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Introduction: Persistent inequities in health and access to healthcare services for indigenous women living in Thailand remain a significant challenge. This study provides narrative accounts of Indigenous women’s experiences accessing healthcare in northern and rural Thailand and explores the complexity of culture and its interaction with multiple intersecting influences on health behaviours.
Methods: A focused ethnographic study was conducted to understand and describe the culture of health behaviors and other cultural phenomena. We recruited 21 female participants aged 20-41 years between March and April of 2017. In-depth semi-structured interviews conducted in Thai were used to explore the experiences of the participants living in a northern rural village. Data analysis was informed and guided by Roper and Shapira’s framework for ethnographic analysis.
Results: Seven themes presented across three phases of experience (pre-access, making choices, and encountering difficulties) revealed an in-depth understanding of the Indigenous women’s lives, the broader sociocultural context in which they lived, and the challenges they faced when accessing healthcare. Analysis of data showed that the participants did not have equal access to healthcare and often disproportionately experienced discriminatory practices and negative attitudes of mainstream healthcare providers.
Conclusions: This is the only study to date that discusses healthcare access challenges experienced by Indigenous women living in a northern rural Thai village. There is an urgent need to focus on citizenship, employment, and general health conditions; gender, familial, and labor roles; specific health conditions, wellness, and cultural practices; the seeking of healthcare services; healthcare provider relationships; the ability to access needed care; and optimization of self-care. Future efforts to improve healthcare access and reduce disease burden might benefit from these findings and allow for the development of more effective strategies, programs, and policies.
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World Health Organization. Health and Human Right [Internet]. Geneva: WHO Media Centre; 2015. Available from: http://www.who.int/mediacentre/factsheets/fs323/en/. Accessed October 8, 2018.
United Nations. State of the world’s Indigenous peoples (2nd volume): Indigenous peoples access to health services [Internet]. New York: Department of Economic and Social Affairs; 2015. Available from: https://www.un.org/development/desa/indigenouspeoples/publications/2015/09/state-of-the-worlds-indigenous-peoples-2nd-volume-health/. Accessed October 8, 2018.
Thummapol O, Park T, Barton S. Exploring health services accessibility by Indigenous women in Asia and identifying actions to improve it: A scoping review. Ethnicity and Health. 2018;1-20.
Dhir RK. Indigenous Peoples in the world of work in Asia and the Pacific: A status report [Internet]. Geneva: International Labour Organization; 2015. Available from: https://www.ilo.org/global/topics/indigenous-tribal/publications/WCMS_438853/lang--en/index.htm. Accessed October 8, 2018.
United Nations. State of the world’s Indigenous peoples (Volume 1) [Internet]. New York: Department of Economic and Social Affairs; 2010. Available from: http://www.un.org/esa/socdev/unpfii/documents/SOWIP/press%20package/sowip-press-package-en.pdf. Accessed October 8, 2018.
Dang H-A. Vietnam: A widening poverty gap for ethnic minorities [Internet]. In Gillette H, Harry, P. (Eds.). Indigenous Peoples, Poverty and Development. Cambridge University Press, Forthcoming; 2012. Available from: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2346307. Accessed October 8, 2018.
Jose JA, Sarkar S, Kumar S, Kar SS. Utilization of maternal health-care services by Tribal women in Kerala. Journal of Natural Science, Biology & Medicine. 2014;5(1):144-147.
Shah R, Bélange D. Socioeconomic correlates of utilization of maternal health services by Tribal women in India. Canadian Studies in Population. 2011;38(1/2):83.
Asia Indigenous Peoples Pact. Overview of the state of Indigenous peoples in Asia [Internet]. Chiang Mai: Publications; 2014. Available from: http://www.gapeinternational.org/wp-content/uploads/2011/08/asia-ip-overview-final.pdf. Accessed October 8, 2018.
Cadchumsang J. People at the rim: A study of Thai ethnicity and nationalism in a Thai border village [dissertation]. Ontario: University of Toronto, Department of Anthropology; 2011.
Spindler W. Thousands of stateless people given nationality in Thailand [Internet]. Geneva: United Nations High Commissioner for Refugees; 2015. Available from: http://www.unhcr.org/news/latest/2015/12/565db8939/thousands-stateless-people-given-nationality-thailand.html. Accessed October 8, 2018.
Lutvey T. Gender mainstreaming manual: Good practices and lessons learnt of an Indigenous Peoples organization [Internet]. Chiang Mai: Asia Indigenous Peoples Pact; 2014. Available from: https://aippnet.org/gender-manual-good-practices-and-lessons-learnt-by-an-indigenous-peoples-organization/. Accessed October 8, 2018.
United Nations High Commissioner for Refugees. Good practices addressing statelessness in South East Asia [Internet]. Geneva: Resources and Publications; 2010. Available from: http://www.unhcr.org/protection/statelessness/4d7de47f9/good-practices-addressing-statelessness-south-east-asia-report-regional.html?query=stateless peoples. Accessed October 8, 2018.
Kritpetcharat O, Sirijaichingkul S, Kritpetcharat P, Wutichouy W. Comparison of pap smear screening results between Akha hill tribe and urban women in Chiang Rai province, Thailand. Asian Pacific Journal of Cancer Prevention. 2012;13(11): 5501-5504.
Apidechkul T. A 20-year retrospective cohort study of TB infection among the hill-tribe HIV/AIDS populations, Thailand. BMC Infectious Diseases. 2016;16(72):1-14. doi:10.1186/s12879-016-1407-4
Chowdhury HE. Framework for tribal peoples plan-health sector support program [Internet]. Bangladesh: Ministry of Health and Family Welfare; 2017. Available from: http://documents.worldbank.org/curated/en/397301492068554569/pdf/SFG3262-IPP-P160846-Box402901B-PUBLIC-Disclosed-4-11-2017.pdf. Accessed October 8, 2018.
Denison J, Varcoe C, Browne A. Aboriginal women's experiences of accessing health care when state apprehension of children is being threatened. Journal of Advanced Nursing. 2014;70(5): 1105-1116.
Morgan L, Wabie J. Aboriginal women’s access and acceptance of reproductive health care. A Journal of Aboriginal & Indigenous Community Health. 2012;10(3):313-325.
Van Herk K, Smith D, Andrew C. Identity matters: Aboriginal mothers' experiences of accessing health care. Contemporary Nurse. 2011;37(1):57-68.
Schooley J, Mundt C, Wagner P, Fullerton J, O’Donnell M. Factors influencing health care-seeking behaviours among Mayan women in Guatemala. Midwifery. 2009;25411-421.
Knoblauch H. Focused ethnography. Forum Qualitative Social Research. 2005;6(3): 1-11p.
Ord M. Shan: Thailand for beginners. The Travelfish [Intternet]; 2015. Available from: https://www.travelfish.org/beginners_detail/thailand/77. Accessed October 8, 2018.
Bonevski B1, Randell M, Paul C, Chapman K, Twyman L, Bryant J, Brozek I, Hughes C. Reaching the hard-to-reach: A systematic review of strategies for improving health and medical research with socially disadvantaged groups. BMC Med Res Methodol. 2014;14:42.
Liamputtong P. Researching the vulnerable. London: SAGE; 2007.
Roper J, Shapira J. Ethnography in nursing research. [Electronic resource]. Thousand Oaks, Calif: SAGE; 2000.
Sixsmith J, Boneham M, Goldring J. Accessing the community: Gaining insider perspectives from the outside. Qualitative Health Research. 2003;13(4): 578-589.
Higginbottom G, Pillay J, Boadu N. Guidance on performing focused ethnographies with an emphasis on healthcare research. Qualitative Report. 2013;18(17):1-16.
Cruz EV, Higginbottom G. The use of focused ethnography in nursing research. Nurse Researcher. 2013;20(4):36-43.
Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18(1): 59-82.
Ortlipp M. Keeping and using reflective journals in the qualitative research process. Qualitative Report. 2008;13(4):695-705.
Al-Amer R, Ramjan L, Glew P, Darwish M, Salamonson Y. Translation of interviews from a source language to a target language: Examining issues in cross-cultural health care research. Journal of Clinical Nursing. 2015;24(9/10): 1151-1162.
Chen H, Boore J. Translation and back-translation in qualitative nursing research: Methodological review. Journal of Clinical Nursing. 2010;19(1-2): 234-239.
Nurjannah I, Mills J, Park T, Usher K. Conducting a grounded theory study in a language other than English. Sage Open. 2014;4(1):1-10.
Maneesriwongul W, Dixon J. Instrument translation process: A methods review. Journal of Advanced Nursing. 2004;48(2):175-186.
Squires A. Language barriers and qualitative nursing research: methodological considerations. International Nursing Review. 2008;55(3):265-273.
Ferrant G, Pesando GL, Nowacka K. Unpaid care work: The missing link in the analysis of gender gaps in labour outcomes. Paris: OECD Development Centre; 2014. Available from: https://www.oecd.org/dev/development-gender/Unpaid_care_work.pdf. Accessed October 8, 2018.
Binder-Finnema P, Lien P, Hoa D, Målqvist M. Determinants of marginalization and inequitable maternal health care in North-Central Vietnam: A framework analysis. Global Health Action. 2015;8(1).
Munro J, McIntyre L. (Not) getting political: Indigenous women and preventing mother-to-child transmission of HIV in West Papua. Culture, Health & Sexuality. 2016;18(2):157-172.
Norsa'adah B, Wnorlida W. Preventive health practices among women at rural villages in Malaysia. International Medical Journal. 2014;21(2):143-145.
Wongwatcharanukul L, Promthet S, Bradshaw P, Jirapornkul C, Tungsrithong N. Factors affecting cervical cancer screening uptake by Hmong hilltribe women in Thailand. Asian Pacific Journal of Cancer Prevention. 2014;15(8):3753-3756.
United Nations Sustainable Development Goals. Sustainable development goal 5: Achieve gender equality and empower all women and girls [Internet]. UN: Department of Public Information; 2015. Available from: http://www.un.org/sustainabledevelopment/gender-equality/. Accessed October 8, 2018.
Sen G, Ostlin P. Unequal, unfair, ineffective and inefficient gender inequity in health: Why it exists and how we can change it [Internet]. WHO: Women and Gender Equity; 2007. Available from: http://www.who.int/social_determinants/resources/csdh_media/wgekn_final_report_07.pdf?ua=1. Accessed October 8, 2018.
Riang'a R, Nangulu A, Broerse J. Food beliefs and practices among the Kalenjin pregnant women in rural Uasin Gishu County, Kenya. Journal of Ethnobiology and Ethnomedicine. 2017;13(29):1-16
Browne A. Issues affecting access to health services in northern, rural and remote regions of Canada. British Columbia: University of Northern British Columbia; 2010. Available from: https://www.unbc.ca/assets/northern_studies/northern/issues_affecting_access_to_health_services_in_northern.pdf. Accessed October 8, 2018.
Lama S, Krishna A. Barriers in utilization of maternal health care services: Perceptions of rural women in Eastern Nepal. Kathmandu University Medical Journal. 2014;12(48):253-258.
Cameron B, Carmargo Plazas M, Salas A, Bourque Bearskin R, Hungler K. Understanding inequalities in access to health care services for aboriginal people: A call for nursing action. Advances in Nursing Science. 2014;37(3): 1-16.
Askew D, Brady J, Brown A, Cass A, Davy C, DeVries J, Fewquandie B, Hackett M, Howard M, Ingram S, Liu H, Mentha R, Peiris D, Simon P, Rickards B, Togni S. To your door: Factors that influence Aboriginal and Torres Strait Islanders peoples seeking care. Kanyini Qualitative Study Monograph Series. 2008;1:1-25.
Davy C, Cass A, Brady J, DeVries J, Fewquandie B, Ingram S., & ... Brown A. Facilitating engagement through strong relationships between primary healthcare and Aboriginal and Torres Strait Islander peoples. Australian & New Zealand Journal Of Public Health. 2016;40(6):535-541.
Castro A, Savage V, Kaufman H. Assessing equitable care for Indigenous and Afrodescendant women in Latin America. Revista Panamericana De Salud Publica-Pan American Journal of Public Health. 2015;38(2):96-109.
Sharma B, Ramani K, Christensson K, Giri G, Johansson E. The transition of childbirth practices among tribal women in Gujarat, India - a grounded theory approach. BMC International Health and Human Rights. 2013;13(1).
Hankivsky O, Reid C, Cormier R, Varcoe C, Clark N, Brotman S, et al. Exploring the promises of intersectionality for advancing women's health research. International Journal for Equity in Health. 2010;91:15.
Iyer A, Sen G, Östlin P. The intersections of gender and class in health status and health care. Global Public Health. 2008;313-24.