Introduction

Since late 2019, COVID-19 has emerged globally as a new, emergent, communicable disease for humans [1]. A large number of infections and deaths have been reported throughout the year-long pandemic [2,3]. Collaborations between people and governments to address this common threat have been observed worldwide [4]. A number of impacts have been reported through forums in both formal and informal settings [5,6]. All of human society has been impacted by this disease, which can be observed in the direct and indirect effects of the disease [7–9]. There are many direct impacts, such as health problems, complications from pathogenesis, economic issues related to access to health care, and reduced quality of life [10–12]. The indirect impact can be measured in the decrease in social relationships, family relationships, quality of education due to online classes, economic losses from the lockdown, etc. [13–15]. However, the severity of the impacts depends on how people can adapt their behaviors, as well as on their education and economic status [16].

Adaptation is defined as the ability of a person or species to survive in a particular ecological niche or a behavior introduced via natural selection [17]. There are at least two forms of adaptation: biological and cultural [18]. Different populations in many scenarios have survived the pandemic [19–21]. For example, to maintain the economy, many people have begun using online markets [22]. Online teaching has been offered by educational institutes [23]. Many social and economic activities are occurring online, including business meetings [24]. Thus, the ability of different people to adapt is critical to overcoming this serious threat and reflects the maintenance capacity of populations. Those who have a high economic and education status are assumed to have a better ability to adapt until a disease-free state is achieved. However, many people live under poor economic conditions where education is also poor, including many without certain state citizenship, such as the hill tribe people in Thailand.

The COVID-19 pandemic will exert a greater impact on vulnerable populations, such as hill tribes and stateless populations, due to their economic and educational status. The hill tribes live along the border areas of Thailand and Myanmar [25]. More than 4 million hill tribe people lived in Thailand in 2020, and 30% of hill tribe people do not have Thai citizenship [26]. Those who hold Thai citizenship are able to access all public services, including health and educational institutes, free of charge [27]. The remaining 30% who are not Thai citizens live without support from the government of Thailand [27]. During the COVID-19 pandemic, the central government of Thailand launched many programs to help sustain the economic and physical health of individuals and families [28,29]. However, these programs are not provided to those without Thai citizenship [30]. Many government policies include direct and indirect measures to reduce the impacts of the disease. However, other policies have impacted village dwellers in different ways. Different age categories experience different levels and forms of impacts; moreover, individual adaptability is also related to different personal backgrounds and social support [31].

This study aimed to investigate the impacts of and adaptations to the COVID-19 pandemic and government interventions among hill tribe people living along the border of Thailand and Myanmar.

Materials and methods

A qualitative method was applied to collect information from key hill tribe informants who were aged 20 years and over and lived in the hill tribe villages along the border areas of Thailand and Myanmar in Mae Fah Laung district, Chiang Rai Province, Thailand. A purposive method was used to select participants who had direct experience with COVID-19.

The research question guidelines were developed from a literature review and were designed to collect preliminary information from the hill tribe villagers. The questions focused on two main issues: COVID-19 impacts and adaptations. In the first set of questions, seven questions were used to determine the impacts of the COVID-19 pandemic: a) Have you been impacted by COVID-19? b) Have you had any health impacts from the disease pandemic? c) Have you had any economic impacts from the disease pandemic? d) Have you been impacted by government control and prevention measures? e) Have you experienced relationship problems from the distancing policy and measures? f) Have you experienced disparities in support from the government based on being impacted by the disease? g) Has your children’s school attendance been impacted by the pandemic?.

The second set comprised seven questions used to collect information on adaptations to the COVID-19 pandemic: a) Have you implemented any self-care adaptations to prevent the disease? b) Have you implemented any adaptations to protect your family members? c) How do you modify your daily practice regarding attending social activities? d) How have you maintained your relationship with family members under social distancing? e) How have you maintained your family financial status, and how have you maintained medical access in case a family member needs to access medical care regularly? f) How have you adapted to government control and prevention measures? And g) How has your community adapted to prevent and control the disease among community members?.

All the questions were then assessed for quality by three experts in the field: social workers, public health professionals, and epidemiologists. Afterwards, questions were provided to five hill tribe people who lived in the hill tribe village in Mae Chan district, Chiang Rai Province, Thailand. Before use in the field, the question guidelines were reassessed by researchers.

The five interviewers had various backgrounds, such as medical anthropology, public health, behavioral science, and social epidemiology. Moreover, all interviewers were trained in qualitative research and had an average of four years of experience in performing qualitative research. Interviewers worked in educational institutions near the participants’ residences and are familiar with one another from previous works.

Seven hill tribe village headmen were contacted after access to the villages was granted by the district government office. On the day of meeting with the village headmen, all essential information on the study was explained. Key informants were selected and informed of the appointment five days in advance. On the date of the interview, informed consent was obtained voluntarily from all participants. Those who could not speak Thai were helped by village health volunteers who were fluent in both Thai and their local languages. Village health volunteers worked as translators to improve the accuracy of the conversation between interviewer and interviewee, but the interviewer (researcher) was the one who gathered information from the participants using the question guidelines. All the participants were provided with information on the interviewers, especially their educational and occupational background. A face-to-face interview was conducted at the participants’ homes, each lasting approximately 45 minutes. With the participants’ approval, all interviews were taped, and field notes were taken. The interviews were conducted in January 2021.

All taped interviews were transcribed into text. The transcriptions were checked for errors before being sent back to participants to confirm the accuracy of the content. Data were coded, and code trees were developed. The files were transferred to the NVivo program (NVivo, qualitative data analysis software; QSR International Pty Ltd., version 11, 2015). The thematic method was used to extract and organize the findings. All key findings were reconsidered by researchers before being sent to participants for their feedback. Finally, researchers drew conclusions based on all information obtained.

The research proposal, protocol, and tools were approved by the Human Research Ethical Consideration Committee from the Chiang Rai Public Health Provincial with IRB No. CRPPHO No. 72/2563. Written informed consent was obtained in Thai before the interviews were conducted. Those who did not understand the content written in Thai were provided explanations of all the content on the consent form by village health volunteers before fingerprinting into the informed consent form. All the data and records were kept confidentially and, after completion of the analysis, were destroyed properly.

Results

Fifty-seven (57) participants provided information for the study, including 36 females and 21 males. The average age was 50.1 years, with a minimum age of 20 and a maximum age of 90. The majority were married (36), previously married (13), or single (8). Twenty-seven (27) individuals were Thai Yai, 14 were Yunan Chinese, eight were Akha, and eight were members of other minor tribes. Regarding education and occupation, 30 individuals were illiterate, 27 had attended different levels of primary school, 40 were unemployed, 13 were employed as daily wage workers and farmers, and four were attending school (Table 1).

Download:

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

Table 1. Characteristics of participants.

https://doi.org/10.1371/journal.pone.0252326.t001

Two sets of findings are presented in this study, one on COVID-19 impacts and the other on adaptations to the pandemic.

Discussion

A total of 57 hill tribe participants living in remote and border areas in northern Thailand described the impacts of the COVID-19 pandemic and of prevention and control measures on their lives. These impacts are discussed based on different age categories. Children attending school experienced impacts associated with obtaining effective learning due to internet access and quality and financial problems associated with obtaining the relevant materials. Job loss and family financial problems were detected in the working-age group. Several concerns about access to health care services were commonly found among the elderly. Although the hill tribe people were constrained in their ability to resolve problems, they presented a number of positive adaptations for surviving the pandemic that were detected in six stages.

In our study, the hill tribe children were impacted by the COVID-19 pandemic through a reduction in their educational effectiveness because most of the educational platforms were changed to online methods. With limited internet access and relevant materials for their education, the children were hindered in understanding the content provided through online classes. This finding is consistent with a study conducted in 62 countries in 2020, which found that students were significantly less satisfied with their academic work and life during the crisis; moreover, the education of female, full-time and first-level students and students facing financial problems was generally affected to a greater degree by the pandemic [32]. Garbe et al. [33] reported that during the COVID-19 pandemic, parents encountered several problems associated with online classes, especially learner motivation, accessibility, and learning outcomes. In Thailand, several approaches have been applied to the Thai educational system, with most teaching provided by online methods and no better options available [34]. The predominance of online teaching methods impacted a large number of students in all grades and levels, particularly in their ability to access the internet and use the associated applications [35].

In the hill tribe people of working age, many had lost their jobs during the COVID-19 pandemic, which led to family financial crises. The World Bank reported negative projections of the gross world product (GWP) and gross domestic product (GDP) in all countries in 2020 [36]. A study conducted in 77 countries on the economic impact of COVID-19 reported that countries’ economies were impacted not only by COVID-19 but also by the implementation of government interventions during the COVID-19 pandemic [37]. A study in the United States reported that minorities were much more economically impacted by the COVID-19 pandemic and government interventions [38]. The Asia Foundation reported that almost all Thai people faced financial problems during the COVID-19 pandemic, particularly those who were living in poor economic and education conditions [39]. Most employees working in the industrial sector experienced the greatest impacts from the pandemic [40], and these included a large proportion of the hill tribes, who were working as employees in industrial sectors in large cities in Thailand.

The hill tribe elderly faced problems associated with their health and access to health care services during the COVID-19 pandemic. A large proportion were worried about their health and access to medicine. Bambra et al. [41] reported that under lockdown interventions to prevent and control COVID-19, elderly populations in most countries had limited access to medical care. Fischer et al. also reported that during the COVID-19 crisis, with its high numbers of infections, elderly individuals who had chronic diseases received less attention from health professionals [42]. A study on mental health problems among individuals from 78 countries found that they were common among elderly people during the COVID-19 pandemic [43].

Elderly Thai people, including the hill tribe elderly population, have been impacted by physical and mental health issues during the COVID-19 pandemic, including difficulty in maintaining doctor appointments [44].

The lockdown policy has also impacted people’s relationships with their relatives and friends, which is not normally observed. This problem was compounded among vulnerable groups of hill tribe people, such as elderly people, disabled people, and children who need care from parents. In some stages, the parents were confined to a particular place or area, and movement was not allowed, which led to suffering from a lack of support. This finding is consistent with a study conducted by members of the Family Health in Europe-Research in Nursing (FAME-RN), which reported that the COVID-19 pandemic interfered with family structures and roles and influenced the health and well-being of each family member [45]. A study in Finland on the impacts of COVID-19 and family coping strategies during lockdown found that the relationship among family members was one of the substantial issues of concern for people, and the researchers attempted to identify the best coping method for Finland’s families [46]. The International Labor Organization (ILO) [47] reported that one of the crises during the COVID-19 pandemic in Thailand was family member relationships because all Thai families maintain contact based on cultural norms, and such norms are common among hill tribe families.

Six stages of adaptation under the COVID-19 pandemic crisis among the hill tribes were detected: the shock stage with no prior experience, looking for help from health and other agencies, considering the national lockdown policy, complying with prevention and control measures, decreasing stressful situations and following the new normal approach, and addressing suffering at home and elsewhere. All adaptation stages found in the hill tribe people were related to cultural and behavioral adaptations and influenced by internal and external factors. Internal factors included fear and shock from the situation, while external factors were found in a number of forms, including prevention and control strategies introduced by health and central government agencies. High adaptive ability is usually found among hill tribe people in Thailand because of their history of migration from South China to northern Thailand over two centuries. Individuals must adapt to the situations and surroundings associated with Thai culture, particularly while contacting Thai people through the trading system and Thai government officers when obtaining official documents. The hill tribe people in Thailand have high adaptability to new situations, which is clearly demonstrated by their survival under serious threats. Presti et al. [48] reported that humans adapted to survive under threats from the COVID-19 pandemic through different forms of coping and responding to certain problems. Pogrebna et al. [49] reported that people adapted their hygiene behaviors, particularly washing their hands, to protect themselves from the infection, and this represented one of the cultural adaptations made by participants in this study, as well.

Moreover, some participants reported that their living environment under COVID-19 was similar to the environment during wartime. In 1982, the Hin Tak war raged between the Thai army and the Khun Sa army in the hill tribe area [50]. People aged 40 years and over living in the hill tribe villages in the study area were exposed to the Hin Tak war and remembered the village environment at that time, with nobody moving freely. Similar feelings were reported regarding the COVID-19 situation, which reflects the fear and hopelessness of the people during the pandemic.

A few limitations exist in this study. First, some participants were not fluent in Thai; thus, translators were required, which means that the translated information might not exactly match the participants’ intended meaning. However, all transcribed text was sent back to the original participant to confirm the content before analysis. Another limitation is that during the interview, the interviewer and interviewee were of different genders, and the interviewee may thus not have fully expressed their intended meaning to the interviewer.

Conclusion

Since the COVID-19 pandemic was first announced in Thailand, many disease prevention and control measures for the population have been implemented via various approaches by local, national, and international agencies. Many of these agencies have a limited ability to reach hill tribe people who live in remote locations and border areas. Children are facing problems with receiving proper education, individuals of working age are losing their jobs and encountering new family financial problems, and the elderly population has had considerable difficulty in accessing medical care and are experiencing a loss of relationships with their offspring. In this serious situation, adaptations have been found among the hill tribes to survive the pandemic, six stages of which were observed: the shock stage with no prior experience, looking for help from health and other agencies, considering the national lockdown policy, complying with prevention and control measures, decreasing stressful situations and following the new normal approach, and addressing suffering at home and elsewhere. Essential and accurate information on COVID-19 prevention and control in the hill tribe languages should be developed and regularly distributed to the target populations. Appropriate teaching methods should be created to support children’s study at home. A mobile mental health clinic should also be developed to support people suffering from mental health problems, especially the elderly population. Moreover, programs and interventions to support and sustain family finances are also recommended.

Supporting information

Acknowledgments

We would like to thank all participants for providing essential information.