Status of the stateless population in Thailand: How does stigma matter in their life?

BACKGROUND: The stateless population in Thailand live by accessing all public services, including the health care system. Stigma is a crucial factor impacting these individuals' lives and their access to medical care. This study aimed to understand the experience of the stateless population in Thailand and how they overcome the problem of stigma.
METHODS: A qualitative method was used to elicit information from key informants who were members of the stateless population, which was classified as those who did not hold Thai identification cards (IDs). A questionnaire was used to guide the interview, which was conducted in a private and confidential room. The interviews were conducted after voluntary agreement was obtained from the participants; each interview was held in August 2021 and lasted for approximately 45 minutes.
RESULTS: Fifty-one people participated in the study; 68.6% were females, 86.3% were married, and 90.2% were Akha or Lahu. The stateless population in Thailand reported four types of perceived stigma: 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 being ranked below other hill tribe people who have IDs. The phrase "life is nothing" was presented by the participants, who reported that they felt like an invisible population in Thailand. Some participants reported that other hill tribe people who have IDs act as stigma perpetuators among members of the stateless population who do not have IDs. Maintaining their privacy within their village, trying to obtain a Thai ID, and practicing the Thai language were the main ways of avoiding the stigma reported by the stateless population. Obtaining a Thai ID was detected as the top goal in their aim to overcome the stigma problem.
CONCLUSIONS: The stateless population in Thailand live as an invisible population and are negatively treated via various patterns from others. Accessing Thai IDs and education are argued to be the most effective procedures for addressing the problem under the implementation schemes of the relevant organizations.

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.

Ethics approval and consent to participate

All research protocols and tools were reviewed and approved by the Committee (No. REH-70/2564). Before the interview, the essential information was clearly communicated in Thai and Burmese to the participants. Informed consent was obtained on a voluntary basis. Those who could write were asked to provide a fingerprint representing informed consent on a voluntary basis.

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).

Table 1

Demographic data of the participants.

Characteristics	n	%
Total	51	100.0
Sex
Male	16	31.4
Female	35	68.6
Age Min = 15, Max = 70, Mean = 43 years
Marital status
Single	3	5.9
Married	44	86.3
Previously married	4	7.8
Tribe
Thai Yai	5	9.8
Lahu	20	39.2
Akha	26	51.0
Religion
Buddhist	14	27.4
Christian	37	72.6
Education
No education	34	66.7
Primary school	12	23.5
Secondary school	4	7.8
Diploma school	1	2.0
Occupation
Farmer	29	56.9
Daily wage employee	14	27.4
Unemployed	7	13.7
In school	1	2.0
Income (baht) Min = 0, Max = 9,500, Median = 2,888 baht

II. Perceptions of stigma

There were different forms and levels of the participants’ perceptions of stigma among the stateless population in Thailand: 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 have IDs.

a) Having a lower ability to request that their needs be met

The stateless population felt that they did not have the power to negotiate and had no voice during everyday situations or when requesting needs, especially regarding access to health care services. This feeling was detected among almost all participants. Some people reported that they voiced their needs but acquired only a minimal response from health care providers. However, many people reported remaining silent about their needs because they feared that they would not receive good care from health care providers.

A 54-year-old woman stated the following [P#20]:

“I had a stomachache a month ago, and I went to see a doctor in a hospital. He prescribed some medicines to me, but they made me feel only a little better. I truly did not know what I should do next. I hoped I would be referred to a larger hospital in the city. However, I had no idea because I have no Thai ID. I do not have any right to ask for help from him. It is like no one can hear my voice.”

A 53-year-old woman stated the following [P#11]:

“A few months ago, I got a bad headache; my expectation was to get good treatment from a big hospital in Chiang Rai, but I did not dare to tell the staff about my expectation. I was afraid that if I said something wrong, I would not get good care from them. I kept it to myself even though I truly wanted to get care from a better hospital.”

A 30-year-old woman stated the following [P#15]:

“When I was at the hospital for the delivery of my baby 3 years ago, I screamed very loud because of the pain, and a nurse came and shouted at me. I stopped and kept quiet even though the pain worsened. I could not ask for any help from her. I was afraid that I would be treated badly.”

Many stateless people have previously been or currently are faced with a limited ability to state their needs and request that they be met. This experience was reported by almost all of the stateless people we interviewed.

b) Being unequal to others

This form of stigma was reported in particular by young adult members of the stateless population. The sense was that stateless individuals are not treated as though they are equal to other people, especially by other hill tribe people who hold Thai IDs and are thus confirmed to be Thai citizens. The perception of not being equal to others was also reported in relation to attending health care services under different scenarios, such as delays in seeing a doctor and repeatedly being queued.

A 15-year-old woman stated the following [P#1]:

“I think nothing is equal in my life. This has always happened to me and my family. I have experienced it since I was young. One day, my grandma got ill, and I brought her to a hospital. I informed a nurse and waited for a long time before getting help from her. Neither of us could speak Thai, so my grandma was queued behind everyone else and got worse. I think about my bad experience a lot. It hurts me so much.”

A 20-year-old woman stated the following [P#25]:

“My main illness is migraines. I have to see my doctor monthly, and I am always the last person being cared for. I accept that because I have no Thai ID and so things are not equal for me.

These population members have faced unequal situations when trying to access health care services. Most of them have experienced delays in seeing a doctor and have many unanswered questions in their minds, but only non-Thai citizenship is given as a reason for such inequality.

c) Not being able to qualify for health care services

All members of the stateless population are charged when they go to any public or private hospital in Thailand, except for some basic public health programs, such as immunizations for children, because they do not have Thai IDs. The card is used to gain free access to all public services and to be considered as having full rights under the Thai Constitution of the Kingdom of Thailand. Being charged medical fees before being able to obtain such services was one of the bad experiences reported among the stateless population. Experiences with being confronted by some typical words or sentences, including physical language from health care providers, were one of the issues that caused the most suffering, according to the stateless population. “A man who was not fully a man” was the definition of their situation because they did not have the full qualifications to access health care services.

A 63-year-old man stated the following [P#13]:

“Without an ID, I feel that I am not fully a man. I am so jealous of those who have an ID. If you have a Thai ID, you have lots of advantages. I feel like I cannot get even essential things in the same way as others. I have now been diagnosed with hypertension. Do you know how much I suffer to see a doctor to get a prescription every month? I have to pay so much money for my medicine. I suffer a lot.”

A 44-year-old woman stated the following [P#17]:

“I had a very bad experience with this hospital. I have money to pay my medical fees, but they still acted like I was a very poor just because I do not have an ID. You know a nurse said to me, “Do you have money to pay for these services? It is expensive for you, you know?” I think because I have no Thai ID, I have been labeled as poor.”

A 47-year-old woman stated the following [P#21]:

“I have had diabetes mellitus for 2 years. The nurse told me that because of my disease, I need to take pills for the rest of my life. I think if I could go to a better hospital, I would be cured, but the problem is that I do not have a Thai ID. I also do not think I am qualified for access to a big hospital in the city. I also fear that because I am not Thai, they might not take good care of me.”

One of the main barriers to health care services is the lack of Thai IDs. Those members of the stateless population who do not have a Thai ID do not qualify for access to free medical and health care services although every country must treat all humans equally.

d. Being ranked below other hill tribe people who have IDs

A large proportion of the hill tribes in Thailand have obtained Thai IDs, which means that they are considered full Thai citizens. Individuals with Thai IDs are members of families who immigrated into Thailand centuries ago and are now in their third or fourth generation. In contrast, the stateless population members only recently moved to Thailand. Many stateless people feel that they live at a standard below that of the tribe people who have access to health care services. Along with successful health care services, other services are granted at a lower priority to tribe people who do not hold Thai IDs. The quotes below provide more information about being provided with services that are secondary in nature compared to those who are in the same tribe but hold a Thai ID.

A 63-year-old man stated the following [P#13]:

“I and some other tribes came from the same original area in Myanmar many years ago. In my mind, we should be the same; but you know, we are not the same. I have no Thai ID, but they do have one. They have full rights as Thai citizens, but I do not. I feel I am standing below everyone … I am lower than some hill tribe people who have IDs. The card makes us different.”

A 30-year-old woman stated the following [P#15]:

“Two years ago, I went to a hospital for antenatal care. While I was waiting in the public waiting room, a hill tribe woman presented her Thai ID to the hospital staff. She was very proud because she did not have to pay her hospital fees. I feel that I am lower than everyone. I am different from other tribes who have IDs; I am lower than them.”

Hierarchies of power occur when social values cause differences to exist between individuals. The stateless population have realized that they are positioned lower than the hill tribe members who have been granted Thai citizenship. This situation means that obtaining IDs could increase these individuals’ power.

e. No better options in life

As members of a stateless population in Thailand, the people we interviewed were treated as secondary after the hill tribe people who hold Thai IDs not only when accessing health care services but also in regard to choosing jobs, accessing schools, and relocating. Stateless people have fewer choices when choosing a job. All professional and high-wage jobs require a Thai ID and school certification. These conditions contribute to the minimized ability of members of the stateless population to obtain a good job. Almost all of the participants reported working as laborers in their hill tribe or on Thai farms for small daily wages.

When individuals live under conditions that cannot fully contribute to obtaining a better life, then individuals become hopeless, or they feel that life is nothing, a feeling that was presented among this group.

A 39-year-old woman stated the following [P#4]:

“I had an appendectomy a couple months ago. With no Thai ID, I was charged 30,000 baht ($1,000). This caused much suffering for me and my husband. If I would have had a Thai ID, then I could have received medical care for free. However, having no Thai ID, I had no better choice.”

A 55-year-old man stated the following [P#2]:

“There are many jobs in this country, but I am not qualified to apply for them because I have no Thai ID. I cannot even go outside this district.”

A 36-year-old woman stated the following [P#9]:

“When I was young, I truly wanted to go to school like other children. I asked my parents why I could not go and they said it was because we did not have IDs. I felt truly upset, and this affected my life. I lost my opportunity to go to school in my childhood, and now I cannot speak Thai. I cannot get a good job and earn money for my family.”

A 15-year-old teenager stated the following [P#1]:

“I have two younger sisters and one younger brother. Although we can go to elementary school, further study at higher levels is impossible. If you do not have a Thai ID, you are not allowed to go to university in Thailand.”

Regarding access to school in Thailand, the Thai government encourages all children to attend school for free until the third year of secondary school. However, at all vocational college and university levels, students are asked to show their Thai IDs or passports that identify them as citizens of another country. Members of the stateless population cannot obtain citizenship cards; thus, they do not meet the qualifications to attend higher levels of school.

The lack of Thai IDs directly impacts the lives of members of the stateless population. Having a Thai ID not only permits access to public services but also allows people to attain a good quality of life, which is affected by one’s education, income and career.

III. Stigmatized people perpetuate the stigma

While many hill tribe people have been granted a Thai ID after living in Thailand for some time, other people do not meet the criteria and thus have received no ID. People who hold Thai IDs can work and attend a higher level of school, including the university level. Afterward, many of the hill tribe people who can pursue a higher level of education are then able to work in a good organization in either the public or private sector. Then, some of these individuals perpetuate the stigma to the other tribe members who do not have an ID.

A translator employed in a local hospital located in the hill tribe villages was reported to have engaged in some of the stigma-related behavior faced by the hill tribe people who do not hold Thai IDs while working at the hospital:

“A few weeks ago, I visited a doctor at a hospital. A certain hill tribe man works at this hospital as a translator. He was hired because he has a Thai ID. When I met him, he acted as though we were of a lower status than him. Because they have Thai IDs and are hired in government offices, they act as if they have a higher status than us. I do not like this.”

IV. Stigma coping strategies

The stateless population reported several approaches to handling the stigma problem. Avoiding problems is one of the priority behaviors used when one encounters stigma, as reported by this population. This skill is dominant among members of this population. Examples include not traveling outside the village, not talking with people with whom they are not familiar, and keeping up with any unexpected event that could result in exposure.

A 23-year-old man stated the following [P#8]:

“I am 23 years old, still young and want to enjoy my life, but I have limited time to spend with friends. Even though I want to go to a town to enjoy things like other adolescents, I have to stay in the village. There is a checkpoint to prohibit stateless people from traveling outside the living area, and many police work there to detect illegal migrants. I do not want to have a problem, so I do not go outside the village; I feel sad when I think about this.”

A 49-year-old man stated the following [P#22]:

“As I do not have a Thai ID, I am very careful when I meet people. I will not talk to people whom I am not familiar with because I do not know who they are; they might be a spy from the police to catch illegal immigrants. My friend in the village told me that if I am caught, I have to pay a lot of money and stay in jail for many years. Are you a spy?”

A 28-year-old man stated the following [P#26]:

“I am a man who would like to enjoy life and work hard for the money. However, I cannot do anything. I moved from Myanmar 10 years ago by walking through the natural route. My status is still that of a stateless person. I cannot go outside the village the same as other stateless persons because I am scared of being caught by the police. I try not to go to parties or get involved in any risky situations, for example, wedding parties and housewarming celebrations. I stop problems before they happen.”

A Thai ID is requested in many situations, especially when participating in government activities. Thus, seeking a way to obtain an ID is one of the most common tactics reported among stateless people. In the field, information was presented that obtaining Thai IDs could be achieved by deceitful approaches.

A 54-year-old woman stated the following [P#20]:

“The government staff surveys the number of stateless population members every year, and I look forward to getting an ID too. I have heard that if you have money and are able to pay for some procedures, you will get an ID easily. However, I am not sure that this information is correct. I, myself, I will not go this way because I do not have much money.”

A 28-year-old woman stated the following [P# 36]:

“I heard that people who have an ID had to get close to a member of the government and pay them a lot of money.”

She added the following:

“Getting an ID is difficult for me. I do not have enough money to deal with the process of receiving a Thai ID. I also do not know a better way to get it. I and my husband would like to follow the government guidelines about getting a card.”

Another tactic for reducing the impact of stigma among the stateless population is practicing the Thai language. Speaking fluent Thai helps to protect against stigma, particularly regarding access to government offices; however, not speaking Thai fluently does not limit one’s daily communication with people who speak Thai, such as when individuals sell their farming products.

A 34-year-old woman stated the following [P# 39]:

“When I go to a hospital, I try to use Thai to contact them; otherwise, the staff look down on me. I try to speak Thai, and I try to speak the same as the general Thai accent. This can help me to make myself feel better.”

A 47-year-old woman stated the following [P# 17]:

“I know they look down me because I cannot speak Thai. If a person speaks the Thai language fluently, it seems as although we are not the same type of Thai. I can see their behaviors, such as their tone of voice and the look in their eyes. You know? I understand them but I cannot speak to them.”

A 37-year-old man stated the following [P# 42]:

“Using the Thai language when selling cabbage and other products from our farm is not difficult. However, every time I go to the district office, I feel nervous and appear to be smaller than I am. I practice speaking in a Thai accent to increase my confidence in talking to them.”

Several approaches were reported to address the stigma among the stateless population. Keeping to themselves in villages is a favorite method of avoiding the impact of the stigma. Another approach is to practice speaking Thai. Those who can speak Thai fluently experience little impact from the stigma.

V. The hope and the brightness

The one and only hope for the stateless population living in Thailand is to have Thai IDs. It is the key to opening everything, including removing the stigma from their lives.

A 58-year-old woman stated the following [P# 3]:

“If I had an ID, it would no longer be difficult to see a doctor in a hospital. No one would ask me about the right to receive treatment.”

A 53-year-old woman stated the following [P# 11]:

“When I go to a hospital, I do not dare speak because I cannot speak Thai fluently. I do not understand what a doctor is saying. Moreover, I feel that some staff members look down on me. They always ask me what right I have to access a service. I feel uncomfortable, truly, so getting an ID is the most important thing in my life.”

A 27-year-old woman stated the following [P# 40]:

“The most desirable thing in my life is getting a Thai ID. Doing so could help me to get a better job and a better life. This would affect not only my life but also my family’s life. Additionally, I would not be part of a secondary population anymore.”

Having a Thai ID is a significant factor that affects the likelihood of having a good future for the stateless population living in Thailand. These IDs are used to access medical services and education. Anyone who has a good education will have a better opportunity to get a good job.

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.

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19 Oct 2021

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This study was supported by a grant from the Center of Excellence for Hill Tribe Health Research, Mae Fa Luang Thailand. The funder had no role in the design of the study, collection, analysis, and interpretation of the data and writing of the manuscript.

Please note that funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The paper is interesting and reflects the significant issue that minorities in Thailand are facing.

The manuscript is well structured.

However, there are some grammatical errors (for example, tenses) and word choices (for example, a mole instead of a spy). The authors need to work more on literature reviews. More discussions on the differences between stigma, prejudice, and discrimination should be added. More reviews on types of stigma: public stigma, self-stigma, & institutional stigma could be a good addition.

The methodology section is well structured and clear.

Some contents in the result section are not matched with headers in the result section, for example, in sections C, D, & E.

The examples related to the Thai language may have a separate section.

It is unclear on the interpretation of “life is nothing.” Is it about meaningless or invisible?

In the conclusion section, the authors may need to suggest more substantial implications or policy recommendations instead of summarizing the findings again.

Reviewer #2: The authors aimed to examine the experience of Thailand's stateless population and how they deal with stigma. The manuscript is a technically sound piece of scientific research that includes data to back up the conclusions. There is a concise statement as well as ethical considerations.

However, there is a lack of theoretical support/discussion. An additional topic of debate might be the concept of stigma in marginalized communities, i.e. Furthermore, the analytical component is demonstrated without a comprehensive literature study or theoretical support/discussion. The analytical focus is solely on Thailand, with only limited implications for other empirical investigations. The author provides no evidence of demographic differences or differing educational backgrounds, which may have an impact on the type/degree of stigma. In many cases, the transcripts were simply inserted without further examination.

Please clearly specify the interviewee selection criteria.

Furthermore, because the definition of a stateless person is "who is not considered as a national by any state under the operation of its law" (The 1954 Convention relating to the Status of Stateless Persons), Simply described, a stateless person is someone who does not have nationality from any country. Thereby, the analytical and conclusion sections, as well as recommendations should be done with caution to avoid recommendations with a tautology-related perspective.

**********

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Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

13 Dec 2021

Response to reviewers’ comments

Dear Plosone,

Thank you very much for given us the opportunity to revise the manuscript. We have carefully checked, cleared, and responded to all points raised by you and reviewers.

Moreover, we have made a bit change on the title from “Status of the stateless population in Thailand: how does stigma matter in their life?” to “Status of the stateless population in Thailand: how does stigma matter in their life ?” which is reported in the cover letter to you as well.

We do hope that you happy in this version, and look forward to hearing from you.

Regards,

TK

PONE-D-21-27010

Status of the stateless population in Thailand: how does stigma matter in their life?

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

: Thank you, we checked and followed the journal guidelines.

2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match.

When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

: Thank you. This problem is now revised.

3. Thank you for stating the following in the Acknowledgments/ Funding Section of your manuscript:

This study was supported by a grant from the Center of Excellence for Hill Tribe Health Research, Mae Fa Luang Thailand. The funder had no role in the design of the study, collection, analysis, and interpretation of the data and writing of the manuscript.

Please note that funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

: Thank you. This information is now revised.

: Please kindly insert the following statement in the funding section:

“Funding

This study was supported by a grant from the Center of Excellence for Hill Tribe Health Research, Mae Fa Luang Thailand (No. 01-2021). The funder had no role in the design of the study; collection, analysis, and interpretation of the data; or writing of the manuscript.”

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

: Thank you. These files are now revised and updated.

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Reviewers' comments:

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1:

1) The paper is interesting and reflects the significant issue that minorities in Thailand are facing.The manuscript is well structured. However, there are some grammatical errors (for example, tenses) and word choices (for example, a mole instead of a spy).

: This manuscript was revised again by American Journal Experts (AJE), reference No 39DA-241D-833B-CF5B-531B

2) The authors need to work more on literature reviews. More discussions on the differences between stigma, prejudice, and discrimination should be added. More reviews on types of stigma: public stigma, self-stigma, & institutional stigma could be a good addition.

: Thank you for the comment. We added the relevant information on page 3, lines 7-21 with references no 15-19.

3) The methodology section is well structured and clear.

: Thank you.

4) Some contents in the result section are not matched with headers in the result section, for example, in sections C, D, & E. The examples related to the Thai language may have a separate section.

: Thank you for this important comment.

: As a team, we carefully discussed this issue and realized that in Parts C and D, two themes were extracted from the analysis: being unable to qualify for health care services and being ranked below other hill tribe people who do hold Thai IDs. We revised all the details of the supported content so it relates to the theme. Meanwhile in Section E, P#9 said she could not get a good job because she did not attend a school when she was young. She also said she could not speak Thai, which was one reason she was not recruited into a good job. We decided to retain the sequence of her story in the manuscript’s contents because we want to ensure that all readers understand the context of the stateless population in Thailand.

: With this important comment, we revised all the contents in the manuscript to ensure that all the information and themes are consistent.

: Thank you very much for the comment and we hope our revisions are clear.

5) It is unclear on the interpretation of “life is nothing.” Is it about meaningless or invisible?

: After carefully reviewing Section E (“Life is nothing”), we completely agree with you that the message lacks interpretation. Thank you very much for the important comment.

: We reviewed all the information and interpreted it. Please see page 11, lines 12-14.

6) In the conclusion section, the authors may need to suggest more substantial implications or policy recommendations instead of summarizing the findings again.

: Thank you for the comment. We improved this section.

Reviewer #2:

1) The authors aimed to examine the experience of Thailand's stateless population and how they deal with stigma. The manuscript is a technically sound piece of scientific research that includes data to back up the conclusions. There is a concise statement as well as ethical considerations.

: Thank you very much.

2) However, there is a lack of theoretical support/discussion. An additional topic of debate might be the concept of stigma in marginalized communities, i.e., Furthermore, the analytical component is demonstrated without a comprehensive literature study or theoretical support/discussion.

: Thank you for the comment.

: Essentially, we reviewed many studies and examined many concentrated conceptual frameworks before undertaking this project. Ultimately, we used the framework integrating normative influence on stigma (FINIS) for the study [15], which turned out to the best fit.

3) The analytical focus is solely on Thailand, with only limited implications for other empirical investigations. The author provides no evidence of demographic differences or differing educational backgrounds, which may have an impact on the type/degree of stigma. In many cases, the transcripts were simply inserted without further examination.

: Thank you for the important comment. This project originated from the stigma experiences among the stateless population in Thailand. During the analysis, we thought carefully about including individual information in the manuscript quotations. However, we realized that inserting increasing amounts of information into the manuscript might violate the ethics of a good human-subject research project. Therefore, we listed the group’s demographics, including education, in Table 1.

: Most of the stateless population in Thailand cannot access education (66.7% had no education and 23.5% attended primary school only), and the stigma impacts may not differ according to their educational level. We hope our explanation is clear.

4) Please clearly specify the interviewee selection criteria.

: The interviewee selection criteria were a) being part of the stateless population, defined as having no Thai ID, and b) experiencing any form of stigma (page 4, lines 19-21).

5) Furthermore, because the definition of a stateless person is "who is not considered as a national by any state under the operation of its law" (The 1954 Convention relating to the Status of Stateless Persons), Simply described, a stateless person is someone who does not have nationality from any country. Thereby, the analytical and conclusion sections, as well as recommendations should be done with caution to avoid recommendations with a tautology-related perspective.

: Thank you so much for such an important comment.

: The first paragraph of the Conclusion was focused on granting Thai IDs because the context of the related laws has changed over time and by case. Therefore, the 1954 Convention relating to the Status of Stateless Persons clearly states the definition of stateless persons, but the new Constitution of Thailand includes much evidence as new criteria to be used for granting IDs. These include making a great contribution to Thai society in any respect, being a person devoted to Thailand through sports, etc. Moreover, the law has been revised to adapt to the new situation of Thai society. Therefore, we included this content in the first paragraph of the Conclusion. We hope that our reasoning is clear.

TK

Assistant Professor Dr. Tawatchai Apidechkul

Dean, School of Health Science, MFU

Director, Center of Excellence of the Hill Tribe Health Research, WHO-CC

Former Hubert H Humphrey Fellow (2013-2014), Emory University

Global Health Delivery Intensive (Harvard School of Public Health)

Submitted filename: Response to reveiwer commentsEE.docx

Click here for additional data file.

27 Jan 2022

29 Jan 2022

Response to reviewer comments

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

: Thank you, we have double check all references. Reference No.7, 9, 16, 17, 18, 26,33, and 34 are revised and completed.

Reviewers' comments:

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors addressed and responded to all of my comments and suggestions. However, I have some comments on their responses.

The name of Section E can be “No better options in life” instead of “Life is nothing.” “No better options in life” may represent the stories in this section clearer. The term “life is nothing” is unclear.

: Thank you, we agreed with you and have changed accordingly, please see page 11, line 4.

In addition, please be careful on the lettering of section “B. Perceptions of stigma.” Should they all be “d), e)”? Another option is using numbers. It may be easier to structure the sections.

: To make sure that the sequence is not difficult for readers, we have revised by using Greek alphabet (I, II...) to the main theme and use English in sub-theme. Thank you

In the conclusion section, the authors suggest that the problems may be alleviated by providing Thai IDs to hill tribe people. They also suggest the promotion of nonstigma behaviors and services toward anyone. In many countries, there are laws on discrimination in healthcare, employment, and education. The authors may explore more on the discrimination laws and regulations.

: Thank you for great comment here, we have added information on creating and implementing relevant laws on discrimination protection in access healthcare services in this section, please see in page 18, lines 27-29.

Like my comment on the subsection “e)”, the term “life is nothing” is unclear. I would suggest that the term “No better options in life” should also be used in the discussion and conclusion.

: We agreed with you and revised.

Reviewer #2: (No Response)

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Thank you,

TK

Submitted filename: Response to reviewer comments.docx

Click here for additional data file.

21 Feb 2022

Status of the stateless population in Thailand: how does stigma matter in their life?

PONE-D-21-27010R2

Dear Dr. Apidechkul,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Ghaffar Ali, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors already responded all my comments and suggestions. However, there is a issue on formatting under section II. The authors should make their decision on the style of subsection. Should they be a), b), c), d), e) or a., b., c., d., e.?

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

4 Mar 2022

PONE-D-21-27010R2

Status of the stateless population in Thailand: how does stigma matter in their life?

Dear Dr. Apidechkul:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

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on behalf of

Prof. Ghaffar Ali

Academic Editor

PLOS ONE