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Migrant beer promoters in Cambodia, Laos, Thailand, and Vietnam were surveyed to determine their experiences in accessing reproductive health care services in the cities of Phnom Penh, Vientiane, Bangkok, and Hanoi. A total of 7 health care institutions were chosen as popular with migrant beer promoters. Staff at these institutions provided information on the institution, and 390 beer promoters were surveyed about their experiences while accessing services. There were discrepancies between findings from the staff interviews and the experiences of the beer promoters. In general, the migrant women were satisfied with the cost, location, friendliness of the health care providers, and knowledge and skills of the providers. They were less positive about confidentiality and waiting times, though many still agreed that these were not an issue. Health care planners and providers should take note of the issues affecting access to reproductive health care services for migrant women when they design and implement services.
Migration of women is a common global phenomenon that has wide-reaching implications for women’s health status and access to health care services. Almost half of all international migrants are women; however, their experiences of migration differ from that of men.1 Migrant women have challenges accessing reproductive health care services in many settings across the globe. For example, Zimbabwean women migrating to South Africa were prevented from accessing reproductive health care by financial hardship, uncertain legal status, and experiences of health workers as unfriendly.2 Similarly, in a study of women migrants to Hong Kong, 42% felt that they were discriminated against in Hong Kong Hospitals.3 Cambodian migrant women working at the Thai-Cambodia border experience significant risks to their health from unsafe abortion because other means of family planning are not readily available.4 Even in culturally diverse countries in the world, migrant women report barriers accessing health care services. For example, women refugees from Africa and the Middle East settling in Australia and New Zealand also experienced challenges negotiating their reproductive rights in their new homeland because of stigma of health care providers and perceived human rights abuses.5 In Canada, migrant women, particularly from non-European source countries, experience systemic barriers to reproductive health services because their gendered and racialized status intersects with low socioeconomic class and renders them less powerful in the face of a health care system characterized by a culture of biomedicine, Western middle-class values, and the assumption that women can afford self-care.6,7
In addition to transnational migration, hundreds of thousands of women migrate within their countries in search of better economic opportunities for themselves and their families. In Southeast Asia, thousands of rural women leave the countryside searching for employment in the larger cities. Working as beer promoters in restaurants, karaoke clubs, and beer gardens is one common source of employment for these young migrants. An International Labour Organization study of Cambodian beer promoters has documented this practice and the vulnerable status of these women.8
Like the women who migrate across international borders, these internal migrants also face challenges accessing health care services. In our pilot study of rural-to-urban migrant beer promoters in Cambodia, Laos, Thailand, and Vietnam, we found that women’s access to reproductive health care services in their urban settings were limited by health care provider stigma, cost, and availability of services, in addition to personal factors such as lack of time and shyness to access services.9 Health care provider stigma was often related to the assumption that beer promoters provide sexual services to their clients; similar populations of women seeking reproductive health care services, such as Lao sex workers, also experience stigmatizing attitudes from health care providers.10
We undertook a study of access to reproductive health care services for internal migrant women who work as beer promoters in the Southeast Asian capitals of Bangkok, Thailand; Hanoi, Vietnam; Phnom Penh, Cambodia; and Vientiane, Laos. The complete study has been described elsewhere11; this article will focus on the migrant beer promoters’ experiences accessing health care at popular health care institutions in these 4 capital cities.
The study was approved by ethics committees in Canada and in the 4 countries where the research was conducted. In the larger study, focus groups were held with beer promoters and key informants to determine the factors affecting access to reproductive health services for beer promoters in these cities. The results of the focus groups informed the development of a survey for beer promoters and enabled us to identify health care facilities frequented by this informant population. The survey was translated from English into the local languages and then backtranslated; corrections were made to ensure consistency and accuracy for all countries. This survey was conducted in popular health care institutions used by beer promoters in each of the 4 capital cities over a 2-week period from November 2010 to March 2011. Convenience sampling was used: beer promoters who were present at the health care institution at the time of the study were asked about their willingness to be surveyed. Those who agreed were asked to sign a consent form. The goal was to survey about 100 women per city. The women were surveyed about the factors affecting their access to local reproductive health institutions. A subset of the survey focused on their experiences at the institution they were visiting that day. In addition, services provided by the institution were documented through an interview with a senior staff member. In this article, we focus on the experiences of the women migrants at these health care institutions.
Table 1 illustrates the institutions participating in the survey and the number of beer promoters from each institution A total of 390 beer promoters were surveyed in 7 different health care institutions. The demographic characteristics of the beer promoters who participated in the survey are provided in Table 2.
The demographic variables for the 4 groups of beer promoters were not entirely uniform. The Cambodian beer promoters tended to be older, were more likely to be married and have children, and had migrated earlier and worked longer as beer promoters than those from other countries. Conversely, the Thai beer promoters were younger on average and more likely to be single and childless. The Lao beer promoters were more recent migrants and had worked as beer promoters for the shortest time. The Thai beer promoters almost all had health care insurance (97%). Health care insurance was provided by the government for 27% of the cohort, by the employer for 62%, and by “other” for 11%. Only 26.7% of the Cambodian beer promoters had health care insurance provided by the employer (16.7%) or “other” (10%). Even fewer beer promoters had health insurance in Laos and Vietnam. In Laos, only 8% of the cohort had insurance from the government (3%) or employer (5%), whereas in Vietnam, 7% of the cohort was covered by government (5%) or employer (2%) health insurance.
The 7 institutions used for the survey varied from nongovernmental organizations (NGOs; 2 in Cambodia and 1 each in Laos and Vietnam) to government health centers (Laos and Thailand) and a government hospital (Thailand). These institutions were popular for reproductive health care services among the beer promoters who participated in focus groups in the first phase of the larger study. A senior staff member of each institution was questioned about the resources available in their institution. The findings from these interviews are documented in Table 3.
The institutions varied from being established for decades as in the case of Thailand to less than a decade (eg, the NGOs in Laos and Vietnam and 1 NGO in Cambodia). The services offered by these organizations also varied somewhat. All but 1 offered counseling around HIV testing, and all but 2 offered HIV testing, though only 2 (a Cambodian NGO and Thai government hospital) provided HIV/AIDS treatment. All centers offered testing and treatment for sexually transmitted infections (STIs). All but one provided family planning services; however, only 2 provided abortion services (a Cambodian NGO and the Thai government hospital). Similarly, only 3 of the 7 institutions would insert intrauterine devices. Four of these institutions provided antenatal care, and 2 conducted obstetrics deliveries as well.
Education was a focus of most of the 7 institutions used in the study. Of the 7 institutions,6 provided safe sex counseling; 4 centers described provided group teaching, and all but 1 conducted outreach programs. All institutions had a variety of providers, including doctors, nurses, midwives, pharmacists, and sexual health counselors. There was a mixture of formally and informally trained individuals working at these institutions, and all centers claimed to have in-service training for their employees, including infection control practices, though the timing of the training varied from when the staff began work, to annually, to monthly, depending on the institution. In each of the institutions, the majority, if not all the staff conducting the reproductive health examinations, were women. All institutions claimed that they offered training on staff attitudes, their front staff were welcoming to beer promoters, they provided confidential services, they had spaces for confidential discussions, they could sterilize equipment, and they were located in a location that beer promoters found easy to access. All institutions claimed to have a waiting period of less than 1 hour, or 1 to 2 hours.
Not all health services at these institutions were free for beer promoters. Although it was not documented exactly how much beer promoters must pay for services, it is clear that in 2 of the centers, the migrant women were expected to pay (Cambodian NGO and Thai hospital for beer promoters not registered at the hospital), and in a third (NGO in Laos), beer promoters had to pay for certain medications.
In the survey of beer promoters, the women were presented with 9 statements about their experiences in the health care institution they were visiting that day. The survey allowed for 5 Likert scale responses from strongly agree, agree, neither agree nor disagree, disagree to strongly disagree. The responses of the 390 beer promoters who either agreed or strongly agreed with the statements are illustrated in Figures 1, ,2,2, ,3,3, andand44 by institution where they were seeking care.
The majority of the Cambodian beer promoters believed that the NGOs they visited were both affordable and convenient and were staffed by friendly health care providers. A minority stated that they had some concerns about confidentiality in these settings. Most agreed or strongly agreed that they were comfortable receiving STI treatment and abortion advice at these NGOs and that the health care providers had the required knowledge and skills to assist them. Although the Cambodian beer promoters generally agreed that both NGOs had private space for discussions, more than half of those visiting the first NGO had a more than 2-hour wait, whereas such a long wait was uncommon at the second NGO.
The Lao beer promoters were not as positive about the Lao health center and NGO as their Cambodian counterparts were about the institutions they visited. About a half of the Lao group visiting the health center found it affordable, whereas only a third of those seeking care at the NGO stated that it was affordable. More than half of both groups agreed that the location of their institution was convenient. Most agreed that the health care providers were friendly; however, there were still concerns about confidentiality by more than half the group visiting the health center and about a third of the group visiting the NGO. Although most were comfortable receiving STI treatment in both institutions and abortion advice at the NGO, less than half of the users of the health center were comfortable receiving abortion advice there. Similarly, although the majority of Lao beer promoters surveyed agreed that the health care providers were skilled and that there was private space in the institutions for discussion, there were more positive views among the beer promoters visiting the NGO than the health center. On the other hand, it appears that the wait was much shorter for the beer promoters at the health center, where few had to wait more than 2 hours. More than half of the visitors to the NGO had a wait of more than 2 hours.
Less than half of the Thai beer promoters felt that the health center or the hospital they visited was affordable. Beyond this, many of the Thai beer promoters’ views on the 2 institutions showed some distinct differences. More beer promoters agreed that the hospital location was convenient, had friendly health care providers, and was a place where they could seek STI treatment with comfort. There were more confidentiality concerns about the hospital, and only about half of the beer promoters at each institution agreed that they would be comfortable receiving abortion advice there. Considerably more beer promoters visiting the hospital felt that the health care providers were skilled and that there was private space for discussion. About a third for both groups agreed that they waited more than 2 hours to be seen.
In Vietnam, beer promoters visiting 1 NGO health center were surveyed. They were generally very positive about the cost, location, and friendliness of the health care providers. Very few agreed that they had concerns about confidentiality at this institution. They were generally comfortable receiving STI treatment and abortion advice. Most felt that the health care providers were skilled and that there was private space to have discussions, and very few agreed that they waited more than 2 hours to be seen.
There were 2 significant limitations to this research. First, the descriptions of the health care institutions were provided by staff. It is possible that this self-report was biased, showing the institution in a better light than was the reality. Indeed, the descriptions of the institutions made it appear that few women had to pay fees; however, many of the beer promoters from Laos and Thailand did not agree that the cost of care was affordable. In addition, more than a quarter of the beer promoters found the waiting time to be in excess of 2 hours, which does not correlate with the claims of the health care staff. Exploration of the dissonance between the views of the health care staff and the beer promoters would require a qualitative method of data collection such as interviews or focus groups.
A second limitation of the research was the sampling frame of beer promoters for the survey and timing of the survey. We used a convenience sample of beer promoters who were at the institution during the time of the research. This method of sampling may produce a cohort of beer promoters whose views do not reflect the views of Southeast Asian beer promoters generally, particularly those beer promoters who do not use health care institutions. In addition, asking beer promoters about health care services while they are at the health care institution may lead to responses that are biased in favor of the institution. Randomization of research participants was not possible, given our resources and the informal position of these women. The beer promoters who participated in this study, for the most part, agreed that the institutions they attended had many of the characteristics they desired. This is not surprising for we chose to do research on these institutions because they were popular with the migrant beer promoters participating in the earlier focus groups. Choosing other institutions that were not as popular may have revealed less favorable results.
Despite the limitations noted above, the research demonstrates important findings. As documented in previous studies of migrant women2,9 cost is a key factor to access for reproductive health care. Migrant workers are generally poor, saving money for themselves and their families; hence they prefer inexpensive or free services. In some places, they do not have access to government health care insurance even if it exists within that locale because of their migrant status (eg, Bangkok, Thailand). Location of the institution close to where the beer promoters live and work is also a key factor because they have neither time nor money for extended travel to obtain health care.
Friendliness of the health care provider is a common concern in the literature relating to migrant women seeking reproductive health care services.2,3,5,9 It is not unusual for migrants to be stigmatized by health care providers, and this is certainly the case for beer promoters, some of whom also work in the sex industry.8,9 Friendliness is valued because it equates with nonstigmatizing, sympathetic health care providers. In addition to positive attitudes, like women everywhere, migrant women want their health care providers to have good knowledge and skills. Clearly, this cohort was happy with the skill set of their health providers because most were comfortable being treated for STIs or receiving abortion advice.
Confidentiality is another factor that is valued by migrant women receiving health care services. The design of the institution needs to allow for private spaces to share confidential information; otherwise, even the best intentions of health care providers will not be sufficient. Finally, waiting times of more than 2 hours can be prohibitive to good care: women may not be willing to wait, particularly if they have work obligations to meet. Waiting times should be addressed by provision of more staff to treat clients during the busy periods.
Cost of health care services, location of health care institution, and friendliness of staff are all important factors to beer promoters seeking reproductive health care services. These women also value confidentiality, health care providers with good knowledge and skills, and short waiting times. Health care planners and providers, both in government and in the NGO sector, should take note of these findings. This research demonstrates that although popular health care institutions are providing access for migrant women to receive reproductive health care services, there is still room for improvement, even in these popular institutions.
This research was only possible through the cooperation of many individuals. We would like to acknowledge the contributions of our research coordinator, Ms Mora Gibbings and our coinvestigator Dr Bunnak Poch in Cambodia. We also acknowledge the research managers and research assistants in various countries: Mr Heng Tola, Ms Pa Sotheary, Ms Sot Kalyan, Mr Lor Monirith, and Ms Reach Phallin in Cambodia; Mrs Luck Bounmixay, Ms Lathsamy Phounthongsy, and Ms Nouandy Vongphackdy in Laos; Lieutenant Colonel Hatairat Kaoaiemm, Ms Korrawa Yodmai, Ms Pimrada Jaruboot, and Ms Passorn Sukriwanas in Thailand; and Ms Nguyen Phuong Hien, Ms Duong Thi Hoa, and Ms Pham Thi Minh Huyen in Vietnam. We also wish to thank the staff and health care institutions who participated in the research as well as the beer promoters who took the time to participate in the survey. Thanks to Ms Jackie Schulz of the Elizabeth Bruyere Research Institute for administrative support and Ms Monica Prince for statistical analysis.
The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Canadian Institutes of Health Research. Additional funds were provided by the Canada Research Chair Program under the administration of the University of Ottawa.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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