Background
Stigma is defined as one of the major barriers to accessing health care services [
1‐
4]. Moreover, its impact is greater among vulnerable populations [
5,
6]. Maternal health and child care (MCH) is a significant service to people globally to ensure that both mothers and children have good health, including promoting survival during the pregnancy, childbirth and postnatal periods [
7]. In 2017, the World Health Organization (WHO) reported that 295,000 women died during and following pregnancy and childbirth [
8]. The WHO also recommends that in all stages of MCH, care should minimize negative experiences to ensure that women and their infants reach their full potential of health and wellbeing, especially among vulnerable populations [
7]. The major negative experience among pregnant women is stigma [
9]. The stigma that women encounter during their visits to MCH services could minimize the rate of access to MCH [
10,
11]. Several impacts have been reported from the stigma in access to MCH services, such as poor child health [
9] and human immunodeficiency virus (HIV) infection [
12]. Many illnesses related to unable to access MCH are required a large amount of money for the treatment and care, especially in developing countries [
13,
14], including Thailand [
15]. Furthermore, a number of illnesses related to women’s reproductive health can lead to premature death and reduce quality of life [
16‐
18].
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‐
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 stigma present for minority groups when attending health care institutions is well recognized [
32]. In the current study, a health stigma and discrimination framework was used as a guideline for understanding the enacted stigma that exists, which is the form of the stigma perceived by individuals [
33] while accessing MCH services among Akha women [
5]. According to Stangl et al. [
5] concept of stigma, a stigma driver is the factor that drives stigma presentation in a phenomenon, and some factors work to facilitate stigma presentation, while the stigma marker is the original marker for the existing stigma. Understanding the component of stigma present for hill tribe women when access MCH services can be applied for health policy formulation and public health implementation to reduce the stigma. Minimizing the stigma encountered by hill tribe women seeking MCH services could improve their access to all clinical services related to women’s health, including screening for cervical and breast cancer. Reducing the stigma encountered during health care services, especially in an MCH service, will improve both the quality and quantity of the services.
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.
Methods
Study design and setting
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?
Sampling and recruitment
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.
Data collection
Face-to-face interviews were conducted in a private and confidential room at the community hall in each village between June and September 2021. A question guide was used in the interview. Before the interview, the participants were asked for permission to record it and take field notes. The interviews started with the objective of research and general questions about maternal and child health. The specific questions on asking about the experience of stigma while attending MCH services were followed. Each interview lasted for 45 min. All methods were carried out in accordance with the Declaration of Helsinki [
35] in the ethical principles for medical research that involve human subjects.
Data analysis
All records were transcribed and checked before further analysis. The transcript was sent to all participants who were the information owner to check its accuracy before further analysis. The information in the transcripts was coded, and coding trees were developed. The codes were transferred into the NVivo program (NVivo, qualitative data analysis software; QSR International Pty Ltd., version 11, 2015) for theme extraction. A content analysis was used to extract major and minor themes with the inductive method, which usually uses the keywords presented from interviews to construct the themes. The major theme was used to present the form or pattern of the stigma while attending MCH services. The minor theme was focused on the other significant surrounding information, including the experiences in addressing the stigma, and expectations of the participants to further solve the problem. All themes identified were constructed and formed. Significant quotations were presented to support the findings.
Rigor and trustworthiness
Before deciding on final interpretations, the researchers once again sent the information back to the participant who was the information owner to ensure the accuracy of the final findings. Two qualitative research experts in the field were asked to validate the final findings and framework (Fig.
1). The final framework was discussed and validated again with eight local Akha people (five women and three community leaders).
Discussion
The Akha women who were pregnant or had delivered their infant one year prior and had attended MCH services generally had a poor socioeconomic status. They faced many forms of stigma when attending MCH services in the previous year, such as being spoken to impolitely or with hostility, being physically abused, being refused treatment, and having their personal information intentionally disclosed to the public. Several factors were extracted as the drivers and facilitators of such stigma. Being a member of the Akha people was a stigma marker. Poor rates of accessing MCH services and breast and cervical cancer screening were found among the Akha hill tribe women who needed to access these services. Some people accepted the suffering caused by the stigmatizing experience, while others preferred to ask for better care and service, including seeking care at a private health care provider. Most Akha women expected to have gender-matched health care providers, active and mobile emergency clinics, and full, standard medical equipment at hospitals located in their village. They also wanted an active health care service.
In our study, speaking Akha, wearing traditional dress, being poor, and having tribal names were found to be the drivers of stigma for Akha women when accessing MCH services, especially in public hospitals in Thailand. These factors were very specific stigma scenarios among the Akha hill tribe women when accessing public hospitals in Thailand. These drivers are very difficult to address fully because it is often impossible for Akha people aged 25 years and older to be fluent Thai speakers because they have never been to school and are unable to speak Thai [
23]. Changing their traditional dress is also unlikely to be undertaken, since Akha hill tribe women strongly prefer to dress in their own style, which relates to their culture and religion [
36]. Moreover, it is very difficult to improve Akha hill tribe family income in the near future given tribe members’ current education status and their nearly universal lack of training in professional skills [
30].
All health care providers being Thai, knowledge gaps between health care providers and clients, and gender mismatch with the client were found to be facilitators of stigma. These findings are supported by a study by Nyblade et al. [
32], which reported that stigma greatly impacts access to health care services, especially stigma related to different characteristics or backgrounds and knowledge gaps between health caregivers and clients, which eventually lead to poor health outcomes for the population. Many personal characteristics, including the attitudes and behaviors of health care providers, have been reported as facilitators of stigma, especially when directed at vulnerable populations [
1,
36,
37].
When attending MCH services in the public hospitals in Thailand, the majority of Akha hill tribes reported experiencing stigma through verbal and physical abuse, a refusal to provide proper treatment and the release of individual information to the public. A high frequency of verbal abuse from health care providers was reported. This point was the strongest and resulted in immense harm to the Akha hill tribe women who attended MCH services in public hospitals. Many questions arose that expressed how this abuse could happen to these people, especially questions regarding why people become nurses or doctors if they will not provide appropriate service or care to people suffering from health problems. The Akha hill tribe women commented that if individuals did not have a health problem, they would not go to a hospital. Verbal abuse from health care providers toward the Akha women made them feel confused about these professionals. Physical abuse, a refusal of treatment and the public sharing of client information were reported in some cases, but none of these should occur in health care settings. Such behavior is contrary to the ethics of health professionals according to the WHO guidelines [
38] and the principles of health care ethics [
39]. People should receive standard care regardless of their race, tribe, or sociodemographic status.
Due to the stigma encountered by the Akha women when attending an MCH clinic in a public hospital, poor access to the services and poor rates of cervical and breast cancer screening were reported. These findings were supported by a study in two district public hospitals located in the hill tribe villages in northern Thailand, which reported a very poor rate of antenatal care (ANC), cervical and breast cancer screening, and other activities related to women’s reproductive health [
40]. In 2018, the Thai Ministry of Public Health [
41] reported 8,622 new annual cases of cervical cancer and 5,015 cervical cancer-related deaths among women. In our study, the cervical cancer screening rate among the Akha women was 31.1% compared to 45.6% for Thai people [
42].
Most activities at MCH services do not require serious medical attention. Being screened for breast and cervical cancer, given the low rate of these diseases, was not viewed as a serious problem by either clients or health care providers. The lack of regular visits to MCH services during pregnancy also did not have serious consequences, which made the Akha women less concerned and consequently, less likely to engage in activities related to reproductive health and MCH. In addition, given the stigma experienced when accessing MCH services, the patients did not expect to visit a large hospital. The Akha women favored visiting a small hospital in their village. At such hospitals, having standard medical equipment and care at the village level were their main expectations. Moreover, access to MCH services at small hospitals located in their village made accessing them less time-consuming and eliminated the need to travel and other barriers posed by the more complicated process of accessing services in a large, urban hospital. Another expectation was being attended by a gender-matched health care provider when receiving MCH services, which could reduce stigma and improve women’s personal perception of services.
Several limitations were detected in the study. First, although no participants refused to participate in the study or provide information, given the familiarity between the Akha women and the health care workers at the small hospital in their village, many women preferred not to voice too many of their negative experiences with these health care providers. Thus, most of the negative experiences discussed occurred with health care providers who were working in large, urban hospitals. Second, the participants in the study were recruited from seven hill tribe villages, thus, the study primarily presents information and experiences from the Akha people in northern Thailand. In addition, some key informants experienced stigma some time ago, which could have impacted their recall of certain points during the interview and might affect the interpretation. Finally, because the participant selection was primarily executed by the village headmen, it is possible that some people who had experienced serious and direct stigma that is relevant to the research question might not have been selected. Having a clear and careful selection of participants for the study is one of the critical processes in the qualitative method.
Conclusion
Akha women who attend a public MCH clinic in Thailand suffer stigma driven by their specific characteristics, such as being unable to speak Thai (or lacking fluency), being poor, wearing their traditional dress and using traditional naming conventions. Health care providers’ background, gender mismatches and knowledge gaps between health care providers and clients were identified as facilitators of stigma for women seeking MCH services. Akha women face many forms of stigma when receiving clinical services, including verbal and physical abuse, a refusal to provide treatment, and the intentional disclosure of their personal information to the public. As a result, such mistreatment affects multiple health and health service outcomes, such as poor rates of attending antenatal care and low rates of cervical and breast cancer screening. Akha hill tribe women use many approaches to adjust to the stigma that they encounter, such as accepting the situation with no better option, defending themselves to obtain better care and services, and using a private clinic instead. Akha women expect to have active services and gender-matched health care providers at MCH services and mobile emergency clinics and that the appropriate equipment be provided to equip standard MCH services at hospitals located in or near the hill tribe villages.
Serious consideration of the problems posed by the stigmatization for Akha hill tribe women is needed to improve their access to health care services, particularly those attending MCH services. Policies with standard protocols to ensure the provision of equal care for everyone should be implemented. The improvement of health facilities located in hill tribe villages should also be considered to familiarize hill tribe people with health care providers in their home setting. Moreover, encouraging hill tribe people to be trained as nurses or medical doctors and then sending them back to work at a hospital in their village could eventually reduce stigma.
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