Abstract
BACKGROUND: Traditionally, most Western models of health viewed sickness and disease as a product of individual factors such as personal behaviors and genetic predisposition; consequently, healthcare interventions were largely focused on fixing the individual, with little attention placed on contributing external factors. The WHO's "Social Determinants of Health" (SDH) framework, however, takes a broader ecological perspective that suggests that interventions must occur at multiple levels in order for good health to be achieved on an equitable basis. This model views health as a function of many circumstantial and environmental factors that are continuously and simultaneously interacting across multiple domains. These factors include structural mechanisms, such as laws and policies; socio-economic conditions, such as education and occupation; and intermediary circumstances, such as living and working conditions. Utilizing the SDH framework as a guide, this qualitative study sought to identify which specific determinants are most significant and present the greatest risk to the health and well-being of the Urak Lawoi' (UL), a "sea nomad" group indigenous to southern Thailand. METHODS: Interviews, household surveys, and focus group discussions were utilized to gather primary data from 71 subjects in three different UL communities in southern Thailand. In addition, a comprehensive literature review of relevant international mechanisms, national laws, and national policies was conducted. All data collected was analyzed and coded utilizing HyperRESEARCH. RESULTS: In all three communities, education and livelihoods were found to be the most critical determinants. Additionally, land grabbing and living conditions were identified as dire issues on Ko Lipe. The law and policy review revealed several deviations between international mechanisms and national laws and policies in both enshrinement and enforcement, with the Royal Thai Government (RTG) often overlooking the interests of the UL when formulating laws and policies. CONCLUSIONS: The above-mentioned determinants, along other structural and intermediary determinants, are synergizing, thereby placing the UL at increased risk of poorer health and health outcomes compared to other Thais living in the same vicinities. To rectify this, the RTG must reform national laws and policies that harm the UL, and civil society must hold them accountable. Several recommendations are offered to achieve a better future for the Urak Lawoi'.