma were invited to an interview. All participants were provided with information about the study and signed written consent forms that stated the voluntary nature of participation. Three researchers who were trained in qualitative methods (one female medical anthropologist (Ph.D.), one female health behavioral scientist (Ph.D.), and one male public health expert (Ph.D.)) and working as university faculty were the interviewers. All interviewers were women who were familiar from previous projects with the hill tribe people living in these areas.
Being members of Akha hill tribe with specific culture, as presented through their language, clothing, poverty, and name, was identified as a driver of stigma for Akha women attending MCH services. Most Akha women spoke Thai as a second language, which is completely different from their native language, and only a few Akha women could speak Thai fluently. Most Akha hill tribe women were not supported in school during their youth compared to men, and limited Thai fluency was very common. Therefore, language issues were one of the drivers of the stigma that the Akha women encountered when attending MCH services.
When I was waiting for delivery, I saw a hill tribe woman next to me being scolded by a nurse after she screamed because she had great pain from the contractions. I truly felt disappointed with the situation. I understood that being a tribe member could cause trouble in communication with Thai people (nurse). I thought, why did a nurse blame her? The nurse should empathize with us.
A large proportion of Akha hill tribe people live in poor economic situations, which is a major consequence of being poorly educated and having scant access to skilled jobs. The Akha hill tribe women identified not being able to speak Thai, dressing in their traditional clothing, and living in a poor family as major drivers of stigma when attending MCH services. Poverty was a strong image for health care providers and was identified as one of the greatest drivers of stigma among Akha hill tribe women attending MCH services.
Even though some Akha hill tribe women had been educated in Thai schools, were able to speak Thai fluently, and dressed in a modern style, some of them still used their local tribal name, which easily identified them as hill tribe people. Thus, the name provided to health care providers when attending MCH acted as one of the drivers of the stigma encountered by the Akha hill tribe women.
Several manifestations of stigma were identified by the Akha hill tribe women attending MCH services such as verbal abuse, physical abuse, a refusal to provide treatment, and the intentional disclosure of personal information to the public.
Verbal abuse was very commonly reported among the Akha hill tribe women when attending MCH services. The Akha hill tribe women faced improper, unhealthy, and uncaring speech from health care providers.
My bad experience happened when I went to a hospital with my one-month-old daughter. I was waiting for (the doctor), and I sat in the wrong chair. Then, a nurse asked me to move to another place. She used an inappropriate voice with me. I was thinking about why she did not speak to me with many polite words. I realized that it was because I am a hill tribe (member).
Due to the experience of stigma faced by the Akha hill tribe women when attending MCH services, many poor health outcomes were reported, such as poor rates of antenatal and postpartum care, breast cancer screening (21.3%), and cervical cancer screening (47.5%).
The first group of Akha hill tribe women reported that they did not have a better option to access MCH services. Some people reported being provided with poor service but being able to accept the suffering caused by mistreatment. Most impacted Akha hill tribe women accepted their suffering due to the fear of being treated even more poorly the next time.
Some Akha hill tribe women preferred to obtain services from a private hospital. Generally, at a private hospital, most services are provided based on need. The service mindset of health care providers at private hospitals was perceived as much better than that at public hospitals, which could be due to the impacts of policy and organizational advantages.
Regarding their expectations of MCH services, the Akha hill tribe women requested gender-matched providers in MCH services, especially for Papanicolaou test (PAP) smears, breast cancer screening, and postpartum care. Regularly offered services at the village level were an expectation because the distance from the village to the health care setting posed a major barrier to accessing care, particularly in the rainy season. Emergency mobile clinics were another need of Akha pregnant hill tribe women because when close to delivery, they needed to be able to secure timely access to a hospital, and using their everyday motorcycle was not comfortable and safe for them during late pregnancy. Moreover, the Akha hill tribe women expressed the necessity of basic standard medical equipment at small health-promoting hospitals located at the village level. The Akha women often needed to obtain services at a district hospital for many medical procedures during pregnancy. 2ff7e9595c
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