Reproductive and maternal health of garment workers in Kampong Speu
Cambodia December 2015
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About Enfants &Développement: Enfants & Développement is a French NGO, created in 1984 to support children victims of the civil war in Cambodia. Today, E&D is working in 4 countries: Cambodia, Vietnam, Burkina Faso and Nepal. E&D has a vision of a society in which children and young people have access to essential social, health, educational and cultural services which allow them to develop harmoniously and to flourish within their family and community without any discrimination. E&D’s mission is to develop actions in partnership with local actors in order to promote, accompany and facilitate access to quality basic services (social, health, educational and cultural) for disadvantaged children, young people and families. E&D is particularly attentive to girls and women. In Cambodia, E&D is currently implementing 3 projects on early childhood care and education, social work and sexual and reproductive health. Website: www.enfantsetdeveloppement.org Contact:
[email protected]
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Acknowledgements The team at Enfants & Développement would sincerely like to thank Kampong Speu Provincial Health Department and Kampong Speu Provincial Labour Department for allowing and supporting this study. Respectful thanks goes to all factories and workers who have devoted their valuable time to provide relevant information to this research. We would also like to thank Australian Red Cross and the Australian Volunteers for International Development (AVID) program for volunteer support. Lastly, we extend our gratitude and thanks to GRET for their technical expertise and advice on the study process. Particular thanks to Sanofi Espoir Foundation and Habitat for Humanity for their financial and logistical support to enable this study.
Privacy statement Enfants & Developpement is committed to protecting the privacy of all participants who contributed to this study by meeting its responsibilities in accordance to the requirements of the Cambodian National Ethics Committee for Health Research. No participant can be identified through the reporting of the research outcomes.
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Contents Acknowledgements
3
Abbreviations
7
Executive summary Project background Methodology Key findings Conclusions and recommendations Program ideas Next steps
8 8 8 9 12 13 16
1 - Objective and approach of the study
17
1.1 Research objectives
17
1.2 Research approach
17
2 - Context
20
2.1 The garment sector in Cambodia Background Working conditions & regulation
20 20 20
2.2 Reproductive, maternal and child health in Cambodia Policy & guidelines Key national indicators Maternal health
22 22 23 23
Child health & child care
23
Family planning & STI:
24
2.3 Literature review: reproductive, maternal and child health for garment workers
25
2.4 Previous and existing interventions CARE Enfants & Developpement GRET ILO – Better Factories Cambodia RHAC Worker health coalition
26 26 26 28 28 29 29
2.5 Kampong Speu Province
30
3 - Main findings
31
3.1 Socio-demographics
31
3.2 Living conditions and transportation Living conditions
32 32
4
Income and budget Transport
32 32
3.3 Working conditions and service provision within workplace Factory RMH policy and practice Key worker health concerns Workplace safety and hygiene Sick leave Infirmary services Service gaps & stakeholder engagement
33 33 34 34 35 35 35
3.4 Health seeking behaviours Use of factory health infirmaries Use of health facilities (outside of factory) Barriers in accessing healthcare
36 36 37 38
3.5 STIs: knowledge and practice
39
3.6 Family planning: knowledge and practice Contraception Condom use
40 40 43
3.7 Maternal health: knowledge and practice Deliveries Antenatal care (ANC) Postnatal care (PNC) Danger signs during pregnancy Miscarriage Abortion knowledge
43 44 45 45 46 47 47
3.8 Childcare & nutrition Breastfeeding and complementary food Childcare arrangements: Hygiene practices
48 48 51 53
4 - Conclusions
55
5 - Recommendations for action
57
Program ideas Next steps
57 60
Annexes
61
Annex 1: Detailed research methodology Participating factories Ethics committee approval Factory stakeholders interviews Female Garment worker survey Focus group discussion Home observation Stakeholder engagement
61 61 62 62 62 65 66 66
5
Annex 2: Factory stakeholder interviews Interview research objectives Methodology Interview questions
68 68 68 68
Annex 3: Female Garment Worker survey
1
Annex 4: Focus group discussion session plan Participants Facilitation Reporting on focus groups Focus group session plan
1 1 1 1 1
Annex 5: Dissemination workshop roundtable discussion topics
4
Bibliography
5
6
Abbreviations ANC : Antenatal Care AVID : Australian Volunteers for International Development BFC: Better factory Cambodia (ILO project) CBHI : Community based health insurance CDHS: Cambodia Demographic and Health SUrvey E&D : Enfants & Developpement FGD : Focus Group Discussion FGW : Female Garment Workers GDP : Growth Domestic Product GMAC: garment manufacturer association of Cambodia GRET : french NGO HEF: health equity fund HIP: health insurance project (GRET project) IEC : Information Education Materials ILO: international labor organization IUD : Intrauterine Device MoH : ministry of health MoLVT: ministry of labor and vocational training MoU : Memorandum of Understanding NSSF: National Social security fund PNC : Postnatal Care PSL : Partnering to Save Lives RMNH: Reproductive Maternal and Neonatal Health RHAC: Reproductive Health Alliance Cambodia SHPA : Social health protection association SIPAR : Soutien à Initiative Privée pour l'Aide à la Reconstruction des pays du sud-est asiatique SPSS : Statistical Software Package STI : Sexually Transmitted Infections TBA: traditional birth attendant WRA : Women at Reproductive Age
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Executive summary Project background Enfants & Développement has been working in Kampong Speu Province since 2006 to address and improve issues of reproductive maternal and neonatal health (RMNH) amongst women and their families, through a strong community based approach. In recent years, E&D observed a decline in participation in traditional village and home visits and outreach activities and increasing child care issues, a result of an increase in factory employment amongst women of childbearing age (15-49 years). In Kampong Speu province, it is estimated that 35 % of childbearing age women are working in garment 1
industry . To better understand this trend and adjust E&D further interventions in the region, E&D team decided to conduct a baseline study exploring knowledge and practice of reproductive and maternal health amongst female garment workers (FGW) of child bearing age in Kampong Speu province. The purpose of the study was to identify the need for targeted intervention matching the needs of FGW in Kampong Speu, seek to identify priority RMH topics, understand child care issues and to explore solutions with relevant stakeholders. Specific objectives of the study are: -
Describe specific socio-demographic profile of childbearing age FGW in rural Kampong Speu
-
Explore working conditions and existing services provided within the workplace
-
Explore their health seeking behaviour and access to health care within and outside workplace
-
Investigate their current knowledge and practice relating to RMNH.
-
Explore childcare arrangements and family structure evolution for families of FGW.
-
Engage stakeholders (workers and management representative, relevant authorities) to discuss issues and potential solutions.
Methodology Previous studies have been conducted on this topic, targeting mainly migrants FGW in urban area and comparing their situation with general population in the area to define a specific profile of FGW and identify key issues. One of the objectives of this research is to show that the rapid industrialization in some rural areas such as Kampong Speu has different impact and FGW have a very different profile with specific issues. The impact of garment industry development on those women’s family is very specific to this situation, as they are not migrants.
1
Data crossed between Provincial office of Labor and Ministry of Planning (see section 2.5 of present study)
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The present study involved a quantitative face-to-face survey with 440 women of reproductive age working in 7 of the 8 participating garment factories in Kampong Speu province, conducted in August and September 2015. To explore all stakeholders’ perception, 16 semi-structured interviews with factory management, union representatives and health infirmary staff from seven of the eight participating factories. Finally, 4 complementary focus group discussion (FGD) and 5 home observations allowed exploring more deeply complex family interactions and challenges. Analysis of the data was made comparing results with existing studies and surveys on similar population, in particular with the “Partnering to Save Lives” coalition baseline survey (2014), hereafter called “PSL 2
study” and the Cambodian Demographic and Health Survey (2014), and hereafter called “CDHS study” . In addition, a number of stakeholder engagement activities were also undertaken throughout the study, to build understanding and support for the project, identify opportunities for collaboration and ensure key stakeholders remained informed of project progress. In particular, a dissemination workshop was conducted with key garment sector stakeholders (Government, Unions, international institution, NGOs, major buyers, media) in February 2016 to collect recommendations and feedback, both integrated to present report (see round table discussion topics in annex 5).
Key findings According to the research results, the average garment factory worker in Kampong Speu province has a very different profile than FGW around Phnom Penh. A majority of FGW in Phnom Penh region migrated 3
from their province in a young age, while still single . In Kampong Speu province, average FGW is slightly older, is married with 2 children, she is not a migrant and lives in her home village with husband and with or close to her parents, she studied until the end of primary school, she earns in average 187US$ per month and her children are taken care of mainly by their grandparents. Main key findings are summarized below. Socio-demographics: -
Only 7 % of participants declared coming originally from another province.
-
Average age is 27.1 years old, slightly older than PSL study (25.8 years old)
-
The mean duration of education was 6.2 years, with 7 % of respondent who never attended school, which is similar to urban FGW.
-
54.8 % of respondents are married and 9.3% report having a regular boyfriend. Almost 30% declare being single (38.9% in PSL survey)
-
48.9 % of the group already had children (against 30.7% in PSL survey), with the average number of children being 2.4.
Living conditions and transport
2
See section 1.2 « research approach » for references.
3
PSL study
9
-
46.8% of women declared living with their husband and/or children, and 41% also live with their parents, while in PSL study this figure is only 6.7 %, as parents usually stay in home village
-
Participants reported an average income of US$187 and almost a quarter (23.2 %) of the respondent stated they were able to save some money every month of the year.
-
92% of FGW declare paying rent and/or utilities for their housing, showing that even when living with their parents, they contribute to housing costs, with a monthly average amount of 68US$ (36% of their average income).
-
20% of FGW declared having no access to toilet facilities at home (either household facility or shared facility)
-
25% of FGW declared drinking rain water stored in jars and 22% declared drinking surface water.
-
42% of FGW declared spending more than one hour in transportation every day, and 11% more than 2 hours, with most common transport being minivan/buses (27%). Average monthly cost for transport is 10US$ in the survey.
Working conditions and service provision within factories -
2 factories out of 8 didn’t have a functional infirmary
-
Health care provided within infirmaries is only for general work-related complaints, there is no provision for reproductive and maternal health
-
all factories reported having ANC, parental leave and sick leave policy
-
Breastfeeding space was available in 6 factories and nursing room as well, but there was no service provision. In one factory the nursing room space was used by management as a meeting room. Childcare services were not functional in any of the participating factory, and the breastfeeding space was used only at one factory by a small number of workers.
-
Availability and hygiene standards of toilets and washing hand facilities were identified as a concern by factory stakeholders.
-
Both management and workers reported maternity as a cause of workforce turnover, due to concerns regarding childcare.
-
Levels of monthly sick leave discussed by factory management varied from approximately 1.2 % up to 17 % of the total workforce. Smaller factories generally had a much higher rate of sick leave than larger factories. From research team observation, this can be explained by the generally better working conditions and services in larger factory.
Access to healthcare: -
43.3% of respondents used factory infirmary in the past 12 months, but only 1.4% of consultation were related to RMNH as it is not part of the services provided by factory infirmaries
-
Outside the factory, 72.6 % of respondents access healthcare from private facilities.
-
Main barriers mentioned to access healthcare are the cost (63 %), travel distance (27 %), lack of information on services availability (20%).
STI & FP knowledge and practices:
10
-
47% of respondent declared that they never heard of or don’t know about STIs
-
8 % of respondent could not name any contraceptive
-
Only one third of the women identified male condoms as a form of contraception
-
40 % of sexually active women stated they had used contraception in the past 12 months, and 49% for married women. This figure is significantly lower than the 65% reported in the CDHS for Kampong Speu.
-
Daily pills is the most commonly used contraception method (62.8 %) followed by injectable (22.3 %)
-
Modern contraceptive are obtained from public facilities for half of respondent, followed by private facility for 28.6%
-
Among women declaring having casual sexual partners, 83% declared systematic use of condoms
-
Among women not using contraceptive, 26 % mention as the main reason the belief the contraceptive are bad for their health.
Maternal health& delivery -
10% of respondent were pregnant during the interviews
-
44% of women were able to identify at least 3 danger signs during pregnancy, but 23% were not able to identify any risk.
-
Most recent deliveries were done in public facilities for 56%, private facility for 17% and at home for 26% of respondent. Deliveries at home are significantly higher than the PSL survey (18.1%). The CDHS figures are even lower, with 15.5% of home deliveries reported in Kampong Speu 15.5% and 3.9% of home deliveries in urban areas.
-
18% of deliveries in the survey have been attended by a traditional birth attendant (10% for Kampong Speu in the CDHS).
-
Only 29.8% of women had 4 or more ANC visits, and 11.2 % of respondent had no ANC at all during their last pregnancy. This result is striking compared to the PSL study, where over 70% of women had followed MoH recommendation, and to the CDHS where 73.9 % of women from rural areas had 4 or more ANC visits.
-
65.4% of respondent declared receiving no PNC after their last delivery (69.9% in PSL, 10.8% in CDHS)
Child nutrition &childcare arrangement -
Half of respondents were able to accurately define “exclusive breastfeeding” and identify recommended length (6 months)
-
Among women with children under 3 years old, 50% declared that they exclusively breastfeed their child for 6 months (a result lower than the CDHS findings), and 6.6% mentioned giving supplementary food before 3 months.
-
Main reason mentioned to stop exclusive breastfeeding before 6 months was return to work (68%)
-
When mother is at work, main child caretakers are grandparents (62%) and fathers (30%). Older siblings are mentioned as main caretaker in 3% of cases.
-
Day-care facility in factories are not functional, also majority of the factories have a dedicated space, but no service (staff and material). Reasons mentioned by workers and management for
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not using the facility are the dangerous and long transportation, and the absence of functional service. -
During focus group discussions, mothers expressed a lot of concern about the care received by their child at home in their absence and the difficulty for them to balance economic activity and family life. In fact all mothers participating to focus group discussions resigned from their position to stay longer with their child after the end of maternity leave, and returned working to another factory when the child was older.
Priority needs and solutions expressed by FGW and factories’ management Within participating factories, there were no current education or health programs, also some workers mentioned previous access to peer education programs, and they did not have any access to basic IEC communications. Factories management teams, union representatives and health infirmary staff expressed a high level of support and interest for initiatives to improve overall workers’ health, with the positive impacts on worker reliability and productivity widely recognized by garment factory management representatives. Health infirmary staff generally has a low level of healthcare capacity, acknowledging their skill level themselves. All factories expressed a desire to have future health education programs and improve access to RMH care for workers, particularly pregnant workers. Although participants identified multiple worker health concerns, general personal hygiene was seen as the biggest priority by management, health staff and union representatives. Other health priority areas included vaginal health especially during menstruation, nutrition and birth spacing.
Conclusions and recommendations Particularly worrying data revealed by present survey to access to RMN services, and in particular the lower use of family planning, prevention during pregnancy and neonatal care, with a high level of women not able to comply with ANC/PNC recommendations and the very high rate of home deliveries compared to general population. Access to health care and capacity to follow MoH guidelines on RMNH is clearly an issue for FGW in rural area even more than in urban area. Workers identified financial barriers, long working hours and transportation time, low general RMNH awareness and a limited offer of services as the main barriers for them to follow MoH guidelines. This is a worrying sign for women workers in Cambodia in general, as garment industry is the most regulated sector in Cambodia. Further similar studies should be done to explore RMNH knowledge and practices in sectors were enforcement of labor law is weaker and working conditions more difficult, such as agriculture, tourism or construction industry. Within families, the rapid industrialization of the province has deeply modified traditional family structure and the role of the different caregivers, resulting in strong difficulties for mothers to balance their professional life and their family life, raising issues between caregivers and in the end resulting in lower quality of care for the children growing up without their mothers. Day-care facilities as specified in MoLVT guidelines are difficult to implement and access in rural area, due to lack of qualified staff and long and unsafe transportation. It is worth noting that the issues around the quality of childcare in the absence of the mother are not specific to FGW families, but also for the families of migrants working in Thailand and Vietnam.
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Program ideas Based on the main findings analysis and on needs expressed by main stakeholders, several areas of relevant interventions have been identified by the research team and are listed below: Access to information and worker’s education: Identified needs:
General lack of education and information, difficulties to discuss RMH issues within factories, in particular on FP, STI, home deliveries and maternal health in general.
Objectives:
Raise general education level and awareness about key RMNH issues through peer-educator program and group activities within the workplace
Approach:
Train-the-trainer lunchtime education program: train workers on short education programs on priority areas that can be delivered over lunchtime
One-on-one education opportunities: train workers as peer educators
General communications: Availability of IEC material, host lunchtime videos & games on key program areas.
Previous & existing
ILO, CARE, GRET, RHAC
interventions Stakeholders
feedbacks
Importance to consider providing diverse source of information depending on the topic and the audience.
One to one RMH counselling is difficult within infirmaries, because of lack of confidentiality and request authorization from manager to access (consider other space available without previous permission)
Peer education: consider the challenge of workers turnover when they are not line managers and type of information they can disseminate (needs to be very basic).
Child care & maternity Identified needs
Nutrition, hygiene and stimulation for children Balance between professional and family life for mothers
Objectives
Support mothers manage professional life and childcare, to improve both childcare concerns and reduce turnover due to maternity
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Approach:
Sensitization on the issue with caretakers and factory stakeholders
Provide factory management with package of tools and guidelines for implementation for functional daycare facilities: caretaker training, activities toolkits and material, etc…
Explore alternative to the day-care facilities within factories, not always relevant in rural areas, and encourage village based child care services and parenting education to main caregivers focusing on basic hygiene and nutrition
Previous & existing
ILO - E&D
interventions Stakeholders
feedbacks
Explore extension of maternity leave as an alternative for women who currently resign – and impact on competitiveness
Childcare in villages may be more relevant than in factories, as factories may not be a suitable place for children and dangerous transportation
Explore parental day care in villages and linkage with existing parenting interventions: home base care, mother health support groups, etc.
Explore impact of pregnant women exposed to chemical products on children
Access to health care Identified needs
Low ANC compliance, home deliveries, difficult access to RMH outside of the factory, especially public health facilities
Objectives
Support women to access reproductive and maternal health services both within and outside the factories
Approach:
Bring ANC and RMNH counselling services into factories, either through advocacy for factories to employ an in-house midwife or through linkage with outreach activities from nearby health center.
Encourage management teams to invest in infirmary staff capacity building, in particular in counselling
Lobby partner factories to make improvements to health infirmary equipment, infrastructure and general hygiene
Address financial barriers to access healthcare by raising awareness of available social health protection mechanism (social health insurance from NSSF for workers and community based and health equity fund for the family members)
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Improve workers information on available services in the area: record book of nearby public and NGO health facilities, which provides details on available services, opening hours, contact details, distance from the factory and costs
Formalize a referral system and stronger relationships between garment factories and nearby public or NGO health facilities to improve service access
Previous & existing
Explore opportunity to extend opening hours of public health facilities
RHAC, Workers health project, GRET/SHPA, RHAC
interventions Stakeholders
Explore transport subsidies and link with NSSF for sustainability
feedbacks
Consider funding issues of existing outreach activities
Consider mobile clinic on Sunday
Explore the issue of integration of factories infirmaries into NSSF system
Factory infrastructure and service delivery: compliance with standards and improvement of standards Identified needs
Incorporate specifications and guidelines for adequate infrastructure and functional services, matching worker’s needs (infirmaries, daycare, etc…) in existing regulation
Objectives
Improve existing standards compliance and improve standards to match the needs of workers
Approach:
Previous & existing
Pilot interventions to document evidence on impact for workers and competitiveness.
Increase coordination and collaboration between stakeholders to bring relevant advocacy topics to decision makers.
Support management and unions representative to negotiate and monitor workplace infrastructure
ILO – Worker health project
interventions Stakeholders
Need for a platform for more collaboration and information sharing between stakeholders
Need for an advocacy working group working on standards improvements
Factory management have very little room for improvement of services if not compulsory by law (compliance with minimal standards for competitiveness issue)
feedbacks
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Explore unregistered factories issues with specific research
Next steps Also a number of stakeholder engagement activities were already undertaken throughout the study, to build understanding and support for the study, identify opportunities for potential future collaboration, survey recommendations are based on the result of this specific survey, and need to be considered in perspective with government strategy and existing stakeholder interventions. This survey will thus be, in priority, used as a ground basis for further discussions, following the research approach of “better diagnosis, better actions”.
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1 - Objective and approach of the study 1.1 Research objectives Enfants & Développement (E&D) has been working in Kampong Speu Province since 2006, delivering projects to address and improve issues of reproductive and maternal health amongst women and their families, through a strong community based approach. In recent years, E&D has observed a decline in 4
participation in traditional village and home visits and outreach activities , a result of an increase in factory employment amongst women of childbearing age. To take this trend into account and adjust E&D approach to continue to reach target groups (women of child bearing age), E&D conducted the present study into knowledge and practice of reproductive and maternal health amongst female garment workers (FGW) in Kampong Speu province. The purpose of the study was to identify the need for targeted intervention matching the needs of FGW in Kampong Speu, seek to identify priority RMH topics, understand child care issues and to explore solutions with relevant stakeholders. More specifically the study aims at exploring / documenting to:
health seeking behaviors, including use of factory infirmaries and health facilities outside of the factory
current knowledge and practice relating to sexually transmitted infections (STIs)
current knowledge and practice relating to family planning (birth spacing)
current knowledge and practice relating to maternal health
child care arrangements & nutrition practices for children of female garment workers.
Engage stakeholders (workers and management representative, relevant authorities) to discuss priority issues and potential solutions.
1.2 Research approach RMNH knowledge and practice among FGW have been explored through quantitative survey and semi structured interviews within the factories. To explore deeper the practices impacting child wellbeing, such as care arrangements, nutrition and hygiene, research team strategy was to conduct focus groups discussions with FGW as well as direct observations of those practices in the villages, following one family the all day. The research approach involved: •
4
16 semi-structured interviews with factory management, union representatives and health infirmary staff from six of the eight participating factories
See more details on E&D projects in section 2.4
17
•
a quantitative face-to-face paper survey of 440 FGW of child bearing age, with seven of the eight participating factories, conducted within factories during lunchbreak
•
4 focus group discussions - conducted within factories during lunchbreak
•
5 home observations
In addition, a number of stakeholder engagement activities were also undertaken throughout the study, to build understanding and support for the study, identify opportunities for potential future collaboration and ensure key stakeholders remained informed of research progress. Face to face survey during lunch break Workers’ lunchbreak – Kampong Speu, 2015
The research approach is summarized in the below figure. The detailed methodology is presented in annex n°1. Figure 1: Summary of research process Methodology, survey design and translation
MoUs with participating garment operators (if requested)
Recruitment and training of student interview team
Ethics approval 18
Survey pilot
Semi-structured interviews (management, health infirmary staff and union representatives)
Survey delivery
Data entry and analysis
Focus group discussions & village observation
Final analysis & peer review
Presentation to stakeholders and feedbacks incorporation into recommendation section
The analysis in present study is based on comparisons established with:
General rural population in Kampong Speu: comparisons are made with the Cambodian Demographic and Health Survey 2014 (CDHS), published by Cambodian ministry of health. This survey is mentioned in the present research as the “CDHS”.
Women of child bearing age in Kampong Speu province, through comparisons with a KAP survey (Knowledge, Attitudes and Practices) designed by E&D in 2014 and conducted by an 5
external consultant . This study is mentioned in the present research as the E&D KAPE survey.
Garment female workers in urban area: comparisons are made with baseline report from the coalition “Partnering to Save lives” (PSL) in 2014 and exploring “Reproductive, Maternal and Neonatal health knowledge, attitudes and practices among female garment factory workers in Phnom Penh and Kandal Provinces”. This report is mentioned in the present research as the “PSL”.
5
“Health survey on reproductive healthcare and practices in Kampong Speu”, Juan Luis Dominguez, 2014
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2 - Context 2.1 The garment sector in Cambodia Background It is estimated that today, Cambodia garment and footwear industry is, together with tourism, the largest industry in the country, employing 1 million workers, and accounting for 80 % of the country’s exports. Among the 1,000 companies estimated to work in the sector, 400 are subcontracted and unregistered, accounting for almost 300,000 unprotected workers. Factories in Cambodia are 95 % foreign owned and import all their material and fabric, main brands and buyers being H&M, Puma, Zara, Levi, Wall Mart, Gap. Garment sector development in Cambodia is based on preferential tariffs and export quotas to the US and EU signed in 2001, as part of an agreement to develop a responsible industry respecting international labour standards and support the country’s economy after civil war. This explains the rapid development of the industry with relatively good working standards for workers, despite low quality infrastructure, little local value added and low skilled work force. The international labour organization 6
(ILO) has been implementing in Cambodia the “Better Factory project” as part of those preferential trade agreements to support good practices and standardization of the industry. With the end of preferential trade agreement in 2018, increasing costs, little local investment and the difficulties for the sector to increase competitiveness, the sector is under constant pressure. Long-term strategy to sustain the activity for manufacturers is to continue developing a niche industry with internationally recognized high standards compared to other countries in the region.
Working conditions & regulation For the reason explained above, garment sector in Cambodia is one of the sectors where enforcement of labour law is the most efficient in terms of workers’ rights and working conditions 7
compare to tourism and construction for example , although garment sector has a very strong impact on other sectors in terms of working conditions. More than 3,000 unions are active in the country, gathered into 90 union federations. Minimum wages in garment sector increased rapidly in recent years,
6
See section 2.4 for more details on the better factories project
7
Globalization, Wages, and the Quality of Jobs: Five Country Studies, Raymond Robertson, World Bank, 2009, and The Mekong
Challenge Cambodia’s Hotel and Guesthouse Workers their recruitment, working conditions and vulnerabilities, ILO 2006.
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following strong unions’ actions. In 2015, minimum wages increased to 128$, just above poverty line (estimated to 120$ a month), but still not enough to cover decent living cost, estimated by unions between 140$ to 180$. Many workers have an average income higher than the minimum wage as they chose (or are requested) to do overtime, and this allows them to support their family. Figure 2: History of minimum wages in garment sector in Cambodia, and recent increases (in US$)
8
Minimum wage in garment sector Cambodia - US$ 160 140 120 100 80 60 40 20 0
140 128 100
2006
2007
2008
80
61
50
2009
2010
2011
2012
2013
2014
2015
2016
In Cambodia, normal working hours should not be more than 8 hours a day, or 48 hours a week and the employees must get at least one full day off per week. Overtime of 2 hours a day is authorized with extra benefits. Children from 15 to 18 years old are authorized to work under very specific conditions and as part of vocational training/apprenticeship program. In fact, it is observed that many minors are working in factories under normal conditions, using ID from older neighbours to be employed. Regarding maternity, the employers give employees who give birth 90 days (3 months) of maternity leave and must pay employees who have at least one year of seniority half their wages and benefits during maternity leave. For the first year of a child's life, mothers have the right to one hour per day of paid time off for breastfeeding breaks during work hours. The law doesn’t allow giving milk formula or payment instead of breastfeeding breaks. Workers receive an allowance for transportation. In Kampong Speu province, collective transportation (trucks, buses, remork, etc...) are most of the time organized privately at village or commune level by vehicle owner, gathering morning and evening all workers from one area and bringing them to respective factories along national road. Due to numerous stops along the way, transport can be as long as 2 hours one way.
8
Arbitration council of Cambodia
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Workers transported in a “remork”, passing in front of a factory – Kampong Speu, 2015 In terms of infrastructure, an employer who employs more than 50 employees at one workplace must set up an infirmary which must be near the workplace, with adequate staffing and material, sickbeds, and be easily accessible, clean, etc. An employer who employs 100 women or more must set up an operational nursing room and day care centre. If an employer is not able to
[DAYCARE IN FACTORIES
set up a day care center for children over 18 months of
“I tried to open a daycare service in my
age then they must pay women employees the cost of
factory, but it didn’t work. The children didn’t
providing day care for their children. In reality, if there is
want to stay; they were crying all day and
an obligation for the employer to provide the facility,
trying to escape. It didn’t work, so we closed
actual service is often not available, due to a lack of
the
guidelines at national level and capacity at factory level. In rural area, it is also very difficult for parents to bring
service
after
one
week
of
experimentation” Factory owner, 2015.
]
their child to the workplace due to transportation duration and conditions.
2.2 Reproductive, maternal and child health in Cambodia Policy & guidelines MoH guidelines related to RMNH are based on recommendations from WHO. As a reminder, main recommendations are for a pregnant woman to receive at least 4 antenatal check-ups during her pregnancy, and 3 postnatal check-ups after delivery. Deliveries should happen in a health facility, and assisted by a qualified birth attendant (doctor or midwife). Children should be exclusively breastfed for 6 full months before introduction of complementary food.
22
Access to healthcare is facilitated by developing social security schemes. Like all employees of the formal sector, factory workers should be covered for accidents under the NSSF scheme. In the whole country, the Health Equity Fund system is covering the most vulnerable (ID poor card holder) to freely access a minimum package of health care, including basic RMNH prevention and care, in any public facility.
Key national indicators9 The below paragraph is a summary of key national indicators as reported in the 2014 CDHS. However detailed results show striking disparities between urban and rural area, as well as according to socioeconomic status. Maternal health
The maternal mortality ratio is 170 maternal deaths per 100,000 live births for the seven-year period preceding the survey. This ratio is lower than the ratio reported in the 2010 CDHS but is not significantly different.
95 % of mothers received antenatal care from a skilled provider.
89 % of births were assisted by a skilled provider.
83 % of births were delivered in a health facility.
90 % of women received postnatal care for their last birth in the first two days after delivery.
Child health & child care
Infant mortality declined from 45 deaths to 27 deaths per 1,000 live births between the 2010 CDHS and the 2014 CDHS.
Under-5 mortality declined from 54 deaths per 1,000 live births to 35 deaths per 1,000 live births between 2010 and 204.
9
Source : CDHS 2014, national data.
23
Figure 3: Trend in early childhood mortality – CDHS.
Deaths per 1,000 live births
124
95 83 65 54
45
35
28
Infant mortality CDHS 2000
Under-five mortality CDHS 2005
CDHS 2010
CDHS 2014
32% of children under age 5 are stunted, 10 % are wasted, and 24 % are underweight.
Breastfeeding is nearly universal in Cambodia. 96% of children born in the last two years have been breastfed.
65% of children less than age 6 months are exclusively breastfed, and the median duration of exclusive breastfeeding is four months.
More than 8 in 10 (82 %) children age 6-8 months (both breastfed and non-breastfed) are introduced to complementary foods at an appropriate time.
Overall, 30 % of children ages 6-23 months are fed appropriately based on recommended infant and young child feeding (IYCF) practices.
One in 10 children under age 5 had been left alone or left in the care of other children under age 10 for one hour or more during the week preceding the interview.
Family planning & STI: Awareness of at least one method of contraception is universal in Cambodia. More than half (56%) of currently married women are using a method of contraception, with most women using a modern method (39%). The daily pill remains the most commonly used method of contraception among currently married women (18%). The government sector remains the major provider of contraceptive methods for nearly half of the users of modern methods (47%). Only two-thirds (66 percent) of young men age 15-24 who had sexual intercourse in the past 12 months reported using a condom during their last sexual encounter.
24
Knowledge of HIV/AIDS in Cambodia is universal; almost all women and men age 15-49 have heard of AIDS. Overall, 39 percent of women and 48 percent of men age 15-49 have comprehensive knowledge about HIV/AIDS.
2.3 Literature review: reproductive, maternal and child health for garment workers A literature scan confirmed that while there is some knowledge of the RNMH of FGW’s based in urban areas, research remains fragmented, with very little known about the health status and RNMH service needs of rurally-based workers. Key messages from the literature scan particularly relevant to this study are summarised below: The typical FGW is under 24 years of age, “young, single and childless”, with low literacy and education 10
and has often migrated from a rural to urban environment due to poverty . Although the RNMH of FGW’s generally reflects that of the wider female population, workers face a number of additional challenges in accessing sexual health care. FGW’s are time poor, come from impoverished families, have low levels of education and literacy, earn minimal salaries and have little, if 11
any, ‘emergency’ money . Specific lifestyle factors result in unmarried FGW’s being more susceptible to risky sexual behaviours. These factors include living with minimal family and community support and guidance due to rural-tourban migration as well as some using forms of commercial sex work to supplement their income, forming ‘sweetheart’ arrangements and receiving gifts or money in return for unprotected sexual 12
activity . Investigations into the prevalence of premarital sex amongst FGW’s are inconclusive. Although Webber 13
et al. proposes that sexual activity amongst unmarried female workers is uncommon, other research findings are contradictory, with conclusions indicating an increase in sexual activity amongst unmarried 14
garment workers, a finding that is initially supported by Sopheab . Little research has been conducted on childcare arrangement for rural garment workers, but similar issues have been raised and studied for migrant parents.
10
Sopheab, H. (2014).
11
Cockroft, M (2014).
12
Nishigaya, K. (2010). Nishigaya, K. (2002). Webber, G., Edwards, N., Amaratunga, C., Graham, I., & Keane, V. (2010a), Webber, G., Edwards, N., Amaratunga, C., Graham, I. & Keane, V. (2010b) 13
Ibid
14
Sopheab, H. (2014)
25
2.4 Previous and existing interventions CARE CARE has been working in the garment industry in Cambodia since 1998, has established relationships with key stakeholders and worked with 75 factories in 2015. CARE’s current interventions include focusing on improving workers’ sexual, reproductive and maternal health, reducing sexual harassment, improving nutrition-related awareness and promoting financial literacy. CARE has worked with Levis since 2010 to improve the wellbeing of workers in their factories through peer education covering health, hygiene, nutrition and financial literacy. Since 2013 CARE has been working with factory HR managers to develop effective workplace sexual harassment policies which protect women in the workplace. HR staff from 92 factories have received training on gender and gender-based violence. CARE is also currently rolling out a package of interactive materials for training workers on sexual and reproductive health in 11 factories. Apart from this, CARE with GMAC has set up the Strengthening Activity for Factory Education (SAFE) working group, which brings together HR and management staff to discuss and share updates on factories’ HR activities (such as training and new policies), worker related initiatives and other relevant topics.
Enfants & Developpement Mid 80-90’s: Technical support to day-care facilities in the factories In the mid 80’s, as part of a project between UNICEF, Ministry of Industry and the Ministry of Health, Enfants & Développement (at that time named “Enfants du Cambodge”) supported the implementation of day-care facilities in “Production Units” (Public factories). E&D brought technical expertise to design appropriate and low cost material, as well as trainings to the caretakers. Due to lack of State resources and the low educational level of the population, the quality of the service was a challenge. In the early 90’s, after the end of the Soviet Union’s support to the country and withdrawal of the Vietnamese troops, Cambodia faced a transition to a free market economy, and day-care facilities were no longer a priority in the newly private factories.
26
Examples of early childhood material designed in Cambodia in the mid 80’s used by UNICEF and local NGOs in daycare facilities and preschools.
Since 2006: community health in remote areas E&D has been running a reproductive and maternal health project in Kampong Speu Province since 2006. The project overall objective is the reduction of maternal and neonatal death, and therefore the community target audience is mainly composed of child bearing age women. The project is designed to reinforce both offer and demand of SRH services, and to build bridges between both. E&D is supporting 37 health centres (HC) in Kampong Speu province through provision of trainings of HC midwives, facilitation of midwives meetings, on-the-job coaching of HC midwives and support to HCMC meetings. On the demand side, E&D adopted an innovative approach through the training and coaching of village volunteers, the doulas. Doulas are community volunteers who were trained on SRH and communication skills and who provide support and accompaniment to women in their community, in all aspects related to SRH and pregnancies. Doulas can be VHSG or other volunteer women, interested in getting involved in their community. They work closely with village, commune and health centre authorities to bring the voice of the women in their village and contribute to the referral system, thus having a strong impact on access to public health care for the population living in the most remote areas. A number of activities have also been implemented to facilitate communities’ access to public health facilities and improve the quality of care; in particular E&D supported the Community Score Card process with 4 health centres and implemented “solidarity funds”, a micro insurance scheme covering emergency transportation in 10 communes.
27
GRET Founded in 1976, GRET is an international development NGO fighting poverty and inequalities. GRET is currently active in more than 30 countries on 7 main development areas. GRET is active in Cambodia since 1988. In the specific sector of social health protection (SHP), GRET has developed the first SHP scheme (SKY) for the informal sector since 1999. SKY has served as a reference for the national guidelines on SHP for the informal sector (at that time CBHI) developed by the Ministry of Health (MoH) in 2005-2006 and has been transferred to local operators supported by MoH in 2012-13. In 2008, GRET launched a health insurance project (HIP) for garment workers in dialogue with the Ministry of Labour and Vocational Training (MoLVT) and GMAC (Garment Manufacturer Association of Cambodia) and transferred it to the National Social Security Fund (NSSF) in 2013. Since the transfer of both HIP and SKY projects, GRET is providing technical assistance to accompany those transfers. In 2010, GRET has extended its multi-countries nutrition program for young children in Cambodia and has developed a locally produced complementary food (the infant cereal Bobor Rong Roeung) adapted to the nutritional needs of Cambodian young children. Combining its expertise in nutrition targeting mothers and young children and its expertise on social health protection for the poor and vulnerable groups, GRET is currently conducting health promotion activities on maternal and child health in the areas of intervention of the health equity fund operator FHD (Family Health Development).
ILO – Better Factories Cambodia The BFC project is implemented as part of the 1999 Cambodia-US trade agreement, setting up expanded access to US markets and quotas on garment exports linked to improvements in labour standards. ILO has been responsible to monitor and report on progress of the standardisation process, through mandatory assessments, and voluntary advisory services and trainings. Project’s coverage is 380 garment factories – estimated to represent 70% of Cambodian garment export industry. Below figure shows trend in compliance with standards for BFC monitored factories. It is worth noting that health and welfare are the areas where compliance is the lowest among all categories. Figure 4: ILO-BFC projects achievements
28
RHAC Reproductive Health Alliance Cambodia is currently running a clinic in Kampong Speu town. Through the clinics, RHAC works to increase access to high quality sexual reproductive health, family planning, and HIV/AIDS/STI services and information by the poor and underserved population, adolescents, other vulnerable groups, and the general population. In 2011, RHAC implemented a workplace programme focusing on garment factories, including Kampong Speu Province factories. This program aimed to improve sexual and reproductive health needs of factory workers by working to provide integrated sexual and reproductive health and HIV/AIDS services to factory workers through RHAC’s clinic services, and to build the capacity of factory clinics to provide selected quality sexual and reproductive health services to their factory workers. In each partner factory, RHAC activities include promoting healthy behaviour through interpersonal communication (peer educators), group discussions, stage performance, health fair, and distribution of IEC materials. This program was stopped in Kampong Speu province in 2012.
SIPAR For over 23 years, Sipar has been helping Cambodia fight illiteracy and develop school and public reading. Enrichment to this program has been the establishment of a publishing branch for books in Khmer 15 years ago. In factories, Sipar organization started a new project in close collaboration with GMAC and MoLVT to set up library resource centres (LRC), to improve workers literacy and general education. The 3 currently operational LRC are run by the workers and organize education and sensitization sessions.
Worker health coalition “Worker Health Coalition” is a USaid funded project, implemented by Marie Stopes International and Population council, and targeting approximately 100,000 workers in 60 factories. The objective of the project is to improve the health of garment workers, particularly women, by increasing their access to high quality reproductive and general health services in their work environment as well as in their communities, and to put in place policies, practices, and public-private-NGO linkages that create sustainable changes in the way workers access health services. The project has four inter-related components:
Enabling Environment/Policy
Worker-Management Engagement
Health Service Delivery and Access
Learning and Evidence
The project is also looking into private sector engagement in a coalition to leverage resources - major international brands, Cambodian factory owners and manufacturers, professional associations.
29
2.5 Kampong Speu Province As shown on the map below, Kampong Speu Province is a rural province located south west of Cambodia, along National Road Number 4 linking capital city of Phnom Penh to international trade harbour of Sihanoukville/Kampong Som.
Kampong Speu Province – map and landscape
A few years ago, Kampong Speu was a province with limited infrastructure and population was primarily occupied in agriculture and forestry activities. In recent years, the province has experienced rapid deforestation, together with industrialization and significant growth in the garment industry. Total population of the province is estimated to be 780,200 inhabitants, among which 15-49 years old women 15 are estimated to be 210,800 (27%) . As reported by the Provincial Labour Department, an estimated 90,000 FGW’s are employed in the province’s garment industry, with approximately 75,000 being women of child bearing age (83%). According to those estimations, 35% of child bearing age women in the province are working in garment industry. Given its prime location and ease of access for major international buyers and brands, growth and expansion across the region is predicated to continue into the future.
15
Ministry of planning, 2014
30
3 - Main findings Key results from the research are presented in the following section. Where possible, comparisons are made with data from the 2014 Partnering to Save Lives (PSL) study, the 2014 CDHS and the 2014 E&D 16
baseline health survey in Kampong Speu .
3.1 Socio-demographics On average survey’s respondents were 27.1 years old. Almost half (47.9 %) were aged between 16 and 24 years old and 68.4 % were 30 years old or younger. The youngest FGW was 16 and the oldest was 48 years old. In comparison, the urban study 17 conducted by PSL had a slightly younger sample, with an average age of 25.8 years old and the proportion of women younger than 30 years old of 79.7 %, but survey’s respondent are still younger than the general population in Cambodia, where women under 30 years old represent only 56.7% of the population. On average, participants had attended six years of schooling, 18 similar to the results of the PSL study of 6.2 years. A total of 7% of women had no schooling and 46.6 % had completed between one and six years. Only 6.1 % (27/440) of women had completed more than ten years of education. Respondent happen to be more educated than the general women population in Cambodia, where almost 20% of women have no schooling, however this can be explained by the fact that in the general population, women with no schooling are generally older women. More than half of the participants were married (54.8 %), significantly higher than the PSL study (34.2 %), and 9.3% mentioned being in a regular relationship. Only 28.9% mentioned being single (39% in PSL survey). Pregnant women made up 10% of the sample and 48.9 % of the group already had children (against 30.7% in PSL survey), with the average number of children being 2.4.
[UNDERAGE WORKERS Five percent of workers in the survey reported being underage (less than 18 years old), and this figure is most probably underestimating the reality, as underage workers might tend to hide their real age. When this was investigated by the team, underage
workers
mentioned
as
a
common practice the use of older relative/ neighbours’ ID to apply for a position in garment sector. Management in some factories also mentioned that they are aware of this practice, and implement further
control
to
avoid
employing
underage workers, such as cross check interviews, registration workers
family
books
certificate, also
and
birth
etc.
Underage
mentioned
garment
employment opportunity as the reason why they dropped out of high school.
]
16
Sopheab, H. (2014). Sopheab, H. (2014). Ibid 18 Ibid. 17
31
3.2 Living conditions and transportation Living conditions 46.8% of women declared living with their husband and/or children (85.4% of married women), and 41% also live with their parents, while in PSL study this figure is only 6.7 %, as parents of migrant workers usually stay in home village. However, in the PSL Study, a further 48.3 % also reported to be living with relatives. This is consistent with the fact that in rural area, majority of FGW are not migrant and staying in their home village as only 7% of participants declared coming originally from another province. 20% of FGW declared having no access to toilet facilities at home (either household facility or shared facility), 25% of FGW declared drinking rain water stored in jars and 22% declared drinking surface water.
Income and budget Participants reported an average income (including overtime and allowances) of US$187 for the previous month, with 79.5 % of women earning up to US$200. This was considerably higher than what was reported in the PSL study ($142), however since the PSL survey two salary increases have been awarded across the garment industry. A large majority (66.5%) of FGW reported not being able to save any money, while almost a quarter (23.2 %) of the women interviewed in Kampong Speu Province stated they were able to save some money every month of the year. Among the FGW who mentioned being able to save money, average monthly saving is 50$ (median: 41$). As per research team observation, savings are used to contribute to family business activities and farming activities. 92% of FGW declare paying rent and/or utilities for their housing, showing that even when living with their parents, they contribute to housing costs, with a monthly average amount of 68US$ (36% of their average income).
Transport 42% of FGW declared spending more than one hour in transportation every day, and 11% more than 2 hours, with most common transport being minivan/buses (27%). Average monthly cost for transport is 10US$ in the survey. From the team observation, transport conditions are often very precarious and dangerous. This observation is shared by workers, who mentioned transport conditions as a reason not to bring their children in the factory to use nursery and day-care services.
Workers transported in a truck.
32
3.3 Working conditions and service provision within workplace Factory stakeholder interviews (management, unions and health staff) allowed exploring working conditions, social benefits and services provided within workplace, as well as compliance with labour law. For details methodology of factory stakeholder engagement interview, see annex 1 & 2. Generally, factories management teams, union representatives and health infirmary staff expressed a high level of support and interest for initiatives to improve overall worker health, with the positive impacts on worker reliability and productivity widely recognized by garment factory management representatives. Table 1: Factories profile Factory
Number of workers (approx.) Total Female
Products
Owners
Infirmary
1
946
927
All Kinds of Sport Shoes (Footwear)
China
Yes
2
600
533
Man/Lady Shirt, Man/Boy Pants
Cambodia
No
3
8,200
8000
Lady Shoes, Lady Boots (Footwear)
Taiwan
4
438
350
Man/Lady Woven & Knitted Shirt
Malaysia
5
893
831
Jeans
China (90%), Cambodia (10%)
Yes
6
287
193
T-shirt
China
No
7
613
313
All Kinds of Handbag
Cambodia
Yes
8
1,437
1,322
Jeans
Canada
Yes
Yes Yes
Factory RMH policy and practice All factories reported to having ANC, maternity care and sick leave policies. Antenatal check-up: About half of the factories currently provide half to a full day of paid leave per month for pregnant workers to access for ANC visits. However in practice, union representative suggested that some workers did not use this leave due to transport and waiting times associated with visiting health centres as well as fear of job security and salary cuts. Nursery and childcare: Although space was available, no workers use the childcare space, and only a small number of workers at one factory used the nursery space, when a relative would bring their child in during a break. Participants noted the lack of use was directly related to transport difficulties. Maternity leave arrangements: For staff employed for over a year, arrangements involved three months maternity leave at half pay, with some factories offering an additional one to two months of unpaid leave.
33
Management also reported that often, women do not return to work after maternity leave due to concerns regarding care.
Key worker health concerns Key worker health concerns identified during interviews varied between management, union and health staff, however general personal hygiene practice amongst garment workers was identified as a key health concern by all groups. Digestive health and diarrhoea were also identified by management as key issues. Gynaecological issues, particularly discharge, were identified by union representatives and health staff as a key health concern, with health staff suggesting that approximately 90% of workers experiencing vaginal discharge. Management representatives felt that often workers are too shy to share these problems with health staff, as the infirmaries space doesn’t usually allow confidentiality. Nutrition and calcium deficiency was also identified as an issue affecting overall health and well-being of the worker population.
Workplace safety and hygiene Participants identified some key gaps in workplace safety of significant concern to overall worker health. Although at one factory masks were encouraged to be worn, take-up was poor and as a result instances of headaches, breathing difficulties and dizziness were common. The quantity and cleanliness of toilets was identified through interviews as a major concern, having significant implications on worker health and hygiene. Comments were made regarding the number, cleanliness, and rubbish disposal of toilets. The availability and hygiene standards of hand wash facilities also varied across the factories, with one factory having no wash basin facilities for both workers and health staff. As a general pattern, concerns were also expressed regarding the hygiene and nutritional value of worker lunches purchased from outside the factory. Workers purchased lunch from outside the factory precinct, or brought from home.
Workers going for lunch in a factory canteen (left) and workers attending factory infirmary service (right) – Kampong Speu 2015
34
Sick leave Levels of monthly sick leave discussed by factory management representatives varied significantly across factories, from approximately 1.2% up to 17% of the total workforce. Smaller factories generally had a much higher rate of sick leave than larger factories. From research team observation, this can be explained by the generally better working conditions and services in larger factory. Reasons for taking leave included gynaecological complaints, stomach and intestinal pain and urination issues. Some staff also took leave to tend to their own businesses.
Infirmary services Among the 8 factories participating to the workers survey, 2 factories do not provide an infirmary service to the workers, while both have more than 200 workers and should, by law, be providing this service. Of the available infirmaries, all were staffed. Opening hours were from 7-11am, closed over lunch, and reopening from 1-4. In the case of overtime shifts, infirmaries remained open and staffed until the end of the shift. Staffing at the health infirmaries varied, from one nurse and an on-call doctor to two doctors and five nurses at the largest factory. None of the infirmaries had a midwife. Two of the factories interviewed also had administrative support staff within the infirmary. Currently, health staff receives no training or support. Health care staff acknowledged that their skill level is sometime too low to allow them to manage the cases they receive, and communicated a desire for future training and upskilling opportunities. Health care is only for general work-related complaints and workers are only able to receive basic first aid at health infirmaries due to availability of equipment, knowledge and training. There is no provision for SRH or ANC/PNC. Participants told that often health infirmaries run out of basic medicine, such as paracetamol. No existing relationships were noted between health infirmaries and nearby public health facilities. In the event of a workplace accident, workers are transported to a nearby health centre. Seven factories consulted had transport solutions available for hospital referral. The factory without transport was located close to a health clinic. Health infirmaries are regularly used by workers. For factories with under 2000 employees, around 20-23% of the total workforce visited the factory infirmary weekly. For the largest factory in the study, this fell to 11% of the total workforce. It is important to note however these findings are based on anecdotal evidence only and do not take into account worker multiple visits. Workers visit the health infirmaries for a range of reasons including dizziness, headache, stomach pain, fainting and difficulty in breathing, and fever. Length of visits range from 5-10 minutes (for workers seeking basic medicine), lasting up to 1-2 hours for workers suffering from dizziness or weakness. Generally, if workers do not improve within two hours, they are transported to a health centre.
Service gaps & stakeholder engagement Given the very basic quality of care available at all health infirmaries, participants identified a number of key service and medical equipment gaps, compared to needs expressed by workers, including:
SRH services and education programs, including birth spacing, ANC and PNC, STIs and testing and gynaecological health
Tetanus vaccination
Sufficient supply of basic medicine for treatment of main worker health complaints (such as headache and vaginal discharge)
35
Within participating factories, there were no current education or health programs, also some workers mentioned previous access to peer education programs, and they did not have
any
access
communications.
to
Factories
basic
IEC
management
teams, union representatives and health infirmary staff expressed a high level of support and interest for initiatives to improve overall workers’ health, with the
*UNIONS’ VIEWS It is worth noting that almost all unions representative mentioned the existence of union supported solidarity funds, to support long term sick leave and serious health
positive impacts on worker reliability and
problems. Among unions representatives
productivity widely recognized by garment
interviewed, 50% mentioned that they need
factory
help
management
representatives.
negotiating
with
management
Health infirmary staff generally has a low
implementation some basic services and/or
level of healthcare capacity, acknowledging
security measures, such as availability of
their skill level themselves. All factories
medicine in the infirmary or ventilation in
expressed a desire to have future health education programs and improve access to
working space.
]
RMH care for workers, particularly pregnant workers. Although participants identified multiple worker health concerns, general personal hygiene was seen as the biggest priority by management, health staff and union representatives. Other health priority areas included vaginal health especially during menstruation, nutrition and birth spacing.
3.4 Health seeking behaviours Use of factory health infirmaries Of the total number of survey participants who worked at a factory with an infirmary (330), 43.3 % (143 women) had used the factory infirmary in the past 12 months. Almost all of the women who had used the infirmary in the last 12 months went for treatment of general illness (97.3 %). Services available in factories infirmaries comply with the minimum standards, thus they do not provide RMH services. Thus in the survey, only 1.4 % of the respondent received RMH advice from the infirmaries. Of those visiting the infirmary, 17 (11.9 %) were referred to services outside of the infirmary. Two of these referrals were for reproductive, maternal or child health care. Only 9% of participants had been referred to services outside of the factory in the PSL survey. The majority of women (87.4 %) stated they were satisfied or highly satisfied with the service they received at the factory health infirmary. For women who did not visit the factory infirmary (187 women, or 56.7 % out of the women who worked at factories with an infirmary), the primarily reason for not doing so was due to not being unwell in the past 12 months (68.4 % of women). Thirty-one women were not aware that the factory they worked in had an infirmary.
36
Use of health facilities (outside of factory) In the past 12 months, 332 women (75%) had visited a health facility outside of the factory. Of these visits, private facilities were most frequently used at 72.6 %, followed by public facilities at 20.2 %. These results are different to the results of the PSL study, where 57.0 % of FGW’s reported to using private facilities, followed by higher use of public facilities (28.6 %). Public facilities are preferred for RMNH services, especially for family planning (50% in public facilities) and ANC (68% in public facilities). This can be explained by the fact that workers are allowed some time to attend public facilities on their working time, while public facilities are closed on their free time (Sunday). Satisfaction is slightly higher with public facilities, with 4.5% of non-satisfaction in public facilities, and 7% in private facilities. As shown in table 2 below, the most common RMH reason for accessing external health services was for general RMH treatment and advice including vaginal discharge, lower abdominal pain, bleeding and STI’s testing/referral (40 women, or 12 %), followed by antenatal care (22 women, or 6.6 %) and family planning (ten women, or three %). Similar to the factory infirmary satisfaction levels, a high proportion of women (93.9 %) were satisfied or highly satisfied with the health services they accessed outside of the factory.
[ACCESS TO PUBLIC HEALTHCARE From research team observation, the greater use of private facilities in the present survey can be explained by the fact that for garment workers in rural area, access to public services is more difficult: public health center opening hours and longer transportation time from their home or working place to the public facilities do not allow FGW to access services on their free time (Sunday), thus making it more difficult for them to access public services.
There
is
also
a
common
belief/understanding among FGW that private facilities are for “minor and daily health problems” and public health center are for prevention, RMNCH, vaccination and referral. This belief is propagated by medical staff in the area, which often works both at public facilities and private facilities, and tends to encourage a “market division”.
]
Table 2: Use of health facilities outside of factory in the past 12 months n= 332 Private facility
Freq 241
% 72.6
Public facility
67
20.2
Pharmacy
16
4.8
NGO facility
7
2.1
Other
1
0.3
291
87.7
Nature of consultations outside the factory infirmary (n= 332) Health issue not related to RMNH
37
n= 332 19 RMNH treatment or advice
Freq 40
% 12.0
ANC service
22
6.6
Family planning
10
3.0
Vaccination
4
1.2
Abortion examination, counselling and/or treatment
2
0.6
PNC service
1
0.3
Other
2
0.6
Highly satisfied
34
10.2
Satisfied
278
83.7
Not Satisfied
20
6.0
Level of satisfaction with the health service visit (n= 332)
Barriers in accessing healthcare 50 % (220 FGW) of participants noted that they regularly face difficulties in accessing healthcare outside of the factory. In the CDHS, more than 91% of women report having “big problems” to access health care in general in Kampong Speu province. The high difference between present study and CDHS can be explained by the way the question was asked. In the CDHS, the question was: “Many different factors can prevent women from getting medical advice or treatment for themselves. When you are sick and want to get medical advice or treatment, is each of the following a big problem or not?” with a list of suggested problems. In our survey, the question was: “What difficulties do you regularly face in accessing health care outside the factory”, with spontaneous answers (no suggestions). In both cases (our survey and CDHS), cost was identified as the primary barrier (62.7 % in our survey, 85.2% in CDHS). Spontaneously, travel distance from work to clinic (27.3 %) was mentioned as the second reason, and a lack of information about available services (19.5 %) as the third main difficulty. Fears of visiting the health facility alone (18.5 %) was spontaneously identified as key issues affecting accessing to healthcare by 18.5% of FGW, while it is mentioned as number 2 issue in CDHS, with 53.4% of women recognizing this as a big problem. Figure 5: Barriers affecting access to health care outside of factories (n= 220)
19
Including vaginal discharge, lower abdominal pain, bleeding and STI testing/referral
38
Other Difficulty in claiming back for sick leave Afraid to ask permission from line manager Afraid of impacts to job security No free time outside working hours Afraid to visit health service alone No information about available services Travel distance to clinic from work Cost
2% 3% 6% 9%
0%
15% 18% 20%
27%
63%
10% 20% 30% 40% 50% 60% 70% %age
3.5 STIs: knowledge and practice Of the women who responded, half had never heard about STIs. As shown in figure 6, of those who had heard about STIs advertising was the most common source of STI information at 37.4 %, with only 6.8 % identifying health infirmary staff as a current information source. Figure 6: Current source of STI information (n= 296) Infirmary health staff
7%
Factory peer support person
9%
Other
11%
Teacher in school
11%
Health staff outside the factory
18%
Friends
20%
Relatives (Parents, brothers, sisters,…
22%
Advertising (TV, radio, newspaper,… 0%
37% 5%
10% 15% 20% 25% 30% 35% 40% %age
When asked about their preferences regarding seeking information on STI’s, more than half (51.3 %) noted health staff outside the factory infirmary, followed by relatives at 17.5 % (Figure ). Figure 7: Preferences seeking information about STIs (n= 439)
39
Other
2%
Don't know
2%
Factory peer support person
2%
Husband
4%
Friend
5%
Village health support group
8%
Infirmary health staff
9%
Relatives (Parents, brothers,…
18%
Health staff outside the factory
51% 0%
10%
20%
30% 40% %age
50%
60%
As shown in figure 8 below, one-on-one communications, including peer listening programs were identified as the preferred communications channel to provide future information on STIs.
Figure 8: Most efficient channel to provide information about STIs (n= 439)
Other
2%
Group discussion
5%
Information, education and communication materials (such as posters, flyers)
20%
Radio/TV
25%
One-on-one communication (such as peer listener programs)
48% 0%
20%
40%
60%
%age
3.6 Family planning: knowledge and practice Contraception When questioned, on average FGWs were able to name 3.4 methods of contraception (median: 3).
40
Awareness was highest of the daily pill (84.9 %), higher than the results of PSL’s urban based study (64.1%), but lower than the CDHS (97.7 %). A significant number of women were also aware of monthly injections (70.9 %, against 97 % in the CDHS) and intrauterine device (IUD) (69.7 %). Only one third of women spontaneously mentioned male condoms as a form of contraception, compared to 95 % in the CDHS. 35 women (eight %) could not name any contraception methods.
Figure 9: Awareness of contraception methods (n= 436) 1% 4% 4% 7% 8% 8%
Rhythm method Female condom None Male condom IUD
23% 30% 38%
70% 71%
Daily pills 0%
20%
40% %age
60%
80%
85% 100%
In the survey, 68 % (302) of participants reported being sexually active, among which 241 women are married, 36 are single without regular boyfriend, 15 are in a relationship and 10 are separated or widowed. Among women who declared being sexually active, 158 (52 %) reported ever having used contraception and 121 women or 40 % stated they had used contraception in the past 12 months. Those figures are consistent with the PSL survey, although the proportion of sexually active women is higher (only 43.7% in PSL), the same proportion of sexually active women declared having used contraception in the past 12 months. Among married women only (n=241), 49 % declared having used contraception in the past 12 months, a figure lower to the general population in Kampong Speu, as in the CDHS, 56% of married women aged 15-49 declared currently using contraception. As shown in figure 10, for those never using contraception, or not using contraception in the past 12 months, 37.0 % were trying to fall pregnant. A further 26.1 % (31 women) viewed modern contraceptives as bad for their health.
41
Figure 10: Main reasons for not using contraception (n= 119)
Other
17%
I am pregnant
20%
I think they are bad for my health
26%
I am trying to have a baby
37% 0%
10%
20%
30%
40%
Out of the women who had used contraception in the past 12 months, 112 or 92.6 % reported using modern contraception and 9 women, or 7.4 % reported using traditional methods. Among women using contraception, the daily pill was the most commonly used th I didn’t want to have a 4 child, but when I used contraception method, with 62.8 % of women daily pills, I had health problems and I gained using this form in the past 12 months, weight, so I stopped. I left the factory to take care compared to the PSL study result of 34 %. of my baby, and I will go back to work when he Other popular methods included injectable will be over 1 year old. I already did this with his (22.3 %), IUDs (10.7 %) and withdrawal (7.4 brothers and sisters, and I had no problem to find %). Those results are very different from the another job in factories. Female garment worker, PSL study, where more than 30% of women 34 years old. declared using traditional methods. As per team observation, traditional methods are more used by unmarried women, who are not aware of modern method or afraid to seek modern method, as there is still a strong social disapproval on pre-marriage sex in Cambodia.
[NOT USING FP
]
Figure 11: Contraception use in the past 12 months (n= 121)
42
Rhythm method (calendar… 1% Male condom
2%
Implant in the arm
2%
Female sterilization
3%
Withdrawal
7%
IUD
11%
Injectable
22%
Daily pills
63% 0%
20%
40% %age
60%
80%
Half of the women using modern contraceptives in the past 12 months sourced them from a public facility, 28.6 % from a private facility, 16.1 % from a pharmacy and only 4.5 % sourced their contraceptives from an NGO. These findings differ to the PSL report, where most common place to source contraceptives was a pharmacy (29.8 % of responses).
Condom use Condoms use is similar to the CDHS (2 %) and lower to the PSL research (6%), with only three women (one married, one unmarried with a partner and one separated/divorced) reported using condoms when asked what methods of contraception they had used in the past 12 months. However, when the sexually active unmarried participants were asked specifically if they use condoms during casual sex, 51 women (83 %) reported using condoms. This can be explained by the fact that condoms, even when used, may not be identified as a contraception method thus we can assume that it is used as a protection against STI.
%age
Figure 12: Condom usage for unmarried/separated women who have sex with partners (n= 73) 80% 70% 60% 50% 40% 30% 20% 10% 0%
70%
16%
14%
I have sex and use Not sure/ don’t know I have sex and don’t condoms use condoms
3.7 Maternal health: knowledge and practice
43
Deliveries
Figure 13: Location of most recent delivery (n= 215)
56%
60% 50% %age
40% 26%
30%
17%
20% 10%
2%
0%
Public facility Women's home Private facility
NGO facility
As shown in Figure13, the highest proportion of deliveries occurred in a public facility (55.8 %), with the next most common place being the women’s home (25.6 %). This is a striking result, higher than the PSL result of 18.1 % and the CDHS result of 18.7% of home delivery in rural areas, and 3.9% in urban areas. It is noted that there is a significant
[HOME DELIVERIES Our research reveals a very high level of home deliveries and deliveries by traditional birth
relation between the level of education of
attendants, and those data are conflicting with
FGW and the choice to deliver at home, with
CDHS results. Two explanations can be brought on
more than 30% of women with 0 to 3 years of
this issue. First our research is on a different and
schooling delivering at home.
smaller sample, thus the margin of error is higher.
Just over three quarters (77.2 %) of deliveries
Secondly from team observation, home deliveries
were assisted by a midwife/nurse and 17.7%
in Kampong Speu take place in very remote
were assisted by a traditional birth attendant. Fewer deliveries were assisted by a health professional in this survey (81.9 %) than the
villages during rainy season, when there is absolutely no possibility to reach any health facility. We can formulate the hypothesis that maybe for logistical reasons; the CDHS team
survey conducted by PSL (over 90 %) and the
didn’t include those very remote villages in the
CDHS (89,3 % in Kampong Speu). A significant
sample.
higher proportion of deliveries were assisted
]
to by a traditional birth attendant in the current sample (17.7 %) to that of the PSL 1
research (8.7%) , while the CDHS reported 10,4 % in Kampong Speu province. E&D internal survey found 13% of deliveries attended by a TBA in Kampong Speu in 2014.
44
Antenatal care (ANC) Almost three quarters (74.3 %) of the participants were aware of MoH recommendation that a woman should attend four or more ANC visits during a pregnancy. However, only 29.8 % of women with children had four or more ANC visits during their last pregnancy, with an average of 3 visits. This result is striking compared to the PSL study, where over 70% of women had followed MoH recommendation, and to the CDHS where 73.9 % of women from rural areas had 4 or more ANC visits. As shown in Table 1, 24 women (11.2 %) did not receive any ANC during their last pregnancy, slightly higher than the PSL report of 8.2 %, and higher than the CDHS for rural area of 5%,
Table 1: Number of ANC visits prior to most recent birth (n= 215) 0
Freq 24
% 11.2
1
37
17.2
2
59
27.4
3
31
14.4
≥4
64
29.8
As shown in Figure 214, public facilities were the most common location for ANC visit, at 88.5% (84.6% in PSL study).
Figure 24: Location of most recent ANC visit (n= 191)
NGO facility
1%
Private facility
11%
Public facility
89% 0%
20%
40% 60% %age
80%
100%
Postnatal care (PNC) Generally, women reported low postnatal care attendance, with 65.9 % of women declaring no PNC (69.9% in PSL survey, 10,8% for rural areas in the CDHS). Once again, there is an important gap between factory studies and CDHS. One explanation could be that when PNC is delivered right after birth, women may not identify this as PNC. Only a quarter of women received two or more PNC visits after their last delivery, similar to the results from the PSL study of 22.1 % of women receiving 2 or more PNC.
45
Table 2: Number of PNC visits after the last delivery (n= 214) 0
Freq 140
% 65.4
1
20
9.3
≥2
54
25.2
Similar to ANC, the most common location for PNC visits was public facilities, at 83.8 %.
Figure 35: Location of the most recent PNC visit (n= 74)
Other
1%
NGO facility
4%
Private facility
11%
Public facility
84% 0%
20%
40% 60% %age
80%
100%
Danger signs during pregnancy As shown in Figure 46, when asked about knowledge of danger signs during pregnancy, 44.2 % of women could identify three or more indicators. However, 24% of women were unable to identify any danger signs (48.3 % in PSL).
Figure 46: Knowledge of danger signs during pregnancy (n= 436) 30%
Precentage
25%
26%
27%
23%
20% 14%
15% 10%
8%
5% 0%
3% 0
1
2 3 4 5 Number of danger signs known
1% 6
46
As detailed in Table 3, vaginal bleeding was the most widely recognized danger sign. While this is similar to the results of the PSL study, the proportion of women identifying this in the PSL study was significantly lower at 26.9 %, compared to almost half in this study. Swelling was also identified by 35.1 % of women and 17.9 % named severe abdominal pain.
Table 3: Knowledge of danger signs during pregnancy (n= 436) Vaginal bleeding
Freq 213
% 48.9
Swelling (face, fingers and feet)
153
35.1
Don't Know
109
25.0
Severe abdominal pain
78
17.9
Anaemia
56
12.8
Fever
54
12.4
Daily-long headaches
37
8.5
Elevated blood pressure
33
7.6
Vaginal watery fluid
29
6.7
Prolonged labour
19
4.4
Convulsions
15
3.4
Increased weight quickly
12
2.8
Loss of foetal movement
10
2.3
Vaginal discharge with bad smell
9
2.1
Bleeding after delivery
9
2.1
Difficulty in breathing
8
1.8
Other
4
0.9
Miscarriage Of the total number of participants, 215 had children, with the average number of children being 2.4. As shown in Table 4, of the women responding to the question ‘how many miscarriages have you had?’, 41 women (13.9 %) reported one miscarriage, 12 (4.1 %) reported two and one woman reported as having three miscarriages. Table 4: Number of miscarriages (n= 296) 0
Freq 242
% 81.8
1
41
13.9
2
12
4.1
3
1
.3
Abortion knowledge As shown in Table 5, although abortion has been legal in Cambodia since 1997, 67.7 % of women stated
47
that abortions were illegal, 20.4 % said they didn’t know, and only 11.9 % were aware of its legal status. These results are similar to the findings from the PSL study, where only 7.9 % of women knew abortion was legal. Table 5: Knowledge of abortion law (n= 437)
Freq
%
Don't know
89
20.4
Legal
52
11.9
Illegal
296
67.7
As presented in Figure 57, although the majority of women were unaware that abortion is legal in Cambodia, most could identify a safe abortion service, with over half (61 %) identifying a public health facility and 43.1 % identifying a trained private health facility. These results differ from the PSL study, where only 27 % of women were able to identify a safe abortion service. In both studies, a higher proportion of women state they know where to access safe abortion services than the proportion who believe the procedure to be legal. When asked about the reasons behind this low awareness of the legality of abortion, research team mentioned that the concept of “legal” as formulated in the question might be blur for some women, with a confusion between what is legal or not according to national laws and what is right or wrong according to moral and/or Buddhist rules. Figure 57: Knowledge on sources of safe abortion services (n= 437) 70% 60%
61%
%age
50%
44%
40% 30% 20%
11%
10% 0%
Trained public health facility
Trained private health facility
Don't know
2%
1%
Pharmacy
NGO facility
3.8 Childcare & nutrition Breastfeeding and complementary food Survey results When asked, only half of the participants were able to accurately define ‘exclusive breastfeeding’. A similar proportion (52.5 %) identified the recommended length of exclusive breastfeeding at six months.
48
In the worker survey, half of the women with children under three years old reported having exclusively breastfed their last baby for six months, a result lower than CDHS findings where 65% of children are exclusively breastfed. Returning to work was by far the most common reason given by women who did not exclusively breastfeed for six months, at 68.4 %. Table 6 provides a detailed breakdown of the key results relating to breastfeeding. Table 6: Breastfeeding Freq
%
Knowledge of exclusive breastfeeding (n= 436)
220
50.5
Knowledge of length of exclusive breastfeeding (n= 436) Exclusive breastfeeding practise for women with children under 3 years old (n= 76) I exclusively breastfed my baby for at least 6 months
229
52.5
Freq 38
% 50.0
Complimentary food given After 4 months
24
31.6
Complimentary food given After 3 months
9
11.8
Complimentary food given before 3 months (12 weeks)
5
6.6
Freq 26
% 68.4
Other
8
21.1
No breast milk
3
7.9
Mother had an illness
1
2.6
Reasons for stopping exclusive breastfeeding before 6 months (n= 38) Mother returned to work
Focus group discussions results: Breastfeeding was one of the issue the research team choose to include in focus group discussion (FGD), as with the distance from home to factory, it is virtually impossible for working mothers to follow MoH recommendations and exclusively breastfeed their child and return to work after maternity leave at the same time. Out of 38 mothers participating to the FGD, only 7 declared during the FGD that they have been exclusively breastfeeding their child, saying explicitly that they did not provide anything else than breast milk, including any kind of liquid. All of them explained that they didn’t come back to work after the end of their maternity leaves in order to exclusively breastfeed their child. It is worth noticing a majority of women in FGD are well aware of the recommendation of health authorities regarding exclusive breastfeeding during the first 6 months of the child, which is consistent with the workers’ survey. While returning to work was the main reason mentioned in the survey for not exclusively breastfeeding a child, FGD showed that 80% of mothers in FGD introduced complementary feeding before the age of 6 months, even though they didn’t come back to work in the factories. Other explanations came up from the FGD. Mothers mentioned social pressure from elders such as grandmothers, who said they always provided complementary food to their children before 6 months and that they grew well. Due to the social position of the elder in Cambodia, mothers therefore followed this example. From the discussions, majority of mothers explained that they believe that breast milk is the
49
best, but that they themselves believe they didn’t have enough milk. Several facts can explain this common belief. One can be a low self-confidence of the mothers, who have generally a low level of education and receive contradictory information from community or health staff. Another reason mentioned is that “the child always put anything to the mouth, so he is hungry even after breast feeding”. This refers the oral stage of child development when children explore their environment. Mothers therefore interpret this “oral exploration” as hunger. In addition to that, the aggressive advertising of infant formula companies and the practice of free formula sampling in the clinics can be one of the reasons why mothers believe that combining breast milk and infant formula is more appropriate for their child. As we explained above, most mothers introduced early complementary food to their child, but they continue breastfeeding at the same time. Most mothers in FGD started to introduce complementary food when their child was around 3 months, regardless the fact that they had to return to work or not. The first complementary foods given to the child are plain water, soft and white bobor (Khmer traditional rice soup) and infant formula. Some mothers explained that once they introduced the infant formula, the child was refusing breast milk and that they prefer the taste of formula. Those women therefore stopped breastfeeding and provide infant formula instead of breast milk. A few mothers leaving nearby the factory told us that they were also breastfeeding once during lunch time for around 15 minutes when they find time to come back home during their one hour of lunch break. Other type of complementary food, generally introduced later in the child alimentation, include enriched bobor (made of rice, fish, carrots, ivy leaf, eggs, pork), boiled bananas, pumpkins, taro. Most mothers explained that as soon as their child was over 6 months, they introduced crack snacks, coffee, ice creams, sugar cane juice, sweets and bread. It is a common practice in Cambodia to use such kind of unhealthy and sweet snacks in order to calm down the children whenever they are crying. Behind those practice there is a common belief that parents leaving their child crying are not good parents.
50
Home observation In order to compare declaration of mothers and
caretakers
and
actual
practices,
research team conducted home observation with 5 children. Among children observed, 4 were still breastfed, once in the morning and during night time after the mother came back from work. Only one child was
[WHITE FOOD
given infant formula, others were still
Globally, the main meals can be seen as “white
breastfed and given the same meal than the
food”, meaning mainly carbohydrates (rice) with
rest of the family as complementary food,
little portion of proteins (fish and meat), minerals
eventually smashed or soften with water.
and vitamin (fruits and vegetables). We observed
After the mother’s departure to work, the
that the children were given the 3 main type of
main care-giver is usually the one to prepare
food (Carbohydrate, proteins, minerals and
breakfast and food for the all day, for the child as well as the all family. In the case where the care-taker is the father, the
vitamins), but the proportions were never fitting the requirements from MoH or WHO, giving a highly bigger proportion of carbohydrate compare to the other groups. The proportion of crack-
mother of the child was the one to prepare
snacks and sweet food such as ice creams and
the child’s food for the day before going to
candies were as well dramatically higher than the
work. Breakfast is composed of bobor (soft
WHO recommendations
rice) enriched with eggs or dried fish. One
]
family added some nutritional powder that has been provided by the local health
center. Lunch and dinner are usually made of rice with a little portion of fish or pork meat and pumpkin. In one case, the rice was enriched with mixed vegetables and leaves. The liquid intakes of the child include plain water, porridge water, milk (soya milk tin, infant formula, powder milk or fresh milk), and any kind of juices. Usually the children were fed by the care takers or siblings, but we observed 2 times the child feeding themselves alone. Between meals, 4 out of the 5 children were given crack snacks (up to 4 times in a day), candies or ice cream following the wish of the child. One assumption we can make is that it is a common that caretakers do not impose their views to the children to encourage them to eat more fruits or vegetables for example.
Childcare arrangements: Workers with a child under three years were also asked about childcare arrangements while the mother is at work. Results identified grandparents as being the most common carer at 61.8 %, with husbands the second most common for 30.3 % of the FGWs. Figure 68: Childcare arrangements during work hours (n= 76)
51
Aunt/uncle
1%
Older sibling
3%
Other
4%
Husband
30%
Grandparents
62% 0%
10%
20%
30% 40% %age
50%
60%
70%
Focus group discussions showed that 30% of mothers returned to work before their child was 6 months, and 10 (out of 38) mothers returned to work just after maternity leave when their child was 3 months old or less. The average age of the child when mothers returned to work was 17 months. In the FGD, the main care taker of the child is the grandmother, which is coherent with the findings of the workers’ survey (above figure 22). One woman said that the main care taker of the child was her younger sister (10 years old) and one mentioned her husband as the main care taker. The main reason mentioned by the mother for choosing the grandmother as the main care taker is that they hardly trust their husbands to take care properly of their child because they are often working far from the house or drinking beer, and the fact that grandmothers have experience in taking care of children. Care takers are usually the ones to take the first action and bring the child to the HC when he/she is sick, but the mothers all mentioned that they would always take leaves from work in case the condition of the child is not improving or require referral at provincial hospital. When asked about their concerns related to child feeding after they return to work, it has been difficult –not to say impossible- to refocus the discussion regarding feeding aspect only. Indeed, FGW showed high emotion and expressed a stream of concerns related to many aspects of the child care and health. Many of them mentioned their fear that the child might not be given enough food (quantity). A much lower number of mothers mentioned the quality of the food given, fearing that the child might be given any kind of unhealthy snacks such as crack-snacks, candies or ice creams. One of the mother said that she was worried about her child not being ready for introduction of complementary food when she returned to work (her child was 3 months old by that time). Mothers were concerned as well that the grandmothers were busy with the rice fields, collecting grass to feed cows, cooking, taking care of several young children and therefore not giving full attention to their child. From home observations conducted by the research team, it was noticed by observers that although there is a main caretaker responsible for the child, during the day many different people are engaged in childcare, such as siblings, grand-fathers or neighbours, according to the availability of the main care taker.
52
The team observed that the main-care taker is a key person to the child and perceived as such. Indeed, he/she is responsible of the basic needs of the child such as preparing food, feeding the child, watching over him and he/she is the first respondent to the child needs. Nevertheless, mothers remain the primary care provider when they are at home, and they are usually the ones to bath and feed the child as well as stimulating him/her by playing and providing strong affection as soon as they come back from work and on Sunday. During home observation, observers noticed that among all the families, care-takers are busy persons and don’t spend necessary full time and attention with the child. For instance, villagers are all farmers, and were busy with the rice field work, cutting grass for the cows, feeding cows and chickens, etc. In the cases of grand-mothers being the main care-taker, they are as well the ones cooking for the whole family. During those activities, the child generally accompanies the care-takers in their daily work, playing nearby or simply resting. Meanwhile, care-takers would always keep an eye on the child, but not providing him/her any kind of stimulation.
Hygiene practices From research team experience, after almost 10 years working rural areas of the province, hygiene level is generally very poor within households. One house-hold didn’t have any latrine or toilets and was sharing with another household. The remaining ones have toilets; though they didn’t have handwashing facilities. In all of our observations, none of the child was assisted or asked to wash hands before eating, neither the care-taker did wash hands before feeding the child. We could observe caretakers feeding the children from directly from the hand, or children eating on their own while playing in the ground at the same time. In 4 out the 5 households observed by the team, people are collecting rain water in big jars without covers. This is the only source of drinking water for the all family. One household was equipped with a water filter and the all family was fetching water from it. In one family, the care-giver explained during the semi-structured interview that they were boiling the water before giving it to the child. During the observation, we couldn’t see anyone boiling water, but the child was taking water directly from the jar to drink. This highlights the dichotomy between knowledge and behaviour. Although those results are from home observation on a very small sample, they are consistent with the FGW survey, where 20% of FGW declared having no access to toilet facilities at home (either household facility or shared facility), 25% of FGW declared drinking rain water stored in jars and 22% declared drinking surface water. Kitchen are generally open space where it is common to see any kind of animals walking around such as dogs, chicken, ducks or cows as we can see in the picture. In all households the food kept in the kitchen was unprotected from flies or animals, and just kept at open air.
53
We noticed as well that in one household, the father was paying attention to general hygiene and would use clean pots to feed the child, washed the dishes with detergent and had soap available. In other households the dishes were simply washed with rain water. In one of the households, the grand-mother explained that the child was given a bath once in a day with the mother when she comes back from work. In all other cases, children were bathed 2 or 3 times a day. In the majority of cases, no soap was used to bath the child. Every care-giver explained that the child is having a bath at night time together with the mother when she comes back from the factory. This time is seen by the mothers themselves as a privileged moment in the mother and child relationship, as FGW mentioned during the FGD as well. During the semi structured interviews with care takers, when asking whether the child had diarrhea, fever or cough within the past 2 weeks, we found that out of 5 children,
1 had diarhea and cough showing rapid breathing 2 had cough and fever 1 had cough 1 didn’t show signs of illness
54
4 - Conclusions This research is the first one conducted to explore RMNH of rural female garment workers, with a focus on access to services, working conditions and childcare arrangements. With strong support both from Provincial Labour department and participating factories, the workers’ survey was conducted within the workplace, thus allowing the research team to explore link between workers declaration, working & living condition observed. Results show that the average female garment worker in Kampong Speu province has a very different profile compared with FGW around Phnom Penh. A majority of FGW in Phnom Penh region migrated from their province in a young age, while still single. In Kampong Speu province, average FGW is older, is married with 2 children, she is not a migrant and lives in her home village with husband and parents, she studied until the end of primary school, she earns in average 187$ per month. She stopped working for a few months to take care of her child after delivery and currently, her children are taken care of mainly by their grandparents, a source of concern for the mother. Factory stakeholder interviews (with management team, union representatives and health staff) showed that access to services within the factory is very limited compared to the needs expressed. Services within infirmaries are strictly limited to work related issues, and not answering workers needs in terms of reproductive and maternal health. Infirmaries staff in the survey never included a midwife, and doctors and nurses among existing staff recognized their low capacity and need for more trainings to answer the needs of the workers, in particular for gynaecological problems, nutrition and birth spacing. Day care facilities and breastfeeding room are not functional and not really relevant in a context where, due to transportation time and conditions, it is very difficult for FGW to bring their child to the workplace. Overall, during the process of this study, participants & stakeholders identified a number of needs for future programs, including:
Personal hygiene and care (including hand washing awareness campaign)
Gynaecological health, especially during menstruation
Birth spacing
Nutrition
Child care services
Parenting education, nutrition and hygiene
General education and awareness
The survey of FGW showed that current access to healthcare for FGW is limited, due to financial barriers, long working hours, travel distance and the lack of information. Workers confirmed that factory infirmaries provide a very limited range of services, almost systematically excluding reproductive and maternal health services. While FGW tend to access health services from private facilities for general health problem, public facilities are preferred for RMNH issues. However, FGW are unable to follow MoH recommendations, especially regarding pregnancy and neonatal care. The main barriers mentioned by FGW for not accessing healthcare are the cost and travel distance. Even when pregnant
55
women are allowed to take leave to go for ANC, some FGW expressed during FGD that pressure from line managers made them afraid to use this option. General knowledge on STIs appeared very limited but knowledge and use of family planning is relatively good compared with
[GOING FURTHER The general conclusion that access to services
general population. One of the main
is generally difficult for garment workers is a
reasons mentioned for not using family
worrying sign for workers in Cambodia in
planning is a belief that they are damaging
general, as garment industry is the most
health. Condom use in the participants is
regulated
similar to the general population, with a
Cambodia. It would be useful to conduct
concern on the 14 % of unmarried sexually
similar studies to explore RMNH knowledge
active women who declared having casual unprotected sex.
and
standardized
sector
in
and practices in sectors were enforcement of labour law is weaker and working conditions more difficult, such as tourism or construction industries. After discussion with other NGOs,
Related to maternal health, a striking figure
it seems that the issues around the quality of
is the very high rate of home deliveries (26
childcare in the absence of the mother are not
%),
general
specific to FGW families, but also for the
population of the province (17 %), and
families of migrants working in Thailand and
strongly related to lower education level of
Vietnam.
the some FGW in the survey. Access of
]
much
higher
than
the
FGW to ANC and PNC services has shown to be difficult, with only one third of women
able to comply with MoH recommendation, despite good awareness and knowledge. Maternity is mentioned as an important cause of workforce turnover, both by mothers and management. Focus group discussion and home observation showed that within families, the rapid industrialization of the province has deeply modified traditional family structure and the role of the different caregiver, resulting in strong difficulties for mothers to balance their professional life and their family life, raising issues between caregivers and in the end resulting in lower quality of care for the children growing up without their mothers. Finally, factories management teams, union representatives and health infirmary staff expressed a high level of support and interest for initiatives to improve overall worker health, with the positive impacts on worker reliability and productivity widely recognized by garment factory management representatives.
56
5 - Recommendations for action This research allowed identifying needs and opportunities for future programs addressing specific issues of FGW from rural areas, to improve access to health care and working conditions in a relatively new and rapidly changing context of industrialization.
Program ideas Based on the main findings analysis and on needs expressed by main stakeholders, several areas of relevant interventions have been identified by the research team and are listed below. Key stakeholders feedbacks and ideas from the dissemination workshop have been integrated. Access to information and worker’s education: Identified needs:
General lack of education and information, difficulties to discuss RMH issues within factories, in particular on FP, STI, home deliveries and maternal health in general.
Objectives:
Raise general education level and awareness about key RMNH issues through peer-educator program and group activities within the workplace
Approach:
Train-the-trainer lunchtime education program: train workers on short education programs on priority areas that can be delivered over lunchtime
One-on-one education opportunities: train workers as peer educators
General communications: Availability of IEC material, host lunchtime videos & games on key program areas.
Previous & existing
ILO, CARE, GRET, RHAC
interventions Stakeholders
feedbacks
Importance to consider providing diverse source of information depending on the topic and the audience.
One to one RMH counselling is difficult within infirmaries, because of lack of confidentiality and request authorization from manager to access (consider other space available without previous permission)
Peer education: consider the challenge of workers turnover when they are not line managers and type of information they can disseminate (needs to be very basic).
57
Child care & maternity Identified needs
Nutrition, hygiene and stimulation for children Balance between professional and family life for mothers
Objectives
Support mothers manage professional life and childcare, to improve both childcare concerns and reduce turnover due to maternity
Approach:
Sensitization on the issue with caretakers and factory stakeholders
Provide factory management with package of tools and guidelines for implementation for functional daycare facilities: caretaker training, activities toolkits and material, etc…
Explore alternative to the day-care facilities within factories, not always relevant in rural areas, and encourage village based child care services and parenting education to main caregivers focusing on basic hygiene and nutrition
Previous & existing
ILO - E&D
interventions Stakeholders
feedbacks
Explore extension of maternity leave as an alternative for women who currently resign – and impact on competitiveness
Childcare in villages may be more relevant than in factories, as factories may not be a suitable place for children and dangerous transportation
Explore parental day care in villages and linkage with existing parenting interventions: home base care, mother health support groups, etc.
Explore impact of pregnant women exposed to chemical products on children
Access to health care Identified needs
Low ANC compliance, home deliveries, difficult access to RMH outside of the factory, especially public health facilities
Objectives
Support women to access reproductive and maternal health services both within and outside the factories
Approach:
Bring ANC and RMNH counselling services into factories, either through advocacy for factories to employ an in-house midwife or through linkage with outreach activities from nearby health center.
Encourage management teams to invest in infirmary staff capacity building, in particular in counselling
58
Lobby partner factories to make improvements to health infirmary equipment, infrastructure and general hygiene
Address financial barriers to access healthcare by raising awareness of available social health protection mechanism (social health insurance from NSSF for workers and community based and health equity fund for the family members)
Improve workers information on available services in the area: record book of nearby public and NGO health facilities, which provides details on available services, opening hours, contact details, distance from the factory and costs
Formalize a referral system and stronger relationships between garment factories and nearby public or NGO health facilities to improve service access
Previous & existing
Explore opportunity to extend opening hours of public health facilities
RHAC, Workers health project, GRET/SHPA, RHAC
interventions Stakeholders
Explore transport subsidies and link with NSSF for sustainability
feedbacks
Consider funding issues of existing outreach activities
Consider mobile clinic on Sunday
Explore the issue of integration of factories infirmaries into NSSF system
Factory infrastructure and service delivery: compliance with standards and improvement of standards Identified needs
Incorporate specifications and guidelines for adequate infrastructure and functional services, matching worker’s needs (infirmaries, daycare, etc…) in existing regulation
Objectives
Improve existing standards compliance and improve standards to match the needs of workers
Approach:
Previous & existing
Pilot interventions to document evidence on impact for workers and competitiveness.
Increase coordination and collaboration between stakeholders to bring relevant advocacy topics to decision makers.
Support management and unions representative to negotiate and monitor workplace infrastructure
ILO – Worker health project
59
interventions Stakeholders
Need for a platform for more collaboration and information sharing between stakeholders
Need for an advocacy working group working on standards improvements
Factory management have very little room for improvement of services if not compulsory by law (compliance with minimal standards for competitiveness issue)
Explore unregistered factories issues with specific research
feedbacks
Next steps Also a number of stakeholder engagement activities were already undertaken throughout the study, to build understanding and support for the study, identify opportunities for potential future collaboration, survey recommendations are based on the result of this specific survey, and need to be considered in perspective with government strategy and existing stakeholder interventions. This survey will thus be, in priority, used as a ground basis for further discussions, following the research approach of “better diagnosis, better actions”.
As identified in section above, some stakeholders are already taking actions related to some key issues mentioned in the recommendations, although not in the area where the survey was conducted. Results of the present survey will thus be presented to relevant stakeholders to identify service gaps, options for scaling up exiting interventions, potential collaboration and opportunity to bring targeted new services, both matching workers needs and supporting higher competitiveness of the garment sector in Cambodia. Increased coordination and collaboration of civil society actors seems also a key element to bring key advocacy topics to relevant decision makers.
60
Annexes Annex 1: Detailed research methodology Participating factories Factories were selected in collaboration with the Kampong Speu Provincial Labour Department, with the Authority making first contact and introducing the E&D project team to factory management through a formal letter. Initial factory selection was based on the strength of existing relationships held with the Provincial Labour Department and select factories, level of interest amongst factory management and factory availability during survey administration. In total, eight factories were involved in the study. With factory selection and initial engagement facilitated by the Kampong Speu Provincial Labour Department, the research project primarily focussed on smaller garment factories under 2,000 workers. This was due to smaller factories with no major brands or buyers often having little capacity to deliver factory health programs and to provide quality health infirmary services, thus more interested in developing partnership with NGOs. Following an initial meeting with the factory to explain the research purpose, objectives and delivery method, agreement was reached with participating factories. A formal Memorandum of Understanding (MoU) was available for signing if operators preferred to formalise the agreement. All project involvement was confidential.
Table summarises the involvement of each participating factory, including the number of completed surveys and factory stakeholder interviews. Table 7: Participating factories profile Factory
Number of workers (approx.)
Pregnant women
Infirmary
Products
Owners
3
Yes
All Kinds of Sport Shoes (Footwear)
China
14
3
No
Man/Lady Shirt, Man/Boy Pants
Cambodia (100%)
8000
200
3
Yes
Lady Shoes, Lady Boots (Footwear)
Taiwan (100%)
438
350
14
3
Yes
Man/Lady Woven & Knitted Shirt
Malaysia (100%)
5
893
831
30
4
Yes
Jeans
China (90%), Cambodia (10%)
6
287
193
1
0
No
T-shirt
China (100%)
7
613
313
13
4
Yes
All Kinds of Handbag
8
1,437
1,322
25
2
Yes
Jeans
Total
Female
No
%
1
946
927
28
2
600
533
3
8,200
4
Cambodia (100%) Canada (100%)
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Table 9: Participating factories involvement
Interviews
Factory
Survey delivery approach
Completed FGW surveys
Management
Health staff
Union reps
1
Factory
62
1
1
1
2
Factory
61
0
0
0
3
Dormitory
76
1
1
1
4
Factory
69
1
1
1
5
Factory
62
1
1
1
6
Factory
56
1
0*
0*
7
Factory
54
0
0*
0
8
Interviews only
0
1
1
1
Ethics committee approval Full ethics approval was granted by the National Ethics Committee for Health Research for this research project. Participation in the survey was completely voluntary and prior to each FGW survey, written informed consent was sought and a participant information sheet read to each participant. Participants were advised they were able to refuse to answer any question and to stop at any time without any negative consequences. No names were recorded on the surveys and privacy and confidentiality were maintained at all times.
Factory stakeholders interviews Sixteen separated semi-structured interviews of up to one hour were conducted with participating factories’ stakeholders: management (six), union representatives (five) and health infirmary staff (five). Written notes were taken during the interviews and information collected in these interviews was also used to inform the final survey design. A full list of interview questions is provided in annex 2.
Female Garment worker survey A 20 minute face-to-face quantitative paper survey involving 440 female FGW’s of child bearing age was undertaken in participating factories over lunch time or at worker dormitories on Sundays. Survey 20 design was based on the recent FGW survey completed by PSL , as well as key findings from initial discussions with garment factory operators and key stakeholders. The survey was peer reviewed by two external specialist consultants (GRET and an independent consultant) and back translated to ensure
20
Sopheab, H. (2014).
62
consistency in question intent. It consisted of 68 questions on the following topics:
Demographic information
Access to health services
Sexually transmitted infections (STIs) and family planning (FP): knowledge and practice
Maternal care& child care
Participant ‘thank you’ pack At the completion of each survey, participants were compensated for their time with a soap and were also provided with an Information Education Materials (IEC) relevant to their SRH status. The survey is provided in Annex 3.
Interview team A total of 33 interviewers were recruited and trained in a two-day workshop and during the field pilot. Generally, interviewers were university students and recent graduates from disciplines including public health, social work, psychology and midwifery. The training focussed on ensuring all interviewers understood each question in the survey and there was consistency in the method of conducting the surveys. The interviewers were also briefed about ethical considerations such as confidentiality and consent. Time was dedicated to practicing the survey, under the observation of E&D staff. Interviewer training
Survey pilot The survey was piloted on three occasions involving all 33 interviewers; two pilots were undertaken in a village with FGW’s on a Sunday and the third occurred in a participating factory. The pilot surveys tested the wording and content of the survey questions and allowed for the survey to be revised accordingly. They also provided an opportunity for the research team to give feedback to the interviewers on their interviewing techniques, such as following the survey in the correct order, gaining informed consent and ensuring consistency amongst the interviewers. Data from the pilots was also used by the project team to test the analysis process and software.
63
Piloting the survey
Sample size and sampling approach Using a five % margin of error and a 95 % confidence interval, the required minimum sample size was calculated to be 383. In total, 440 surveys were conducted. Interviews took place in July and August 2015. Convenience sampling was used to select the participants during their lunch hour at the factory or during a Sunday at the dormitory. Management previously informed all FGW of the implementation of the research in their factory, seeking FGW good participation with the interviewer team. Participants were randomly approached by interviewers on the way out from the lunch place and gave their consent after explanations of the research objectives and confidentiality policy. The sample size of each factory was approximately 60 participants, influenced by the size of the survey team and factory staff. Only 3 women approached did not complete the survey (0.6%), and the research team was able to reach the necessary sample size and interviewed 440 women.
Data collection The interview team was supervised by at least three members of the project team while conducting the surveys. The supervisors ensured all interviewers adhered to gaining informed consent and maintaining the confidentiality of the participants. Each survey was also reviewed by a supervisor after completion to ensure all necessary questions had been answered and that the interviewer had not made any obvious mistakes (e.g. circled two answers when the question was a single-answer only question).Feedback was also given to the group of interviewers before and after each day of work to clarify common queries. Data entry and analysis The researchers entered the data into the statistical software package SPSS. The dataset was cleaned and descriptive statistics were calculated. Relationships between age group, marital status, education level, income earned in the last month and Figure 7: Review of completed surveys occasionally having children/not having children (where seen relevant) and most variables were tested. Undertaking data analysis
64
Focus group discussion The aim of conducting focus group discussions with FGW mothers of young children was to complement the quantitative survey with qualitative information on specific issues. The analysis of the discussion gives us precious information on the practices of FGW related to their children with the intention of designing a tailor made project fitting the needs and based on current practices. Through the focus groups discussions, the objective was to explore in details the following areas: -
Breastfeeding and exclusive breastfeeding practices Introduction of complementary feeding at the end of the maternity leave, when mothers return to work Child care arrangements during working hours
Factory managers selected women participating to this phase of the survey according to the criteria defined by E&D team i.e. pregnant women and mothers of young children. The focus group discussions took place during lunch hours in order to limit the incidence on the productivity of the factories, and lasted around 45 minutes. The questions and process was peer reviewed by our partner GRET. The team did a pilot in the village before conducting the FGD in the factories, in order to polish our method and for the facilitators to be comfortable and confident. E&D team was composed of one facilitator and one note taker per group. We conducted the FGD in 2 factories, during lunch time (lunch was provided to all the participants), involving two groups of FGW each time, so in total, 4 groups went through the same process, with 42 participants.
Date
Factory
10th November
10th November
11th November
11th November
2015
2015
2015
2015
Factory 1
Factory 1
Number of
13 participants
13 participants
participants
(includes 3 pregnant
(includes 3
Factory 2 9 participants
Factory 2 9 participants
65
women)
pregnant women)
Age of the child 4 babies less than 6 months when mother
1 baby less than 6
3 babies less than 6
3 babies less than
months
months
6 months
returned to
1 baby between 6
3 babies between 6
3 babies between 6
3 babies between
work
and 12 months
and 12 months
and 12 months
6 and 12 months
5 babies over 12
3 babies over 12
3 babies over 12
3 babies over 12
months
months
months
months
Home observation Observation of FGW children life at home had several objectives such as: -
Allow caretaker to express their challenges and motivation
-
Compare mothers and caretaker declarations to actual practices
-
Have a clear picture and better understanding of the current practices
In arrangement with the Village Chief and the family, E&D proposes to assign a staff member to observe FGW’s children at home, from the time their mother leave for work, to the time she returns home. E&D staff members role during that day was to observe the day’s practice only, making sure that they did not interfere or provide advice on any practice they observe. Throughout the day, the E&D staff member captured the child’s day in an activity chart. E&D shared the plan and objective of observation to the PHD Maternal and Child Health officer as well as health center chief to in order to inform them and get their approval for this activity. This allowed us to make sure that there was no NGO program currently run in the selected villages related directly to child-care practices and nutrition. The collection of information was made in 2 ways: -
A semi-structured interview to the main care-takers (see annex 4)
-
A day of observation exploring more specifically practices related to child-care arrangement, nutrition and hygiene
The next step, after the village observations was a team meeting to review the results and share the main finding related to above objectives than making the report. 3 E&D staffs were involved during this village observation during 2 days. They could observe 5 families and more especially FGW children from the departure of their mother to the factory until the time they went to bed. The children were aged between 13 and 18 months, with 4 boys and 1 girl. Within the 5 families followed, 3 of the main child care takers were their grand-mothers, 1 was the child’s aunt (mother’s sister) and 1 was the father of the child.
Stakeholder engagement
66
Throughout the study, key stakeholders were consulted to identify opportunities for collaboration and ensure individuals and groups were aware of, and were kept updated on the progress of the research. Stakeholders consulted throughout the project included:
Habitat for Humanity (project partner)
Kampong Speu Provincial Labour Department
Kampong Speu Provincial Health Department
CARE International,
Partnering to Save Lives
International Labour Organisation
Population Council
Reproductive Health Association of Cambodia
GRET
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Annex 2: Factory stakeholder interviews Interview research objectives Management, Union Representative and Health Clinic interviews will aim to: Introduce the research project to key stakeholders Build support and participation Explore current use and service provision of factory health infirmaries for reproductive, maternal, neonatal and child health (RMNCH) Explore key RMNCH needs and opportunities of garment factories and their workforce.
Methodology Up to 6 one-hour interviews for each participating factory will be held, as below: Management: up to 2 representatives Health staff: up to 2 representatives Union representative: up to 2 representatives Key findings from management interviews will inform survey design. Efforts will be made to complete all interviews in early July 2015, before the garment factory worker quantitative survey is finalised. Contact details will be sourced from key factory contacts. Interview times/locations will be scheduled and attended by members of E&D’s project team. A team debrief will be held with E&Ds interviewers to discuss key findings, responses, and any necessary follow-up actions, such as additional interviews to seek further information. All participants and responses will be treated as confidential. No one will be identified through transcripts or reporting.
Interview questions Interview questions are summarized below.
Interview cohort
Investigation areas
Interview questions
Factory
Available services and existing
How many shifts do workers have? What do
management
gaps at factory health infirmary
they do on their breaks? (note: this question
Skill level of health infirmary staff
What are the main health concerns of your
Worker satisfaction of infirmary Key health concerns of garment factory workers Previous/current
will informal future program design)
RMNCH
workers? How much time/productivity is lost from worker SRH issues (absenteeism)? What services are available at the infirmary?
programs
How often do workers use the infirmary?
Previous/current relationships
What do workers use the infirmary for?
68
with NGOS RMNCH
leave
What is your policy and practice around ANC/ arrangements
PNC, breastfeeding and childcare?
and use
To what extent do workers use these services?
Breast feeding and childcare
What are your ideas to improve RMNCH? (If
services
you could deliver one program to improve the
Ideas/opportunities to address
RMNCH of your workers, what would it be?)
key health needs and service gaps Factory
health
infirmary staff
Available services and existing
What are the main health concerns of your
gaps at factory health infirmary
workers?
Skill level of health infirmary
What services are available at the infirmary?
staff
What are the key infirmary service/skill gaps?
Worker satisfaction of infirmary Key health concerns of garment factory workers Ideas/opportunities to address
How often do workers use the infirmary? What do workers use the infirmary for? What support/training do health staff receive?
key health needs and service
What support do you need to improve
gaps
infirmary services (equipment and skill level)?
Union
Key health concerns of garment
What are the key RMNCH concerns of garment
representatives
factory workers
factory workers in Kampong Speu?
Staff satisfaction of infirmaries
What health programs/initiatives do unions
RMNCH programs and support
support?
services currently available to
What ideas do you have to improve worker
factories in Kampong Speu
health?
province RMNCH
leave
arrangements
and use Key challenges facing garment factory workers in Kampong Speu province Ideas/opportunities to address key health needs and service gaps
69
Annex 3: Female Garment Worker survey INTERVIEWER NAME:
DATE:
SURVEY CODE:
TIME START:
PARTICIPANT ADDRESS: Weekend address
TIME END: COMMUNE:
DISTRICT :
1. Boseth 2. Chbar Mon (City of Kampong Speu) 3. Kong Pisey 4. Aoral
5. 6. 7. 8. 9.
Udong Phnom Sruoch Samrong Tong Thpong OTHER
PROVINCE:
CHECKED BY: 1. Kampong Speu Province 2. OTHER
NOTE: INTERVIEWER INSTRUCTIONS IN GREY
Section 1: Demographic information 1.1
How old are you now?
Remarks .....................................Yrs
IN WESTERN AGE 1.2
1.3
What grade did you reach in school?
..................................... Grade
TRANSLATE IF IN OLD SCHOOL SYSTEM
0 IF NO SCHOOLING
What is your current marital status?
1. Single and not in a regular relationship
LIST OPTIONS ONE BY ONE ONE ANSWER ONLY
2. Single with regular boyfriend (sweetheart) 3. Married 4. Separated/ divorced 5. Widowed (Husband died)
1
1.4
Do you live in a different place during the work week?
1. Yes 2. No (SKIP TO 1.13)
1.5
How far is your weekend home from the factory?
1. Less than 30 minutes from the factory
ONE ANSWER ONLY
2. 30 minutes to one hour from the factory 3. From 1 to 2 hours from the factory 4. More than 2 hours from the factory
1.6
How do you usually travel from your weekend home to the factory? ONE ANSWER ONLY
1. Own motorr 2. Van 3. Truck 4. Remorque 5. Other (SPECIFY): …......................................................................
1.7
1.8
1.9
If you live away from your home, how much remittance do you send to your family per month?
....................................Riels
ONE ANSWER ONLY
0 IF NONE
How satisfied are you with the built condition of your home during the working week (walls, floors, roof and floor)?
1. Highly satisfied
LIST OPTIONS ONE BY ONE
3. Not satisfied
ONE ANSWER ONLY
4. Highly unsatisfied
During the work week, does your home have:
1. Electricity
2. Satisfied
2. Drainage LIST OPTIONS ONE BY ONE MULTIPLE ANSWER
3. A waterproof roof 4. Waterproof walls
2
1.10
During the work week, how many people usually sleep in the same room as you? ONE ANSWER ONLY
1.11 1.12
................................People.
How big is the room where you sleep during the week? ONE ANSWER ONLY
……......................…m²
Do you think that you have enough space to sleep?
1. Yes 2. No
1.13
ONE ANSWER ONLY
3. Don’t know/ not sure
Who do you live with during the work week?
1. Parents 2. Peers
MULTIPLE ANSWER
3. Husband and children 4. Other relatives 5. Alone 6. Other (SPECIFY): ..................................................................
1.14
How much do you pay for your rent and utilities monthly? ONE ANSWER ONLY
1.................................. Riels (TOTAL) 2. I don’t pay any things 3. I don’t know/ I’m not sure
1.15
During the work week, what is the main source of drinking water at your home? MULTIPLE ANSWER RECORD ALL MENTIONED
1.
From a tap inside my home
2.
From an outside container/tank filled by rainwater or another water source (tanker)
3.
Well or Borehole
4.
Directly from surface water (river/dam/lake/pond/stream/canal/ irrigation channel)
5.
Bottled water
3
6. 1.16
1.17
Other (SPECIFY): .................................................
During the work week, what kind of toilet facilities do you use at home?
1. No facilities (bush / fields / bucket)
ONE ANSWER ONLY
3. Facilities for your household only
Yesterday, at home, when did you washed your hands:
1. Before eating
2. Shared facilities
2. Before preparing food PROBE FOR FURTHER ANSWERS (any other time?)
3. Before feeding children
RECORD ALL MENTIONED
4. After defecating
MULTIPLE ANSWER
5. After urinating 6. After cleaning children 7. After working 8. When hands are dirty 9. When hands have bad smell 10. Other (SPECIFY):.......................................................................
1.18
How do you wash your hands?
1. Soap
ONE ANSWER ONLY
2. Ashes 3. Water only 4. Other (specify) ……………………………………………….
1.19
1.20
How much did you earn last month in RIEL? (Including overtime and other source of income) ONE ANSWER ONLY
………………………Riels
How often do you manage to save money for unplanned expenditure or emergencies (for personal use)?
1. Always (every month)
LIST OPTIONS ONE BY ONE
3. Only some months (less than 6 months of the year)
ONE ANSWER ONLY
4.
2. Almost every month (around 8 months of the year) Never
(SKIP TO 1.22)
4
1.21
On the month where you manage to save money, how much to you save?
………………………Riels
ONE ANSWER ONLY 1.22
During the work week, how much time from the factory is the place where you sleep? CLARIFY RESPONSE ONE ANSWER ONLY
1.23
During the work week, how do you usually travel to work? ONE ANSWER ONLY
1. Less than 30 minutes from the factory 2. 30 minutes to one hour from the factory 3. From 1 to 2 hours from the factory 4. More than 2 hours from the factory 1. Walk 2. Own motor 3. Van 4. Truck 5. Remorque 6. Other (SPECIFY):.........................................
1.24
How much money do you spend on transport per month? ………………………Riels 0 IF NONE
Section 2: Access to health services 2.1
Have you used the factory infirmary in the past 12 months? ONE ANSWER ONLY
2.2
If NO, why not?
1. Yes (SKIP TO 2.3) 2. No 1. I was not sick 2. Infirmary not available at convenient times
PROBE FOR FURTHER ANSWERS (any other reasons than the ones you have mentioned?)
3. I have to wait too long 4. Service is too expensive 5. Quality of service is not good
5
MULTIPLE ANSWER
6. Provider is unfriendly
RECORD ALL MENTIONED
7. Type of health service required is not available 8. Infirmary is not clean
SKIP TO QUESTION 2.7
9. Lack of confidentiality 10. Other (SPECIFY):
2.3
What services have you received at the factory infirmary? PROBE FOR FURTHER ANSWERS (any other services than the ones you have mentioned?)
……………………….......................
1. Treatment for general illness (for example: headache, fever, stomach pain, feeling sick, dizziness, tiredness or feeling faint) 2. SRH treatment or advice (including vaginal discharge, lower abdominal pain, bleeding and Sexually Transmitted Infections testing/referral (including HIV) and prevention) 3. Family planning method (condom, pill, injection) and / or counselling
MULTIPLE ANSWER
4. ANC service
RECORD ALL MENTIONED
5. PNC service 6. Abortion examination, counselling and/or treatment 7. Vaccination 8. Other (SPECIFY):
2.4
2.5
How satisfied are you with the services provided at the infirmary?
1. Highly satisfied
LIST OPTIONS ONE BY ONE
3. Not satisfied
ONE ANSWER ONLY
4. Highly unsatisfied
Have you received a referral for outside health services from infirmary staff in the past 12 months?
1. Yes
……………….....................................
2. Satisfied
2. No
(SKIP TO 2.7)
3. I don’t know/not sure 2.6
If you have received a referral for outside health services,
(SKIP TO 2.7)
1. Health issue not related to SRH and maternal care
6
what was it for? PROBE FOR FURTHER ANSWERS (anythingelse than the ones you have mentioned?) MULTIPLE ANSWER RECORD ALL MENTIONED
2. SRH treatment or advice (including vaginal discharge, lower abdominal pain, bleeding and Sexually Transmitted Infections testing/referral (including HIV) and prevention) 3. Family planning method (condom, pill, injection) and / or counselling 4. ANC service 5. PNC service 6. Abortion examination, counselling and/or treatment 7. Vaccination 8. Other (SPECIFY):
2.7
How many times have you accessed health facilities outside the factory within the past 12 months for your own health? ONE ANSWER ONLY
2.8
When you last accessed health care outside the factory, what type did you access?
……………….....................................
……… Times 0 FOR NO TIMES (IF 0 SKIP TO 2.11) 1. Public facility 2. Private facility 3. NGO facility
ONE ANSWER ONLY
4. Pharmacy 5. Traditional healer 6. Other (specify): ……………………...............................................................................
2.9
What were the reasons for your last visit?
PROBE FOR FURTHER ANSWERS (anything else than the ones you have mentioned?)
1. Health issue not related to SRH and maternal care 2. SRH treatment or advice (including vaginal discharge, lower abdominal pain, bleeding and Sexually Transmitted Infections testing/referral (including HIV) and prevention) 3. Family planning method (condom, pill, injection) and / or counselling 4. ANC service
7
MULTIPLE ANSWER
5. PNC service
RECORD ALL MENTIONED
6. Abortion examination, counselling and/or treatment 7. Vaccination 8. Other (SPECIFY):
2.10
How satisfied were you with the services you received?
……………….....................................
1. Highly satisfied 2. Satisfied
LIST OPTIONS ONE BY ONE
3. Not satisfied
ONE ANSWER ONLY
4. Highly unsatisfied 5. Don’t know / not sure
2.11
What difficulties do you regularly face in accessing healthcare outside your factory?
1. None. I don’t face any difficulty when I need to access healthcare 2. Cost 3. Travel distance to clinic from work
PROBE FOR FURTHER ANSWERS (does anything else than what you have mentioned make it difficult for you to access healthcare for yourself?)
4. No information about available services
MULTIPLE ANSWERS
7. Afraid of impacts to job security
RECORD ALL MENTIONED
5. Afraid to visit health care alone 6. No free time outside working hours 8. Afraid to ask permission from line manager 9. Difficulty in claiming back for sick leave 10. Other (SPECIFY): ……………………...............................................................................
2.12
IF SINGLE AND NOT IN A REGULAR RELATIONSHIP SKIP TO SECTION 3
1. No 2. Yes from an NGO clinic 3. Yes from a health centre outside of the factory
Have you ever received financial support for ANC or PNC (such as a voucher or subsidised fees)?
4. Yes from Village Health Support Group 5. Yes from a peer support person inside the factory
8
6. Yes from factory management CLARIFY RESPONSE (for example, if someone replies YES, ask, ánd who was that from’?
7. Other (SPECIFY): ………………………………
ONE ANSWER ONLY Section 3: Sexually Transmitted Infections (STIs): knowledge and practice 3.1
From where or whom have you heard about sexually transmitted infections (STIs)?
1. I have not heard about STIs 2. Advertising (TV, radio, newspaper, poster, leaflets) 3. Relatives (Parents, brothers, sisters, close family)
STIS are infections infection which is passed from one
4. Friends
person to another person during sexual activity
5. Infirmary health staff 6. Health staff outside the factory
3.2
PROBE FOR FURTHER ANSWERS
7. Factory peer support person
MULTIPLE ANSWERS
8. Teacher in school
RECORD ALL MENTIONED
9. Other (SPECIFY): ……………………………..
If you wanted to find out more about sexually transmitted infections, from who would seek information at first?
1. Relatives (Parents, brothers, sisters, close family) 2. Husband 3. Friend
ONE ANSWER ONLY
4. Infirmary health staff 5. Health staff outside the factory 6. Factory peer support person 7. Village health support group 8. Other (SPECIFY): …………………………….......................................................................
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3.3
What would be the most efficient (comfortable, accessibility, easiest) channel to provide you with information on STIs?
1. Information, education and communication materials (such as posters, flyers) 2. Group discussion (workshops) 3. Radio/TV
3.4
LIST OPTIONS ONE BY ONE
4. One-on-one communication (such as peer listener programs)
ONE ANSWER ONLY
5. Other (SPECIFY): …………………………….....................................................
If you have sex with sweethearts/casual partners, do you use condoms with them? ONE ANSWER ONLY
1. 2. 3. 4.
If married women skip to Section 4
I don’t have sex with sweethearts/casual partners Not sure/ don’t know I have sex and use condoms I have sex and don’t use condoms
Section 4: Family Planning: knowledge and practice 4.1
What methods of contraception have you heard of? PROBE FOR FURTHER ANSWERS (are you aware of any other forms of contraception?) MULTIPLE ANSWERS RECORD ALL MENTIONED
4.2
1. None
9. Female condom
2. Female sterilization
10. Emergency contraception
3. Male sterilization
11. Breastfeeding (Lactational Amenorrhea method)
4. IUD
12. Rhythm method (calendar method)
5. Implant in arm
13. Withdrawal
6. Monthly injection
14. Abstinence
7. Daily pills
15. Abortion
8. Condom (male)
16. Other (SPECIFY): ………………………
Have you ever used any method of contraception?
1. Yes 2. No (SKIP TO 4.6)
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3. Not sure/don’t know ONE ANSWER ONLY 4.3 4.4
In the past 12 months have you used any method of contraception?
1.
No (SKIP TO 4.6)
IF NO, SKIP TO 4.6
3. Don't know / maybe
2. Yes
If you have used contraception in the past 12 months, what have you used? MULTIPLE ANSWERS RECORD ALL MENTIONED
4.5
1. Female sterilization
8.
Female condom
2. Male sterilization
9.
Emergency contraception
3. IUD
10. Breastfeeding (Lactational Amenorrhea method)
4. Implant in the arm
11. Rhythm method (calendar method)
5. Injectable
12. Withdrawal
6. Daily pills
13. Abstinence
7. Condom (male)
14. Other (SPECIFY):
………………………
Last time, where did you go to get modern contraception from?
1. I am not using modern contraception
ONE ANSWER ONLY
3. Private facility
ONCE COMPLETE , SKIP TO 4.7
4. NGO facility
2. Public facility
5. Pharmacy 6. Other (SPECIFY):………………………. 4.6
If you have NOT used any method of modern contraception, why not?
1. I am not currently sexually active 2. I am trying to have a baby / I would like a baby in the next couple of years
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3. I am pregnant ONE ANSWER ONLY
4. I think they are bad for my health 5. Other (SPECIFY): ………………………………………
4.7
4.8
Do you know whether abortions are legal or illegal in Cambodia?
1. Don't know
ONE ANSWER ONLY
3. Illegal
Do you know where women can access safe abortion services?
1. Don't know
2. Legal
2. Trained public health facility 3. Trained private health facility
PROBE FOR FURTHER ANSWERS (are you aware of any other options?)
4. NGO facility (SPECIFY): ………………………
MULTIPLE ANSWERS
6. Other (SPECIFY): .........................................................................................................
RECORD ALL MENTIONED
5. Pharmacy
Section 5: Maternal care: knowledge and practice 5.1
1. Vaginal bleeding
9. Anaemia
2. Vaginal watery fluid
10. Increased weight quickly
3. Vaginal discharge with bad smell
11. Swelling (face, fingers and feet)
4. Severe abdominal pain
12. Convulsions
5. Daily-long headaches
13. Loss of foetal movement
6. Fever
14. Prolonged labour
RECORD ALL MENTIONED
7. Elevated blood pressure
15. Bleeding after delivery
8. Difficulty in breathing
16. Other (SPECIFY): ………………………..................
FOR ‘SINGLE AND NOT IN REGULAR RELATIONSHIP’
1. Yes
Can you name all the danger signs that you are aware of that indicate problems during pregnancy? PROBE FOR FURTHER ANSWERS (are you aware of any other signs?) MULTIPLE ANSWERS
5.2
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SKIP TO 5.9
2. No
Are you pregnant?
3. Don’t know / maybe
ONE ANSWER ONLY 5.3
How many miscarriages have you had? ONE ANSWER ONLY DEFINITION: miscarriage is a condition in which a pregnancy ends too early and does not result in the birth of a live baby
5.4
Do you have any children?
............ NUMBER (0 IF NO TIMES)
1. Yes 2. No
5.5
(SKIP TO 5.9)
How many children do you have? ............ NUMBER
5.6
How many of your children are under 3 years? ............ NUMBER (0 IF NONE UNDER 3 YEARS)
5.7
For your last birth, where did you deliver your baby?
1. Public facility 2. Private facility
ONE ANSWER ONLY
3. NGO facility 4. My home 5. Other (SPECIFY): ..........................................................................................................
5.8
Who mostly assisted with the delivery of your last birth?
1. Doctor/medical assistance 2. Midwife/ nurse
ONE ANSWER ONLY
3. Traditional birth attendant 4. Relative/friend
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5. Other (SPECIFY): .......................................................................................................... 5.9
Do you know how many times a women should at least go for an antenatal care consultation before delivery? ONE ANSWER ONLY If the woman have no children skip to 5.15
5.10
1. Don't know 2. Four times (or more than 4) CORRECT ANSWER 3. Wrong answer (RECORD):...............................................................
During your last full term pregnancy, how many antenatal care visits did you have? ONE ANSWER ONLY
.............times 0 FOR NO TIMES FOR 0 SKIP TO 5.12
FOR 0 SKIP TO 5.12 5.11
Where did you go for your most recent antenatal care visit?
1. Public facility 2. Private facility
ONE ANSWER ONLY
3. NGO facility 4. Other (SPECIFY): ………………………......................................................................
5.12
With your last baby, how many postnatal care visits did you have?
..................times (0 FOR NO TIMES) IF 0 SKIP TO 5.14
ONE ANSWER ONLY 5.13
Where did you go for your last postnatal care visit?
1. Public facility 2. Private facility
ONE ANSWER ONLY
3. NGO facility 4. My home 5. Other (SPECIFY): ............................................................................................................
5.14
Did anyone talk to you about your contraception choice within
1. Don’t know / maybe
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5.15
5.16
24 hours after your most recent birth?
2. No
ONE ANSWER ONLY
3. Yes
Do you know what exclusive breastfeeding is?
1. Don’t know/not sure
ONE ANSWER ONLY
2. Only breast milk (not other solid or liquid food)
EXPLAIN AFTER ANSWER PROVIDED: EXCLUSIVE BREASTFEEDING IS ONLY BREST MILK, NO OTHER SOLID OR LIQUID FOOD, INCLUDING FORMULA OR OTHER MILK
3. Wrong answer:(RECORD):.............................................
Do you know how long a child should be exclusively breastfed?
1. Don't Know
ONE ANSWER ONLY
5.17
5.18
2. 6 months 3. Wrong answer (RECORD):..............................................................
FOR WOMEN WITH NO CHILDREN or NO CHILDREN UNDER 3 YEARS FINISH SURVEY
1. I exclusively breastfed my baby until 6 months old (SKIP TO 5.19)
If you have a baby under three years, and he/she was given anything to drink or eat other than breast milk in the first 6 months, how old were they?
2. Under 3 months (12 weeks)
ONE ANSWER ONLY
5. Don’t know/ not sure
Why did you stop exclusively breastfeeding your child?
1. Mother returned to work
3. After 3 months 4. After 4 months
2. No breast milk ONE ANSWER ONLY
3. Mother had breast infection or pain during feeding 4. Mother had an illness 5. Mother had a second child 6. Other (SPECIFY)................................................................
5.19
How do you manage the breastfeeding when you go to work?
1. Give expressed breast milk (breast milk expressed manually or
15
PROBE FOR FURTHER ANSWERS (do you do anything else?)
with a pump) 2. Fed by other breastfeeding mother 3. Baby stays at workplace for the day
MULTIPLE ANSWERS
4. Mother returns home and breastfeeds during breaks 5. Carer brings baby to workplace in breaks for breastfeeding 6. Give Infant formula 7. Skip breast feeds during the working day 8. Don't know/not sure 9. Other (SPECIFY): .................................................................................................
5.20
If you have children less than three years, who mostly cares for them when you are working?
1. Husband 2. Grandparents 3. Aunt/uncle
ONE ANSWER ONLY
4. Older sibling (SPECIFY AGE): .............................. 5. Neighbours 6. Child care center 7. Other (SPECIFY): ........................................................................................................
16
INTERVIEWER COMMENTS
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Annex 4: Focus group discussion session plan To better understand some of the key findings, E& has delivered 4 focus groups in garment factories over lunch. Focus groups have been approximately 45 minutes in duration. As an incentive, E&D provided lunch for participants. The aim of the focus groups is to explore feeding and childcare practices of babies up to twelve months when the mother returns to work. Specific objectives of the focus groups are to explore:
Transition from exclusive (up to six months) to complementary breastfeeding (from six to 36 months)
Wider feeding (snacking) practices among babies up to 36 months
Childcare arrangements of babies when the mother returns to work
Participants Focus groups have been attended by eight female garment workers who currently have a baby 36 months of age or under. With the support of Kampong Speu Provincial Labor Office, E&D will work with participating garment factories to recruit workers who match the above criteria. If factories are unable to assist in pre-selection of participants, E&D will recruit workers as they commence their lunch break.
Facilitation Focus groups will be facilitated by female E&D staff. Facilitators will be supported by one assistant, who will assist in participant selection and will be responsible for note taking. Prior to survey delivery, focus group staff will be briefed on:
Key findings of the recently completed survey and management interviews
purpose and key objectives of the focus groups
detailed focus group session plan (detailed in this document).
Reporting on focus groups
Focus groups will be recorded by the focus group assistant. A thematic summary of key findings will be presented in table format.
Focus group session plan Focus groups will be delivered according to the below session plan. Duration
Activity
Objectives and key questions
Facilitator speaking notes
5mins
Welcome
Welcome and thank you (sign-in sheet – ensure participants understand this
Present the inform consent with asking the participant to sign in the inform consent
1
Duration
Activity
Objectives and key questions
Facilitator speaking notes
is confidential)
10mins
Self-
Facilitator introductions(present inform consent)
Introduce E&D and purpose of the focus group and how E&D will use the information
Participant confidentiality
Self-introductions (around the circle): name, age of baby, age of baby when you returned to work at the factory
Raise hands if you participated in E&D’s survey
Can you describe how you fed your child from delivery, until you returned to work? When you returned to work, if you were still breastfeeding, how did you manage this? What were your concerns about managing your baby’s feeding when returning to work?
introduction s
15mins
Exclusively breastfeedin g (returning
to work)
10mins
Complement
ary breastfeedin g (including snacking)
5mins
Thank you and close
form.
Exclusive breastfeeding means only breast milk up to six months
If you introduced complementary feeding (including formula) to your baby before it was six months old, what were the reasons for this? What types of foods were first introduced to your baby? Can you describe the types of food and snacks your baby eats during the day, and who feeds them to him/her? Thank participants for their time Explain again how E&D will use the information
2
Focus group session plan.
Focus groups will be delivered according to the below session plan. Duration
Activity
Objectives and key questions
Facilitator speaking notes
5mins
Welcome
Welcome and thank you (sign-in sheet – ensure participants understand this is confidential)
Facilitator introductions
Present the inform consent with asking the participant to sign in the inform consent form.
Introduce E&D and purpose of the focus group and how E&D will use the information (present inform consent)
Participant confidentiality
Self-introductions (around the circle): name, age of baby, age of baby when you returned to work at the factory
Raise hands if you participated in E&D’s survey
Exclusively
breastfeeding
Can you describe how you fed your child from delivery, until you returned to work? When you returned to work, if you were still breastfeeding, how did you manage this? What were your concerns about managing your baby’s feeding when returning to work?
Exclusive breastfeeding means only breast milk up to six months
10mins
Selfintroductions
10mins
(returning to work)
15mins
Childcare arrangements
5mins
Thank you and close
Who takes care of your child when you are at work on a normal day? When your baby gets sick and you are at work, what happens (who is the main person to care for it)? During the working week, how long do you normally spend at home (from the time you leave in the morning, to the time you arrive home)? Of this time, how much of it are you able to spend with your baby? During this time, what do you do with your baby (describe exhaustively)? Thank participants for their time Explain again how E&D will use the information
3
Annex 5: Dissemination workshop roundtable discussion topics February 19th, 2016
Round table #1: Access to information and education Issue: how to improve access to information & education for garment workers?
What are the most efficient ways to share information with FGW? (peer education, resource center, IEC, drama)
Who should be involved, with what tools?
How to involve FGW in the process of designing tool and intervention?
Round table #2: Childcare and maternity Issue: How to help mothers manage professional life and childcare, to improve both childcare concerns and reduce turnover due to maternity?
What can be done to help mothers comply with MoH recommendations on breastfeeding?
How to make day care facilities functional?
How to improve childcare practices by caretakers?
Round table #3: Access to reproductive and maternal health services Issue: How to help women to access reproductive and maternal health services?
What can be done to address difficulties mentioned by the workers to access health care (i.e.: cost, transportation, etc…)
What are the options to make RMH services available within factories?
How to improve factory infirmaries service delivery to answer workers’ needs?
Round table #4: factory infrastructure and service delivery: compliance with standards and improvement of standards Issue: How to improve standards implementation and improve standards to match the needs of workers?
What can be done to support standards implementation of standards at factory level (involve management and unions)
How can stakeholders work together to discuss and carry out standards improvements?
How to involve with unregistered factories?
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Bibliography Cockroft, M (2014), Literature review: sexual and reproductive health and rights of migrant garment factory workers in Cambodia. United Nations Population Fund, Cambodia, November 2014. National Institute of Statistics, Directorate General for Health and the DHS Program ICF International Rockville, Maryland, USA (2015), Cambodia, Demographic and Health Survey 2014, 479. Dominguez, MD, (2014), Health survey on reproductive healthcare and practices in Kampong Speu Province, Improving access to and quality of sexual and reproductive health services in Kampong Speu province, Cambodia, Project, Enfants &Développement, 31. Nishigaya, K. (2002), Female garment factory workers in Cambodia: migration, sex work and HIV/AIDS. Women & Health, 35 (4), 27-42; Nishigaya, K. (2010), Living away from home: premarital sex and covariates: factory women in Phnom Penh, Cambodia. Asian Population Studies, 6 (2), 215-239. Reproductive Health Association of Cambodia (RHAC), August 2012, Together for Good Health (ToGoH): Fifth Year Annual Workplan (October 2012 - September 2013). Sopheab, H. (2014), Baseline survey report: reproductive, maternal and neonatal health knowledge, attitudes and practices among female garment factory workers in Phnom Penh and Kandal Provinces. Partnering to Save Lives, Phnom Penh, Cambodia, August 2014. USAID-CAMBODIA, (2013), Final Performance Evaluation of the Reproductive Maternal Newborn Child Health /Health Systems Strengthening Program 2008 – 2013, 162. Webber, G., Edwards, N., Amaratunga, C., Graham, I., & Keane, V. (2010), Knowledge and views regarding condom use amongst female garment factory workers in Cambodia.Southeast Asian Journal of Tropical Medicine and Public Health, 41 (3), 685-695. Webber, G., Edwards, N., Amaratunga, C., Graham, I. & Keane, V. (2010b) Life in the big city: the multiple vulnerabilities of migrant Cambodian garment factory workers to HIV. Women's Studies International Forum, 33 (3), 159–169.
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Research team: E&D team: Vincent KUCHLY, Chanrak PUN, Fanny THEBAULT, Sareth VONG AVID- Australian Red Cross volunteers: Lucy MARSHALL, Emily O’KEARNEY Peer review /GRET: Camille BOUILLAULT, Pascale LEROY, Chanty MEAS
Coordination: Sophors MAO, Estelle ROESCH
Published by: Enfants &Développement Cambodia #9AB, street 446, SangkatToulTompoung 1, Khan Chamkarmorn - Phnom Penh, Cambodge P.O.Box: 882 Phone: (855) 023 21 21 96 www.enfantsetdeveloppement.org
Published with the support of:
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