Research context
A summary of sources of information to gather information for the needs assessment is shown in Table 1. Through observation, discussion and the limited available literature we were able to learn about the context and lives of garment factory workers in Phnom Penh.(13) There were several factories in the area each employing several thousand workers, typically working six days per week. Workers sat at sewing machines or did other tasks at individual work stations. Between the noise and the factory floors lay-out, there were limited opportunities to talk among colleagues during working hours. Meal times were when workers gathered in small groups, with different people (different ages and different place of origins) coming together rather than a fixed group of friends. The breaks tended to be short, and people either chatted or looked at their phones while having their meals. In terms of living conditions, workers who came from far away areas rented rooms in apartment blocks nears the factories, sharing with family or other co-workers, often from their same area. Apartments were carved up in different rooms typically rented separately, so space was very limited and privacy of any kind hard to come by. While nearby guest houses provided the opportunity for discreet romantic relationships, factory workers tended to be surrounded by other people at all times. Shops around factories catered to the needs of the mostly young, hard-working residents: food and daily necessities shops, mobile phone sellers and service providers, and licensed and unlicensed healthcare providers, from simple drugstores to clinics with consultation rooms and beds. There were no government or NGO clinics in the immediate vicinity of our research area, although some private providers had previously received trainings from NGOs through social marketing or social franchising activities. The factories we visited all had infirmaries for first-aid and minor ailments. Mobile phone shops sold new and used mobile phones, ranging from USD 15 for an old style feature phone to USD 200 for a smartphone. Specialized shops created Facebook accounts on behalf of their clients, did small repairs, downloaded apps and downloaded content such as film and music, cheaper than using contract data to download online content. To complete the general picture of the life of factory workers, it is worth noting that as of January 2019, the minimum monthly wage was USD182 per month,(14) which could increase with overtime or for skilled workers, or be lower if workers did fewer hours or worked for workshops instead of established factories. Our interviewees reported paying an average rent of USD 35 per month (for a shared room) plus about USD5 in utilities. Finally, garment factory workers tended to be more in debt than the average Cambodian (40% of factory worker households are in debt, versus a national rate of 37%).(15)
Table 1
Sources of information for the needs assessment
Information domain
|
Published and grey literature
|
Observation
|
Interviews (including discussions)
|
Factory worker demographics
|
70% are aged < 30 years, half have only primary school education, and most of them have migrated from rural areas away from their family and community support.
Higher rate of abortion compared to young women in the national survey, contraception use
|
Observations of factory workers in and outside of factories consistent with literature
|
Interviews consistent with literature and observations, although not randomly selected
|
Factory workers daily life and living conditions outside the factory
|
Grey literature (NGO reports and newspaper articles) but very limited in detail. Academic literature focused on specific aspects of health and earnings. Limited qualitative work highlighting living conditions (Chansanphors 2008)
|
Observations in factories (working space, canteen, infirmary, public spaces), in shops and markets near factories and in 1 worker’s home. This provided a useful perspective in the spaces where workers live, what kind of goods and services they have access to, how far they need to go to access specific services.
|
Formal interviews with 33 female factory workers. “Hanging out” at break times, over meals and at their homes for informal conversations. This allowed us to build rapport, and to contextualize, triangulate and clarify information received from a variety of sources.
|
Sources of information for family planning and abortion
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Literature and grey literature on contraception and abortion needs and services. No research exists on use of web sources for health/sexual health information in Cambodia.
|
- Direct observation of online activities did not yield any finding regarding searching for family planning information.
- Direct search on YouTube for ‘family planning’ ‘abortion’ ‘medical abortion’ ‘contraceptive pill’ showed several videos on the topics, some instructional some editorial. All videos had comments, many from 2019 (regardless of when the video was first published), which indicate increasing engagement with online sources to look for family planning information.
|
Interviews with factory workers indicated a strong reliance on family and friends for information related to contraception and abortion. Medical practitioners were also cited as a source of information, but less influential. Interviewees who were asked directly denied looking for family planning information online, but some said they looked for other health information on Facebook or Youtube.
|
Family planning providers reproductive health practices
|
Published literature on family planning in Cambodia
|
Observation in garment factory infirmaries and private providers
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Interviews with 22 providers, including factory nurses, pharmacist, private nurses and doctors.
|
Reproductive health
We conducted 16 interviews with women seeking abortion from private providers located near the factories and 13 interviews with private providers working in different facilities such as infirmaries, pharmacies and bigger clinics. Findings from these interviews are reported elsewhere.(9) In brief, for health issues during worktime, workers were able to use the factory infirmary, and outside of work the option to use public or private providers. The main role of the infirmaries was to treat minor ailments. Only the largest factory provided contraception. Infirmary staff reported that women would seek consultation elsewhere in the event of an unintended pregnancy.
Factory workers’ opportunities for using contraception to prevent pregnancy were constrained by their long working hours, limiting their ability to attend distant clinics with restricted opening hours e.g. for long acting contraception. Pharmacies close to their home and workplace were therefore the most practical option for healthcare seeking. There was sensitivity and stigma related to obtaining contraception or MA. Women seeking supplies from drug stores or pharmacies would need to wait until no one else was at the counter or whisper to the provider to achieve any privacy. For young unmarried women privacy in taking visible contraception such as the pill was often essential due to negative social attitudes to sexual activity for unmarried women, yet very difficult to achieve in cramped shared living conditions. Young women either shared a room with other young women or sometimes lived with an older female relative. There was also the suggestion that young women in relationships with older, wealthier men (meeting in nearby guest houses) might be unwilling or unable to insist on condom use. For married women long periods living away from partners meant that contraception was only needed intermittently and unpredictably.
Regarding contraception use in general, women reported receiving information from a variety of sources such as family, friends, healthcare providers, or the media. Women had concerns about contraceptives. Some women reported discontinuing contraception due to experience of side effects such as ‘body heat’ sensation, weight loss due to reduced appetite, vomiting, menstruation changes, skin changes, dizziness and fatigue. Some women had never used contraception due to fear of side-effects including fear of infertility.
Financial constraints or a desire to space pregnancies were the main reported reasons to seek an abortion. In most cases, women obtained information about abortion from family and friends. In a few cases, women went directly to a clinic. None reported seeking information via the internet. Although most private providers were owned by a medical professional such as a doctor or pharmacist, the day-to-day running was often done by a nurse or pharmacist who was a family member or hired staff. Most had undergone formal training but some had learnt on the job or through short training courses. There was limited use of treatment guidelines or protocols. Several providers expressed a wish for more training, including Comprehensive Abortion Care (CAC) training. All of the providers offered short-acting contraceptives and medical abortion. Some larger clinics offered ultrasound, surgical abortion (vacuum aspiration) and had beds for patients. A variety of medical abortion products were available in the private providers around the factories. In some cases someone would request the drugs on behalf of someone else. Information given to women was often verbal, with packaging and the drug information leaflet withheld, sometimes upon request of the women to protect their privacy in their homes, but also to prevent clients from knowing the brand name and looking for the drug elsewhere. In the cases where a drug information leaflet was given it was not always in the Khmer language nor had pictorial instructions. Hence women often had to remember the sequence of taking the drugs, side-effects and potential warning signs. Information on post-abortion family planning was variable and follow up was generally in the case of problems rather than routine.
Videos about family planning in Cambodia
Given the observed widespread use of Facebook and Youtube among factory workers, and the preference for receiving information via images, video and voice rather than text that emerged from interviews and observations, we searched Youtube for information on contraception, abortion and medical abortion, using a variety of search terms that reflected both medical and more popular terms. There were few results, and none of the videos we found had been posted by NGOs or government sources, possibly because such videos, although they exist, are not optimized for Khmer language and thus not findable when searching in Khmer. The videos that existed were not professionally produced, often consisting of little more than a slide show or a static image with a voice-over, but they were very descriptive and factual, and were beginning to show views in the thousands and tens of thousands. A detailed analysis of this phase of the research will be reported elsewhere, but our working hypothesis, based on YouTube searches, interviews with factory workers and mobile providers, and the increasing number of mobile internet users in the country, was that the use of the internet to seek health information is just at the beginning for the large number of factory workers who are just starting to go online, and that it will increase significally in the next few years.
Intervention development
We held a mid-point workshop in Cambodia in order to discuss the research findings and their implications. Findings were also discussed in separate meetings with stakeholders in the Cambodian Ministry of Health and other NGOs. Consistent with previous research in Cambodia, we identified concerns or experience of side-effects as an important determinant leading to non-use of effective contraception and subsequent unintended pregnancy.(16)(17) These experiences or concerns were shared by potential users of contraception and healthcare providers. Some of the reported side-effects such as ‘body heat’, or ‘weight loss’ (as opposed to weight gain) did not appear to be reported in standard contraception provider guidance or materials developed for potential users. We discussed the possibility that Cambodian women could experience more pronounced hormonal side-effects compared with western women due to differences in size and metabolism. This hormonal ‘mismatch’ theory has been described elsewhere,(18) but it was beyond the scope of our study to explore this systematically. We also discussed similarities and differences between Cambodian womens reports and those of women in the UK talking about hormonal contraception being ‘unnatural’ making them feel ‘out of balance’, which again is not widely raised in materials developed for potential users.(19) An attempt was made to construct a logic model of the problem, as per Intervention Mapping techniques (Fig. 1). In this model we considered the health problem to be unintended pregnancy (clearly for women who did not want the pregnancy), and the ‘at-risk’ population to be factory workers with unmet need for contraception. We considered behaviors of the at-risk group and environmental agents, and determinants leading to those behaviors.
A summary of potential interventions is shown in Table 2 using some terminology from the World Health Organization classification of digital health interventions.(20) We felt interventions aimed primarily at providers would be challenging due to the number of different providers, their competing financial and business concerns and the need for sustained effort and follow up, and was beyond the scope of the project. It was apparent that some providers had received training on reproductive health topics such as contraception and abortion from NGOs through social marketing or other programmes. Most providers were interested in more training. We facilitated additional training for those that requested it but it was beyond the scope of this project to provide a comprehensive training package. There was also interest from providers in peer-to-peer support for questions and advise leveraging social and informal ties,(21) such as through social media or instant messaging, potentially moderated by a reproductive health expert from an NGO or department health. There did not seem to be any capacity to do this at scale at the time of the study as it would have required a medium-term investment in human resources and a joint approach to be effective. Marie Stopes Ladies, an MSI global service delivery channel that has recently been started in Cambodia, is utilizing such a strategy, by setting up a Facebook group to share information among the service providers.(22) In terms of interventions aimed at factory workers, we considered ways of direct provider-to-client communication, such as enrolling potential users of contraception through private providers or infirmaries, but opted against this due to concerns about maintaining communication, due to the high frequency of phone and/or SIM switching, or potential harm arising from other people listening to messaging, since phones were often accessible to several people aside from their owner (23)(24).
Table 2
Examples of possible interventions
Example(s)
|
Intervention classification
|
Main target
|
Potential benefits
|
Potential challenges/disadvantages
|
Edutainment video about contraception
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Targeted client communication (transmit targeted health information to client based on health status or demographics)
Goal is to increase awareness, not to instruct on specific details of contraceptive methods
|
Clients (potential or existing users of contraception, factory workers)
|
Potential for increased reach
Potential to influence attitudes and behaviour about contraception use
|
Does not provide detailed information about pros and cons of contraceptive method
|
Provider-to-client communication
|
Targeted alerts/reminders on mobile phones
|
Existing clients
|
Increase in follow-up visits and continuity of care
Increase in adherence to instructions
|
Privacy (if phones are shared or anyway accessible to other people)
Frequent changes of numbers and loss of phones make it difficult to have unique phone ID for unique clients
|
Provider to provider communication
|
Increase sharing of best practices in informal private online groups (e.g. Whatsapp and Facebook group chats)
|
Providers, especially private providers who do not have regular opportunities for professional updates and training
|
- Provide informal opportunities for sharing best practices and asking for advice
- Leverage social and informal ties to create strong ‘communities of practice’ (Lave & Wenger, 1991)
|
- Informal groups can be difficult to sustain without participants’ buy-in; need a few motivated individuals.
- Peer-to-peer information exchanges are not necessarily medically sound, so they could help spread misinformation
|
Instructional video about contraception methods
|
On-demand information services to clients
|
- Existing clients
- Potential users already considering a specific method
- Providers who need reminding/training about how specific methods work
|
- Video more attractive format compared with written text, and already a common source of information among targeted audiences.
- Can reach clients who are not comfortable or able to go to pharmacies/clinics
- comments to the videos can offer insights into frequent questions, and potentially serve as a source of referral for clinics.
|
Unclear how likely videos are in influencing attitudes and behaviour
Rely on being found in the midst of other commercial videos fighting for attention
Rely on users having the connectivity to watch the video
Requires resources to produce, post, and keep updated
Requires resources to potentially monitor and answer comments and questions
|
Video about abortion
|
Education about abortion
|
- Clinic/pharmacy clients
- Women at risk of or with unintended pregnancy
|
- Can reach audiences that are uncomfortable with text and/or with visiting clinics to ask for information
- Can offer a medically sound perspective, among propaganda and medically dubious videos currently available online.
|
- Difficult topic to engage with through an accurate, but accessible and engaging video
- Requires significant effort in managing the online presence of such videos (moderation, reliability, findability among competing anti-abortion videos, etc)
|
Instructional video about medical abortion
|
Education about MA
|
- Women with unintended pregnancy
|
- More accessible alternative to written text for those with low-literacy levels.
- Can be easier to access in private than written leaflets.
|
- Needs to be found online, against existing competing videos that might be less accurate but are ranked higher in search results
- Privacy issues, as it remains in search history
|
Given the widespread consumption of online videos, we considered that this medium could be the most effective in terms of reach and engagement, so we developed three short ‘edutainment’ videos about contraception. In addition we adapted three informative videos made by MSI from English to the Khmer language, and also adapted the MSI medical abortion ‘Mariprist’ instruction leaflet to a simple video format. These videos were not formally evaluated. The three short ‘edutainment’ videos were aimed at users or potential users of contraception aimed to address personal determinants, particularly knowledge and attitudes, towards contraception. Our objective was to frame contraception in a positive way, whilst acknowledging these frequently experienced and discussed context specific side-effects such as body heat but being careful not to perpetuate them or dismiss them as imagined or unimportant. We felt that videos aimed at the general public that could be watched on mobile phones could be an effective way to deliver an intervention whilst limiting potential for harm. We decided to make three videos because female factory workers are not homogenous. Working from the data we gathered from fieldwork, we constructed two “personas,” that is fictional characters that represent characteristics associated with distinct groups of women.(25) The first persona represents married women, possibly with children, interested in spacing out births, and able to discuss contraception and abortion with their husbands. The second represents single women who may or may not be in a stable relationship, and who are interested in information about contraception and medical abortion, but don’t necessarily discuss it with their partners.
We wrote a terms of reference and invited local media agencies to pitch ideas. We then worked in collaboration with Phare agency to produce the videos.(11) This involved providing the agency with information on target audience and a visit to garment factory area for a pre-testing workshop with garment factory workers to seek their feedback on some prototype videos and opinions on how to further improve the content. During this workshop it was discussed that some of the factory workers would act in one of the videos. There was a two-way process by which the scripts were developed. English language versions of the scripts are shown in Appendix 1. The videos were filmed and Khmer subtitles added and the videos were released sequentially through MSIC’s social media communication channels.(26)(27) The first video (“Mother”) was aimed at married parous women, showing a conversation between a mother and her children whereby the woman was experiencing side-effects from using contraception with the children providing reassurance in a light hearted way. The key message aimed to be that there is a contraceptive method that will fit with you. This was filmed by the agency in Battambang. The second video (“Love”) was aimed at unmarried nulliparous women with the concept of a romance story being watched on a smartphone by a goup of factory workers. The key message aimed to be being in a romantic relationship and still having other life opportunities because of using contraception. The romance scenes were filmed in Battambang and the factory worker scenes were filmed in Phnom Penh. The third video (“Baby”) was aimed at married or unmarried women with the concept of a Khmer karaoke-style comedy dance/song with a key message of finding the right method that fits with you and your family.
The videos were posted at one monthly intervals on Facebook and evaluated by Havas Champagne, a Cambodian media company after one month.(12) The videos were boosted on the MSIC Facebook page aimed to engage the target audience, female factory workers and reach the wider public. Geo-targeted ads were used to identify and show content where most factories were located. A click to message campaign was also used to encourage people to send messages to MSIC Facebook page. The videos were placed on the News Feed and Facebook suggested videos feed, and Facebook Watch feed. A shortened version rather than the original baby video was released. Overall, unique reach (number of people who saw a post a least once) was 3,462,176 with 2,839,255 engagements (number of people interacting with the content e.g. like, share, comment, reaction), 7,876,734 video plays, 16,000,000 impressions (number of people who saw a post, but may include multiple views by the same people), and 25,637 click to messages (number of people who click the “Send to Message” button that will lead to MSIC Facebook messenger). An automated response was set for those who sent a Facebook message and MSIC counselors provided more comprehensive information regarding the topic they asked about and referred to MSIC clinics or services if required. Key metrics per each video are shown in Table 3. In terms of Click and engagement, the ‘Love’ video achieved the highest click amount to MSI. Figure 2 shows trends in total calls to the MSIC contact centre and shows the number of Facebook messages sent to MSIC during the project period. Both figures show increases through sept and oct with a decrease afterward corresponding to the timing of release of the ‘love’ and ‘song’ videos. Data was not collected from the MSIC contact centre or clinics regarding whether referrals were as a result of any specific content.
Table 3
Key metrics of the three videos one month after release
|
Mother
|
Love
|
Baby (shortened)
|
Video release
|
13 Aug 2019
|
Sept 13, 2019
|
11 Oct 2019
|
Boost budget
|
$1,016
|
$1,016
|
$1,166
|
Video plays
|
2,268,736
|
2,834,282
|
2,704,121
|
Engagement and rate (e.g. likes, shares, comments)
|
679,591
|
1,265,398
|
873,388
|
Engagement rate
|
20%
|
38%
|
24%
|
Reach (nationwide)
|
1,406,274
|
1,307,140
|
1,305,075
|
Cost per reach (CPR) (nationwide)
|
$0.30
|
$0.32
|
$0.32
|
Click to Action (CTA) (*send message to Marie Stopes)
|
3,997
|
23,700
|
4,728
|
Cost per click (CPC)
|
$0.03
|
$0.01
|
$0.03
|
Definitions: Reach is the number of people who saw a post at least once. Engagement is the number of people interacting with the content. Example is like, share, comment, reactions. Click to Action measures the number of people who click the “Send message” button that will lead to MSIC Facebook messenger.