a. Verbal.

Stigma through verbal language was the major form of stigma. The expression of healthcare workers through language greatly impacted these hill tribe members in a particular context of communication. A large proportion of the hill tribe members could not speak fluent Thai, including having difficulties with accents while speaking, which was not entirely understandable by native Thai speakers. This could lead to poor confidentiality and patients’ fear of healthcare workers. This reflects the powerlessness of the patient in their interactions with the healthcare workers.

A 47-year-old woman said [P#55]:

“When I visited a doctor due to a very painful stomach, a nurse asked me to cooperate with her in doing something. However, I had such pain in my stomach that I could not follow her. She then spoke badly to me. Even though I felt much pain, I also did not like what she said. However, I did not respond to her because I feared I might not receive good treatment from her.”

A 65-year-old woman said [P#58]:

“Last month, I went to a hospital to get drugs, and I saw a nurse speaking harshly to an old Akha lady. She said something the old lady did not understand and spoke many blaming words. I really didn’t like it”.

A 47-year-old woman said [P#60]:

“Just last week, while I visited a doctor at a hospital, a nurse shouted at me. She was furious and said, “You are the highland people; why don’t you understand what I say?” Indeed, I did not clearly understand what she said.”

Being spoken to negatively by a nurse, particularly for those who are older and not fluent in Thai, is a pervasive stigma experienced among hill tribe people in Thailand. Negative verbal expressions had the most significant impact on the emotions of hill tribe people while they were attending a hospital. However, the patients did not respond to the healthcare workers because they feared that they would not receive good treatment.

b. Physical.

Several physical actions by healthcare workers expressed stigma were reported by the participants, such as throwing paper, finger-pointing, not being spoken to and being ignored, or being the recipient of threatening actions. Almost all forms of stigma are made by healthcare workers working at district hospitals. These physical actions were reported by all of the participants who neither spoke nor understood Thai. This stigma was reported as most frequently occurring in outpatient and labor departments. Some women reported having been physically abused during labor.

A 16-year-old man said [P#25]:

“Maybe 4–5 months ago, I got in a traffic accident and needed to have my wounds dressed at a hospital. The nurse who treated me processed me very roughly, which hurt. I saw that she treated me without standard care. I felt she was practicing wound dressing on me because she knew I was a hill tribe member. Before dressing my wound, she called my name and asked, “Are you a hill tribe?”.

A 64-year-old man said [P#73]:

“This was very important for my life. I went to see a doctor to get drugs for hypertension. I was diagnosed with hypertension several years ago. On that day, I left my home very early. I sat down close to a nurse when I reached the hospital. Immediately, the nurse moved to another place. I know that sometimes this happens, but in my case, I felt that the nurse did not like me and did not want to sit close to me. Yes, absolutely, I accepted it”.

A 24-year-old man said [P#65]:

“A couple of years ago, I had dengue fever, and unfortunately, I was admitted to a hospital. During admission, I received less care than another patient whose bed was beside mine at the hospital. The nurse had many conversations with that person but did not even look at me. I felt that I had a very high fever, and I needed someone to help me. I requested medicine from her, but she did not respond. I know she might have a lot of work to do, but she should care fairly for everyone the same.”

Physical stigma is another essential type of stigma experienced by hill tribe people while they are attended to in hospitals. Physical stigma often occurs during medical procedures and in the documentary process.

c. Looks of contempt.

In Thai culture, cynicism or a look of contempt is another stigma that significantly impacts the victim. Thai women are frequently subjected to this type of stigma, directed toward those who look inferior or are not equal in some aspect, particularly with respect to economic and educational status. Stigma expressed by a look of contempt can impact anyone. This form of stigma not only occurs between Thai healthcare workers and hill tribe patients but is also common in daily life among people with different economic or educational statuses.

A 53-year-old woman said [P#50]:

“I clearly remember when I attended a hospital last month. I do not have an ID card and did not attend school. Therefore, I was not confident in talking about my symptoms with the nurse because I was afraid that I would not speak well and make her misunderstand my points. However, all my words disappeared when I made eye contact with the nurse. My feeling at that time was that I was afraid to say anything to her because she looked at me so unfriendly”.

A 47-year-old man said [P#54]:

“One day, I visited a doctor, and before meeting with them, a nurse called me in to take my history. I felt like a tiny man when she looked at me harshly and said, “Do you have money to pay doctor’s fees?” I spoke very little and said without confidence that I had little money when she looked at me and talked to me. Do you know it was very upsetting?”

A 49-year-old woman said [P#53]:

“This was a very particular experience to me. I remember two months ago when I visited a doctor, and a local Thai woman looked at me from head to toe. I felt that she did not like me. I could sense that she looked at me like a poor person. I did not like that situation.”

Stigma, expressed as a look of contempt, impacts many people without verbal expression. Both healthcare workers and the general Thai people can easily inflict this form of stigma. Being looked at negatively can discourage people and make them see themselves negatively, especially hill tribe people who live in poor communities in Thailand.

a. No understanding of the message, no impact.

At this level, no impact was detected by the hill tribe individuals because they did not understand the meaning of the messages. The effect was detected by their relatives, who cared for them while at the hospital. Therefore, when the participants were asked about their experience of stigma, they responded that there was no impact; however, impacts were felt by their relatives, who took them to the hospital. This means that individuals who cannot speak Thai are not directly impacted by stigma, particularly when expressed verbally. Nevertheless, it affected their relatives, who fully understood the messages.

A 44-year-old woman said [P#51]:

“When I visited a doctor, I heard many words from the nurse but did not understand what she said. At that time, I felt nothing. However, after coming back home, my son told me that the nurse spoke to me very roughly and repeated it over and over! However, anyway, I do not know, and I do not want to know what she said.”

A 60-year-old woman said [P#80]:

“A year ago, one of my nephews brought me to a hospital, and I was admitted. During the hospital stay, my nephew told me that a nurse said tough words to me, including saying that I had a bad smell and why didn’t I take a shower?”

She added

“Luckily, I did not know what she said, and I felt nothing. Is that good?” (laughing).

A 44-year-old man said [P#49]:

“I guess I heard many hard words from nurses while attending a hospital. However, I did not understand Thai, so I did not know the meaning. However, my son said that the nurses were rough to me. However, I did not feel bad anymore”.

b. Little understanding of the message, little pain received.

Some hill tribe people spoke Thai and understood the meaning of what the healthcare worker said, making them feel bad. Most conflict occurred when the patient tried to explain what he or she wanted or needed help with, but the healthcare worker did not wholly understand the main ideas. The level of the response from the healthcare workers to the patients was not proper or adequate or did not directly respond to the need. Without effective communication, misunderstandings can impact several things, such as being misdiagnosed and misprescribed.

A 65-year-old woman said [P#58]:

“Basically, I can use Thai a little. One day last year, I went to see a doctor for strong abdominal pain. I told a nurse about my problem, but she did not understand what I said. Moreover, I knew that she complained about me, but I did not clearly understand. The next day, my son told me that the nurse said tough words to me, but I felt nothing because I did not clearly understand what she said.”

A 47-year-old woman said [P#57]:

“Last year, I met a nurse while attending a hospital to get medicine for my hypertension illness. She told me something very fast in Thai. After a while she asked me, “Did you understand what I said?” I nodded my head to show her that I understood. In fact, I received little information from her. Do you know why I did that—because I was afraid she would not care for me properly.”

c. Fully understood message, full impact received.

Stigma can cause harm and pain to anyone, and the severity of the problem increases when a completely negative message is communicated from one person to another. Hill tribe people, who fully understood the negative messages from healthcare workers, experienced hurt and pain. Almost all hill tribe people under 30 years of age speak fluent Thai, and this particular group is impacted by a full understanding of the negative messages of healthcare workers.

A 16-year-old woman said [P#25]:

“Last year, I was referred to an emergency room due to a car accident. It was almost 11:30 pm. The nurse did the wound dressing very roughly, which hurt a lot. During this time, she swore that the hill tribe people never used motorcycles carefully, which is not true. The accident was caused by heavy rain. I felt she liked this because we are the hill tribe.”

A 28-year-old woman said: [P#23]:

“Last week, I visited a hospital. One of the staff members asked me, “Do you have a Thai ID card?” I felt that this question had the same meaning as “Do you have money?” She asked me other questions without looking at me, such as “Which mountains are you from?” I felt terrible and shy.”

A 30-year-old man said [P#42]:

“Two years ago, I brought my father to the hospital. I heard a nurse ask questions to a woman close to me who was a hill tribe member and could not understand Thai. The nurse said, “Most hill tribe people do not understand anything.” I looked at her and felt very angry even though she did not talk with me directly.”

The impact of stigma depended on how much a person can use and understand Thai. The stigma had little impact on those who understood only a small amount of information because they could not understand the meaning of the messages. The fear of being improperly cared for was another concern among the hill tribe people, who faced stigma from healthcare providers.

a. Nonresponse.

There were two reasons for nonresponse to stigma. First, the recipient understood everything but kept silent out of fear. They feared they would not receive good-quality care from healthcare workers. This is the result of unequal power, especially concerning the ability of power to save life. The second reason was that patients did not understand the context of what was said in Thai. Therefore, they did not respond to the situation. Nonresponses due to a lack of understanding of the context commonly occur among elderly people. Owing to the limited use of Thai and different cultures, they did not understand basic aggressive words and negative physical language.

A 35-year-old woman said [P#33]:

“A year ago, I brought my mom to visit a hospital. A nurse spoke to my mom and me harshly, and she blamed us poor people who could not afford to pay for the treatment. However, we did not respond to her. We kept quiet because we feared she might not care for us properly.”

A 47-year-old woman said [P#55]:

“Five years ago, I got a hand injury while working on the farm. I went to see a doctor at a hospital. Before meeting the doctor, I had been asked many questions by a nurse in the emergency room. Some questions hurt me, but I did not respond because I feared I would not be cared for properly.”

A 42-year-old woman said [P#56]:

“Last year, I went to see a doctor about my diabetes mellitus. One of the staff told me to fill out a form. I told him that I could not write. Immediately, he shouted at me with some bad words. I was sitting close to him, and I did not know what to do next. I kept everything in my heart because I feared he would not care for me.”

b. Response.

Responses to bad situations, including conversations and other interactions between hill tribe patients and healthcare workers, were presented at three levels: proper, nonproper immediate, and aggressive responses. The responses of hill tribe members who were fluent in Thai and aged 35 years and younger were recorded. In this age group, almost all the participants had attended school at some level and were exposed to people outside their village, including those who were familiar with other cultures and lifestyles. Because they were frequently exposed to negative messages and actions, these patients preferred to respond when they experienced negative comments or improper actions from healthcare workers.

Proper response: In this type of response, the patient addresses the problems calmly and directly when they arise. Although most responses were initiated by relatives, this indicates that patients often hold less power in interactions with healthcare workers.

A 23-year-old man said [P#9]:

“I remember that one day in 2017, I visited a hospital with a severe headache. A nurse called my name, asked me for my history, and checked my blood pressure. The nurse asked me to explain my problem. I had only said a few words when she shouted, “Go wait there.” I kept everything normal and responded, “I would very much appreciate it if you told me with normal words. I understand how busy you are today.” I smiled at her.”

A 30-year-old man said [P#10]:

“Last year, I brought my wife to see a doctor at a primary care hospital to check her health during pregnancy; this was a small health center in our village. The staff member asked my wife some questions, and I responded that she could not speak Thai. The staff member turned to my wife and asked why she could not speak Thai. I was slightly surprised and responded, “How many languages do you speak because of graduating with a university degree? She never attended school—why do you expect her to speak Thai?”

Nonproper immediate response: Patients were the primary responders in this response type. When hill tribe patients suffer from illness, they responded nonproperly and immediately to healthcare workers who expressed any kind of stigma.

A 47-year-old man said [P#54]:

“Last month, when I visited the diabetes mellitus clinic at a hospital, the staff member shouted at me with hard words. I looked at her face immediately and then stood up. Afterward, she calmed down and talked to me normally.”

Aggressive response: Some people reported aggressive responses. A long wait time or ignoring severe suffering were sources of aggressive reactions. Aggressive responses were frequently reported in outpatient departments and labor rooms when patients were suffering severely but did not receive proper care.

A 20-year-old woman said [P#76]:

“Last year, my son, who was five years old, got a foot injury, and I brought him to a hospital emergency room. A nurse cleaned his wound very roughly, and my son told me that it hurt a lot. I felt that she did not treat him carefully and mindfully. I immediately told her, “Could you please treat my son better, as he is a human? I felt very angry.”

A 65-year-old man said [P#65]:

“One day, a couple of weeks ago, I visited a hospital because I had a very severe headache. I waited in a long queue. A few moments later, a man dressed in a very modern style came and jumped the queue in front of me, and the nurse said it was fine. I felt it was not okay, so I asked the nurse to explain what happened. I started to ask many people who were sitting down in that area.”

Many hill tribe people chose not to respond to the stigma because they feared being improperly cared for. When people did respond, they did so using three forms of the response: proper, nonproper, and aggressive. The responses depended on the situation and whether the patient was a loved one, such as a son.

a. Speaking fluent Thai.

Among hill tribe people, speaking fluent Thai protected against stigma in any form received from healthcare workers. The ability to communicate smoothly and effectively in Thai reduced the incidence of stigma and its adverse effects. The fluent use of Thai increased the respect of healthcare workers.

A 26-year-old man said [P#82]:

“I am an Akha, and I graduated high school. I can speak Thai very well. I know some people look physically different, which cannot be changed. However, we can adapt ourselves. When I go to a hospital, I can speak Thai and never have a problem with them. Speaking Thai truly helps me.”

A 24-year-old man said [P#63]:

“A couple of years ago, I visited a hospital to seek care after getting in a traffic accident. In the emergency room, I received good treatment. The nurse was very polite to me. This was because I could speak with them very well, even though I am Akha.”

A 49-year-old woman said [P#84]:

“I am Lahu, and I have lived in Thailand for 20 years. I did not attend school but can speak Thai because of my daily practice with Thais. I have not had any problems while visiting hospitals.”

b. Wearing modern clothing.

Hill tribe people who wear traditional clothes are more likely to experience stigma or negative experiences with healthcare workers. When hill tribe people wore modern clothing, they experienced less stigma. Stigma could be completely absent if they wore modern clothes and spoke fluent Thai. However, most hill tribe women in all tribes commonly wear their traditional style of clothing, which is part of their social culture. Thus, hill tribe women face more frequent and severe stigma when accessing health services. Women who wore traditional clothing and could not speak fluent Thai faced more severe stigma from healthcare workers.

A 47-year-old woman said [P#57]:

“Actually, the hill tribe people always dress in the traditional form. However, I prefer to dress in modern clothes when visiting a doctor in a hospital. I feel that I receive more respect from people, including healthcare staff, while wearing modern clothes.”

A 20-year-old woman said [P#61]:

“I am Akha. I have noticed unfriendly looks from people around me. I decided to wear modern clothes, and I was surprised that I received less negative attention from people around me when I went to the city and hospital.”

c. Affordability for medical fees.

Most hill tribe people who can afford medical fees prefer to visit private hospitals. In a private hospital, services are based on a mix of standard health professional practices and private standard services. Anyone who accesses a private hospital will be served better than at public hospitals, which are nonprofit organizations. Hill tribe members who can afford it choose private hospitals to reduce the incidents of stigma. In addition, the service is always better and quicker than at public hospitals.

A 43-year-old woman said [P#39]:

“Three years ago, I felt terrible while visiting a hospital. I was asked for money to pay medical fees before receiving care. I told them that I had a lot of money, and the actions of the hospital staff changed immediately. They were nice to me, but it’s not right!”

A 28-year-old woman said [P#23]:

“I prefer to go to a private hospital. Although we have to pay medical fees, we will receive good care. In a public hospital, I do not need to pay all the medical fees because I have a Thai ID card, but I feel that I have not received proper care from them. My friends say that money is very important to obtain good service from a hospital.”

Those who dressed in modern clothing, spoke Thai well, and could afford to pay medical fees experienced less stigma. These characteristics indicate a higher level of socioeconomic status in the social environment. Those who had a lower socioeconomic status suffered in two ways—from their lower status and from experiencing stigma.

Domination by a majority produces significant stigma, stimulating inequity in accessing healthcare services by minority people through discounting the value of different cultures and socioeconomic groups. The ability of minority and vulnerable populations, owing to their socioeconomic status, to make a difference by setting their profiles as the standard for humankind is a source of both intentional and unintentional stigma.