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Scholarly Works (11 results)

  • Thesis
  • Peer Reviewed
UC Berkeley Electronic Theses and Dissertations (2012)

Maternal mortality has been one of the most daunting public health problems facing developing countries for several decades. The average lifetime risk of maternal death in least developed countries is 1 in 22 compared with 1 in 8000 in industrialized countries. Such vast regional differences demonstrate how available and accessible resources can completely change the picture. Even in low-resource settings, it has been shown that basic district health systems can deliver the services needed to save women's lives. But women face many barriers to accessing care including distance, transportation, cost, perceived poor quality or actual poor quality. One mechanism that researchers and policy makers have been experimenting with to address several of these barriers is a voucher. Within a health voucher program, a woman can purchase a voucher for a fraction of the cost of services or receive it for free and redeem it an accredited health facilities (public or private) for specific services. Facilities are reimbursed for the care they deliver through government or development aid. Voucher programs aim to give patients the economic power to demand high-quality healthcare, to target aid to high-risk or low-income patients for critical services and to increase utilization rates within these populations.

Funders and policymakers have already shown support for this concept but more evidence is needed in order to evaluate if these programs should be taken to greater scale. This dissertation aims to address gaps in evidence and to work towards building stronger and more evidence- based policy around maternal health vouchers.

The first component of this dissertation is a systematic review of the literature on voucher programs for health goods and services in developing countries. The review aims to assess whether the evidence for voucher programs thus far has shown that they are achieving their objectives and examines contextual factors associated with program success. The second component is an evaluation of how a reproductive health voucher programs impacts the job satisfaction of management and frontline health care providers in Uganda. The third component is a qualitative assessment of the experiences of women who are eligible to receive a reproductive health voucher in Cambodia and assesses facilitative and inhibitive factors that affect voucher use.

As a result of this dissertation experience, next steps for improved policymaking around vouchers have been identified and include the need to focus efforts on evaluating if policy makers should use health voucher to support broader health system strengthening and how program implementers can use the experiences of beneficiaries (providers and patients) to tailor voucher programs to the local context while maintaining program fidelity.

    Cover page: Evidence to Policy: Do Voucher Programs Improve Maternal Health in Developing Countries?
    • Article
    • Peer Reviewed
    Berkeley Research Impact Initiative (BRII) (2013)

    One approach to delivering healthcare in developing countries is through voucher programs, where vouchers are distributed to a specific population for free or subsidized health care. Recent evaluations suggest that vouchers have the potential to extend coverage of priority health services to the poor in developing countries. In Cambodia, a reproductive health voucher program was implemented in January 2011. This study aims to explore women’s early experiences accessing health services with their vouchers at accredited clinics.

    Methods

    This qualitative exploratory study used focus group methodology to gather information from five groups of older (>25 years) and four groups of younger (18–25 years) women who were eligible for the voucher program in three rural provinces. Focus groups were digitally recorded, transcribed and translated from Khmer into English. Data analysis was an iterative process, which comprised of open coding to find commonalities that reflected categories or themes and axial coding to relate initial themes to each other. Next, a basic framework for analysis was formed by integrating the themes into the framework.

    Results

    Two overarching themes were identified in the data: 1) factors that facilitate voucher use and 2) factors that inhibit voucher use. Within each of these themes, three subthemes were identified: 1) pre-existing factors, 2) distribution factors, and 3) redemption factors. Overall, women expressed positive feelings towards the voucher program, while several areas for program improvement were identified including the importance of addressing pre-existing demand-side barriers to using reproductive health services, the need for more comprehensive counselling during voucher distribution, and the persistent cost of unofficial payments expected by midwives after delivery irrespective of voucher use.

    Conclusions

    Early information from program beneficiaries can lead to timely and responsive changes that can help to maximize program success. This study highlights the importance of tailoring voucher programs to specific community needs, a strategy that can lead to better program uptake.

      • Article
      • Peer Reviewed
      UC San Francisco Previously Published Works (2013)
      Abstract Background One approach to delivering healthcare in developing countries is through voucher programs, where vouchers are distributed to a specific population for free or subsidized health care. Recent evaluations suggest that vouchers have the potential to extend coverage of priority health services to the poor in developing countries. In Cambodia, a reproductive health voucher program was implemented in January 2011. This study aims to explore women’s early experiences accessing health services with their vouchers at accredited clinics. Methods This qualitative exploratory study used focus group methodology to gather information from five groups of older (>25 years) and four groups of younger (18–25 years) women who were eligible for the voucher program in three rural provinces. Focus groups were digitally recorded, transcribed and translated from Khmer into English. Data analysis was an iterative process, which comprised of open coding to find commonalities that reflected categories or themes and axial coding to relate initial themes to each other. Next, a basic framework for analysis was formed by integrating the themes into the framework. Results Two overarching themes were identified in the data: 1) factors that facilitate voucher use and 2) factors that inhibit voucher use. Within each of these themes, three subthemes were identified: 1) pre-existing factors, 2) distribution factors, and 3) redemption factors. Overall, women expressed positive feelings towards the voucher program, while several areas for program improvement were identified including the importance of addressing pre-existing demand-side barriers to using reproductive health services, the need for more comprehensive counselling during voucher distribution, and the persistent cost of unofficial payments expected by midwives after delivery irrespective of voucher use. Conclusions Early information from program beneficiaries can lead to timely and responsive changes that can help to maximize program success. This study highlights the importance of tailoring voucher programs to specific community needs, a strategy that can lead to better program uptake.
        Cover page: Redeeming qualities: exploring factors that affect women¿s use of reproductive health vouchers in Cambodia
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2013)
        BACKGROUND: One approach to delivering healthcare in developing countries is through voucher programs, where vouchers are distributed to a specific population for free or subsidized health care. Recent evaluations suggest that vouchers have the potential to extend coverage of priority health services to the poor in developing countries. In Cambodia, a reproductive health voucher program was implemented in January 2011. This study aims to explore womens early experiences accessing health services with their vouchers at accredited clinics. METHODS: This qualitative exploratory study used focus group methodology to gather information from five groups of older (>25 years) and four groups of younger (18-25 years) women who were eligible for the voucher program in three rural provinces. Focus groups were digitally recorded, transcribed and translated from Khmer into English. Data analysis was an iterative process, which comprised of open coding to find commonalities that reflected categories or themes and axial coding to relate initial themes to each other. Next, a basic framework for analysis was formed by integrating the themes into the framework. RESULTS: Two overarching themes were identified in the data: 1) factors that facilitate voucher use and 2) factors that inhibit voucher use. Within each of these themes, three subthemes were identified: 1) pre-existing factors, 2) distribution factors, and 3) redemption factors. Overall, women expressed positive feelings towards the voucher program, while several areas for program improvement were identified including the importance of addressing pre-existing demand-side barriers to using reproductive health services, the need for more comprehensive counselling during voucher distribution, and the persistent cost of unofficial payments expected by midwives after delivery irrespective of voucher use. CONCLUSIONS: Early information from program beneficiaries can lead to timely and responsive changes that can help to maximize program success. This study highlights the importance of tailoring voucher programs to specific community needs, a strategy that can lead to better program uptake.
          Cover page: Redeeming qualities: exploring factors that affect womens use of reproductive health vouchers in Cambodia.
          • Article
          • Peer Reviewed
          UCLA Previously Published Works (2020)
          Background: Female entertainment workers (FEWs) in Cambodia work in predominantly alcohol-based venues and therefore may face occupational risks. Studies have suggested that FEWs are pressured to consume alcohol while at the workplace, which may have adverse health outcomes. This study aims to explore the experiences of alcohol use among FEWs in Cambodia. Methods: Twenty-seven focus group discussions (FGDs) with FEWs were conducted across five sites in four provinces in Cambodia. FGD participants were FEWs who worked at entertainment venues, including karaoke TV bars, beer gardens, and massage parlors, as well as women who worked as on-call or street-based sex workers, and women across entertainment venues who were parenting. Results: The authors modified a conceptual model to create a framework based on the major themes identified within the FGDs on autonomy in alcohol use among FEWs. The framework and thematic components highlight the continuum of autonomy from pressured or coerced alcohol use to, economically or socially rational alcohol use to voluntary alcohol use. Factors that impacted alcohol use across the spectrum include experiencing an economic shock, needing to maintain a livelihood, experiencing psychological distress, having the desire to thrive in employment environment and drinking socially for personal enjoyment. Conclusion/Importance: Much of the motivation behind alcohol use is related to the need for economic security. For women who do not have other employment or income-generating options, individual behavior change programing is unlikely to be effective. Structural changes are needed to improve the health and safety of FEWs in Cambodia.
            Cover page: “We Cannot Avoid Drinking”: Alcohol Use among Female Entertainment Workers in Cambodia
            • Article
            • Peer Reviewed
            UCLA Previously Published Works (2019)
            After publication of our article [1] we became aware that several sections of text in our Methods section were copied from a previously published article [2]. We would like to formally apologize and give credit to the authors of that article [2]: Chris Smith, Uk Vannak, Ly Sokhey, Thoai D Ngo, Judy Gold, Khemrin Khut, Phil Edwards, Tung Rathavy and Caroline Free.
              Cover page: Correction to: Mobile Link – a theory-based messaging intervention for improving sexual and reproductive health of female entertainment workers in Cambodia: study protocol of a randomized controlled trial
              • Article
              • Peer Reviewed
              UCLA Previously Published Works (2020)
              Background: Female entertainment workers (FEWs) in Cambodia work in predominantly alcohol-based venues and therefore may face occupational risks. Studies have suggested that FEWs are pressured to consume alcohol while at the workplace, which may have adverse health outcomes. This study aims to explore the experiences of alcohol use among FEWs in Cambodia. Methods: Twenty-seven focus group discussions (FGDs) with FEWs were conducted across five sites in four provinces in Cambodia. FGD participants were FEWs who worked at entertainment venues, including karaoke TV bars, beer gardens, and massage parlors, as well as women who worked as on-call or street-based sex workers, and women across entertainment venues who were parenting. Results: The authors modified a conceptual model to create a framework based on the major themes identified within the FGDs on autonomy in alcohol use among FEWs. The framework and thematic components highlight the continuum of autonomy from pressured or coerced alcohol use to, economically or socially rational alcohol use to voluntary alcohol use. Factors that impacted alcohol use across the spectrum include experiencing an economic shock, needing to maintain a livelihood, experiencing psychological distress, having the desire to thrive in employment environment and drinking socially for personal enjoyment. Conclusion/Importance: Much of the motivation behind alcohol use is related to the need for economic security. For women who do not have other employment or income-generating options, individual behavior change programing is unlikely to be effective. Structural changes are needed to improve the health and safety of FEWs in Cambodia.
                • Article
                • Peer Reviewed
                UCLA Previously Published Works (2019)

                Background

                Entertainment venues have been identified as an important location for HIV prevention due to the increasing number of young female entertainment and sex workers at these venues. The purpose of this study is to increase understanding of the childhood conditions, pathways to entertainment work and current practices of female entertainment workers (FEWs) in Cambodia.

                Methods

                Data used for this study were collected in April 2018 as part of the baseline survey of the Mobile Link, a randomized controlled trial to improve sexual and reproductive health of FEWs in Cambodia. We used a stratified random sampling method to recruit 600 FEWs for face-to-face interviews using a structured questionnaire. Descriptive analyses were performed.

                Results

                Most participants came from childhood homes without electricity (82.0%) or running water (87.0%). Most women moved to the city in the last ten years (80.5%) for economic reasons (43.7%). About a third worked in the garment industry prior to the entertainment industry (36.7%). Participation in transactional sex in the past three months was reported by 36.0%. Women reported low condom use practices with non-paying partners (23.4% used a condom at last sex), excessive and forced alcohol use at work (33.1% reported being forced to drink alcohol at work more than once a month), low modern contraception use (31.4% was using modern contraception), and experiences of gender-based violence (23.3% reported verbal threats, physical abuse or forced sex in the past six months).

                Conclusions

                This information will help to support the development of future individual and structural level interventions for the safety and support of FEWs. In addition, these results may contribute to an evidence base that can inform policy level changes intended to support the realization of full human rights for entertainment works in Cambodia including the rights to health, safety and respectful employment.
                  Cover page: Childhood conditions, pathways to entertainment work and current practices of female entertainment workers in Cambodia: Baseline findings from the Mobile Link trial
                  • Article
                  • Peer Reviewed
                  UCLA Previously Published Works (2022)

                  Objective

                  To examine the relationship between gender-based violence, HIV risks, psychological distress and binge drinking among female entertainment workers (FEWs) in Cambodia.

                  Design

                  Cross-sectional study.

                  Setting

                  Phnom Penh and three other provinces in Cambodia.

                  Participants

                  We recruited 600 FEWs from entertainment venues using a stratified random sampling method. Participants were eligible if they were at least 18 years old, working in the selected entertainment venues and self-identified as a FEW.

                  Primary outcome measure

                  Binge drinking was defined as drinking more than five units of alcoholic drinks in 24 hours on at least one occasion in the past 3 months.

                  Results

                  The prevalence of binge drinking was 76.7%. Adjusted odds of binge drinking were significantly higher among FEWs who earned >US$250 per month than those who earned ≤US$120 per month (adjusted OR (AOR) 2.96, 95% CI: 1.40 to 6.24), had been forced to drink more than once per month in the past 3 months than those who had never been forced to drink (AOR 5.66, 95% CI: 2.19 to 14.65), worked at karaoke bars than those working at a restaurants/café (AOR 1.85, 95% CI: 1.19 to 2.88) and experienced emotional abuse in the past 6 months than those who did not experience it (AOR 2.71, 95% CI: 1.22 to 6.02). The odds of binge drinking were significantly higher among FEWs with lower psychological distress than those with higher psychological distress (AOR 1.65, 95% CI: 1.09 to 2.49).

                  Conclusions

                  This study highlights a high prevalence of binge drinking among FEWs and its associations with working environments, conditions and contexts. Our findings suggest that individual-based behavioural intervention may not effectively reduce binge drinking among FEWs. Structural and occupational health policy interventions may be needed to change the working environment.
                    Cover page: Gender-based violence, psychological distress, sexual behaviours and binge drinking among female entertainment workers in Cambodia: a cross-sectional study
                    • Article
                    • Peer Reviewed
                    UCLA Previously Published Works (2022)

                    Background

                    Female entertainment workers (FEWs) in Cambodia experience a greater prevalence of human immunodeficiency virus (HIV), other sexually transmitted infections (STIs), psychological distress, substance abuse, and gender-based violence (GBV) than the general female population. Reaching FEWs with health education and linking them to services has been difficult because of their hidden and stigmatized status.

                    Objective

                    This study evaluated the efficacy of the Mobile Link intervention in improving FEWs' health by engaging and connecting them to existing HIV, sexual and reproductive health, and GBV services.

                    Methods

                    A randomized controlled trial was conducted between March 2018 and June 2019 in the capital city and 3 other provinces in Cambodia. FEWs in the intervention arm received automated twice-weekly Short Message Service messages and voice messages with health information and direct links to outreach workers. The control group received the existing standard care, including free HIV and STI counseling and testing and a toll-free helpline staffed by trained counselors. We used a stratified random sampling method to select participants from 5 study sites in the 4 selected provinces. Initially, we randomly selected 600 participants from a list of 4000 FEWs by age group (18-24 and 25-30 years) and study site using a random number generator and enrolled them in person. The primary outcome measures included self-reported HIV and STI testing, condom use, and contraceptive use assessed through a face-to-face structured interview. We also measured secondary outcomes, including contact with outreach workers, escorted referral service use, forced drinking, and GBV experiences. Intervention effects were modeled using repeated measures, multilevel mixed-effects logistic regression.

                    Results

                    A total of 1118 participants were recruited and enrolled in the study. We included 218 FEWs in the intervention arm and 170 FEWs in the control arm in the per protocol analyses after removing 730 dropouts. Evidence of positive intervention effects was detected for the following secondary outcomes: contacting an outreach worker (at 30 weeks: adjusted odds ratio [AOR] 3.29, 95% CI 1.28-8.47), receiving an escorted referral (at 30 weeks: AOR 2.86, 95% CI 1.09-7.52; at 60 weeks: AOR 8.15, 95% CI 1.65-40.25), and never being forced to drink at work (at 60 weeks: AOR 3.95, 95% CI 1.62-9.60). Over time, no significant differences between intervention and control groups were observed for any primary outcomes in the fully adjusted models.

                    Conclusions

                    The Mobile Link intervention effectively connected FEWs with outreach workers and escorted referrals but did not show an effect on primary outcomes. Reduced forced drinking at work was also significantly more extensive in the intervention group than in the control group. Longer-term messaging may increase access to services and impact FEWs' health outcomes in the future.

                    Trial registration

                    Clinicaltrials.gov NCT03117842; https://clinicaltrials.gov/ct2/show/NCT03117842.

                    International registered report identifier (irrid)

                    RR2-10.1186/s13063-018-2614-7.
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