Introduction

Stigma is defined as a negative social attitude attached to a characteristic of an individual who may be regarded as having a mental, physical, or social deficiency [1]. The impacts of stigma are present at different levels: an individual [2], a family [3] or a group of people who have specific characteristics [4, 5]. The impacts also involve several dimensions, such as an increasing lack of access to health care services [6, 7], facing a large barrier to job access [8], and having one’s value as a human being minimized [9]. Stigma has been detected in all societies [10], but the impacts may be different. Some individuals must manage only one form of stigma [11], while others see stigma as having a massive impact on their lives [12]. While some stigma is present at the individual or family level, specific groups are faced with stigma as a whole merely by virtue of belonging to the group, such as the stateless population in Thailand. In 2020, 479,943 people were classified as stateless people in Thailand [13]; these individuals live in distant and remote areas of Thailand where accessing information from the Thai government is very difficult [14].

Stigma refers to an attribute that is deeply discrediting or that enables varieties of discrimination that ultimately deny the individual or group full social acceptance and that reduce the individual’s opportunity [15]. Prejudice is a result of the cognitive and affective responses to stereotypes [16]. Amiot and Bourhis [17] defined discrimination as positive or negative behaviors toward a social group and its members. Generally, the behavior is negative and can be classified as direct or indirect. Abrams [18] added that prejudice includes behaviors and opinions, while discrimination constitutes behaviors toward another group or person. Therefore, in this study, we aimed to understand the stigma that deeply interferes with the stateless population in Thailand.

To understand the context of the stigma facing the stateless population in Thailand, the framework integrating normative influence on stigma (FINIS) was applied [19]. Many theories and concepts attempt to explain stigma in various contexts. However, the FINIS is best able to explain the stigma experience in daily life among the stateless population. The FINIS focuses on three layers: the micro, meso, and macro. The microlayer focuses on individual characteristics, while the mesolayer focuses on family and community contexts. Finally, the macrolayer focuses on the stigma embedded in a larger national cultural context.

The stateless population in Thailand consist of a group of people who have migrated from neighboring countries to settle in Thailand, especially along the border areas of Thailand and Myanmar; they do not have Thai identification cards (IDs) [20]. Essentially, the stateless population in Thailand are often members of typical hill tribes, such as the Akha, Lahu, Hmong, Lisu, Yao, etc. [21]. These tribes have their own languages, clothing, and lifestyles, which specifically act as influencers of stigma from others [22]. Most of the stateless population in Thailand live in a poor socioeconomic situation [23] and have less opportunity than Thai citizens do to access schools [24]. This situation is largely because access to schools and employment at good professional jobs in Thailand require a Thai ID.

People living in Thailand who are not granted a Thai ID are identified as members of the stateless population [25]. The Thai ID is used to access all public services in Thailand and is officially used to identify those with Thai citizenship [26]. The card consists of 13 digits and is required to access all government procedures in Thailand. Moreover, it is used for access to education and to apply for a professional job, including purchasing real estate. The most important advantage of having a Thai ID is access to health care services. Therefore, the absence of Thai IDs among the stateless population leads to an inability to access almost all of the activities that support a good quality of life. Furthermore, those who lack Thai IDs become victims of stigma from people around them through several processes. The severity of such stigma minimizes the value of an individual’s status as a human being.

The current study aimed to understand the stigma-related experiences of the stateless population living in Thailand and their approaches to managing the problem. The findings could be used to determine specific and powerful national and international policies aimed at improving the relevant systems, with the ultimate goal of supporting an improvement in the quality of life of these individuals.

Methods

Qualitative and face-to-face in-depth interviews were used to gather information from the participants. A purposive selection was made of the participants who lived in the five remote hill tribe villages located along the border of Thailand and Myanmar. The participants were considered to meet the criteria if they were stateless people living in Thailand who did not hold a Thai ID and who had experienced any forms of stigma.

A questionnaire was developed during the literature review and subsequently discussed with the hill tribe village leaders, including six stateless people. The questions were assessed for appropriateness, including validity, by the research team and two experts working in the field (one medical anthropologist and one sociologist). The questionnaire consisted of six questions: 1) “What do you think about being a member of a ‘stateless population’?” 2) “Have you experienced any events that have made you feel uncomfortable when you have contacted people or health care providers?” 3) “Could you please tell me about stigma-related situations that you face in your daily life?” 4) “How do these situations impact you and your life?” 5) “How do you cope with these situations?” 6) “What other expectations do you have about such a stigma?”

All the project concepts and tools were approved by the Chiang Rai Public Health Office Ethics Committee on Human Research (Committee; CRPPH0 No. 69/2564) before the project commenced. The five targeted hill tribe village leaders were contacted, and the contents of the study were explained to them, including the objectives. After being granted access to the villages, five days ahead of the desired date, an appointment was made to enter the village, and the village leaders were asked to introduce those people who did not possess Thai IDs to participate in the project. On the date of the data collection, all participants were confirmed to conform to the criteria of the study before engaging in the interview. Before the interviews, all participants were asked to provide informed consent. For those who could not speak Thai, public health volunteers from the village were asked to help translate all of the study contents before the participants fingerprinted the consent form. Afterward, the interviews were conducted in a private room at the village hall, which had previously been prepared by the village leaders.

Each interview began with an introduction of the interviewer, who had long-term experience working with qualitative methods and was familiar with this population after having worked with them for more than ten years. All interviews were recorded after obtaining approval from the participants. The interviews lasted approximately 45 minutes each.

All records were typed and checked for errors. The transcripts were determined to have reached the level of saturation by the research team. Each transcript was sent back to the related participant to confirm the accuracy of the information before further analysis. The information was coded and developed as a preliminary coding tree. All information was transferred into the NVivo program (NVivo, qualitative data analysis software; QSR International Pty Ltd., version 11, 2015) to derive the themes. The final themes were reconsidered among the research team before any conclusions were made. The findings were sent to the participants again before interpretations were drawn.

Results

I. General characteristics

Fifty-one participants were interviewed to extract information regarding the purpose of the study: 68.6% were females, 86.3% were married, and 90.2% were Akha or Lahu. The majority were Christian (72.6%), had no education (66.7%), and were farmers (56.9%), with a median monthly income of 2,888 baht on average ($93) (Table 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Demographic data of the participants.

https://doi.org/10.1371/journal.pone.0264959.t001

Discussion

The stateless population in Thailand suffer from stigma about which they have various perceptions: having a lower ability to request that their needs be met, not being equal to others, not being able to qualify for health care services and even being ranked below other hill tribe people who do have IDs. “Life is nothing” is reported as the viewpoint of the invisible population in Thailand. Some hill tribe people act as stigma perpetuators among members of the stateless population, which perpetuates the stigma. Keeping within their village, trying to get a Thai ID, and practicing speaking Thai are ways of avoiding the stigma, according to the members of the stateless population interviewed herein. Having a Thai ID was detected as the single goal that would help them overcome the stigma problem.

The stateless population living in Thailand reported several stigma perceptions: having a lower ability to request that their needs be met, not being equal to others, not being able to qualify for health care services and even being ranked below other hill tribe people who do have IDs; in other words, feeling as through life is nothing. These perceptions were presented through the scenarios described by the interviewees. Stateless people in Thailand live as invisible persons. The major factor that forces them to be invisible people is not holding Thai IDs. Thai IDs are used to gain access to all public services in Thailand, including access to health care services [27]. Scenarios of these individuals having no ability to request the help needed were clearly present during the COVID-19 epidemic; i.e., all Thai people who held Thai IDs were financially supported by the central government, while the stateless population remained invisible to policy-makers [28, 29]. All members of the stateless population belong to one of the tribes that live in border villages in Thailand. Those who have not been granted Thai IDs for any reason are defined as the stateless population. Thus, while those who have a Thai ID are helped by the central Thai government and have full rights to access all services, the stateless are not. Some members of the stateless population have been hired to work in either the government or private sector, especially as translators for specific communication requirements. For instance, a hospital hired a stateless population member who spoke tribal languages and facilitated the communication of health professionals; these groups of people are paid approximately 9,000 baht ($300) per month. However, the stateless person who was hired then undertook some derogatory action and perpetuated the stigma among other stateless population members while they were attending the hospital. This perpetuated stigma was attached to the person’s peers, which greatly impacted the victims as other stateless population members in the village. Suffering from peer-perpetuated stigma could have multiple impacts on individuals. In contrast, individuals often try not to be part of a group of people who are treated as victims in society. People move away from unpleasant zones of life, which might be a common human behavior.

Several approaches were used to cope with the problem of the stigma faced by people among the stateless population in Thailand. The stateless population tried to remain in private and confidential zones and to avoid interacting with people outside the village. These findings are related to the immigration regulations of the Kingdom of Thailand that prohibit stateless persons from traveling outside of “the restriction areas”. This prohibition means they are not allowed to leave the specific areas mentioned. However, under these regulations, if anyone needs to leave the village area, they must have the approval of a government officer. This process requires a long period of time [30]. The statement of “not talking with people who do not know” reflects the concern of these villages about being caught by the police who work under Thai laws [30, 31]. A study in the United States also reported that illegal immigrants within the country fear being caught by police who work under US laws [32].

Moreover, stateless people try to obtain Thai IDs, which are stamped documents for Thai citizenship. The Constitution of Thailand permits very few ways to obtain an ID [33]; however, doing so is only the way to remove themselves and their subsequent generations from the suffering zone. To preliminarily protect themselves from the stigma, these individuals, especially the younger generation, are improving their skills in regard to speaking Thai. Under Thai regulations, all children living in Thailand are able to fully access primary education until grade 12 [24, 34], regardless of whether they hold Thai IDs [35]. Thus, one of the best options for the new generation is to try to attend school. If they attend school, children will be able to speak Thai fluently, and they will eventually free themselves from the stigma. Therefore, having Thai IDs is the only hope and bright spot among the stateless population in Thailand. If they hold a Thai ID, they can apply for any job position in Thailand, be elected as a politician, and even become the Prime Minster of Thailand.

A few limitations were detected in the study. Some participants could not speak Thai fluently, which might impact the amount and accuracy of the information obtained. However, during the interviews, the researcher asked local people who were fluent in Thai to help collect the information. Two or three participants presented their fears about their status in Thailand to the interviewers. These issues, i.e., real information pertaining to the purpose of the study, were clearly passed to the interviewers through the village leaders. Finally, all of the participants openly provided information to the researchers. In the context of their tremendous stigma-related suffering, some participants were hesitant to talk about their experiences because they did not feel secure doing so. In this situation, the interviewer had to become familiar with these individuals by talking to them for slightly longer than others before being able to collect accurate information.

Conclusion

The stateless population living in Thailand, especially along the border of Thailand and Myanmar, are treated as an invisible population with limited access to health care services. They have a lower ability to request that their needs be met, they feel unequal to others, they do not qualify for health care services, and they are even ranked below other hill tribe people who have IDs. These are some of the impacts of the stigma that are found in the lives of stateless individuals, including the outlook that “No better options in life”, i.e., that one’s life is empty. The stateless population are also victimized by other members of the hill tribe who hold Thai IDs and thus serve as reproducers of the stigma.

To address this problem, the Thai government, including all relevant agencies, should promote the obtaining of Thai IDs to these individuals and encourage them to attend school. These individuals would be excellent human resources for the future development of the country. Giving IDs to these people and encouraging them to attend school would also help to ensure that all people in Thailand are granted basic human rights. Another intervention that should be implemented throughout all government offices and services is promoting nonstigma behaviors toward anyone who attempts to receive services or government-office programs. Implementing access to educational institutions without barriers, especially the Thai ID requirement, should be promoted. In addition, creating laws to reduce discrimination to access public services including employment should be implemented.

Supporting information

Acknowledgments

We thank all the health care workers who worked in the study setting for their assistance in obtaining access and recruiting the participants. We also thank all of the participants for their participation in the study.