After 5 years of successful partnership under the GSK Frontline Health Worker Programme, building the capacity of frontline health workers in rural southern Cambodia, GSK and CARE Cambodia launched a new project in 2016, focusing on young, female garment factories in urban Phnom Penh.
About 80% of the 700,000 garment and footwear factory workers in Cambodia are women. Many are young, female migrants in the 18-30 age group with low levels of education. At least half of these are sexually active and about one third already have children, while less than a third of those who are sexually active use contraception, pointing to the importance of holistically addressing sexual, reproductive, and maternal health. In addition, poor nutrition is cited as a key contributing factor to the “fainting spells” in Cambodian factories.
The CARE-GSK project, called Healthy Women, Healthy Workplace, seeks to improve the sexual, reproductive, maternal health and nutrition status of this marginalised group. Within this global partnership, CARE tailors its work in each country to find new ways to achieve maximum impact.
The project in Cambodia focuses on both supply and demand-side barriers to good health. On the supply side, this means improving the quality and accessibility of care at urban health centres and infirmaries for young workers and on the demand side this means influencing the attitudes and behaviours of the workers themselves as well as supporting factory management to improve the factory environment.
The design challenge
The question that emerged was how to have real, lasting impact on attitudes and behaviours in Cambodia?
For sexual and reproductive health, CARE could begin engagement right away, implementing the evidence-based, award-winning Chat! Contraception, an innovative package that includes activity-oriented sessions, video dramas, and a mobile quiz app, which complement each other and empower workers to make healthy decisions about sex, contraception and abortion. A solution was still needed for issues of maternal health and nutrition, however.
CARE formed a partnership with design thinking experts from the international NGO, iDE, and the marketing and communications firm, Melon Rouge, to approach the challenge. To do this, the team customised a human-centred design (HCD) approach targeting maternal health, nutrition, and hygiene.
The HCD approach involved three critical phases: discovery, ideation, and prototyping.
Discovery was all about letting go of assumptions and exploring. The team spent days inside and outside of the factories, joining workers over lunch, shadowing them to and from work, and even meeting their families. From this, emerged an understanding not only of their decisions and habits, but their hopes and aspirations. Discovery helped us define ‘personas’ that we would move forward to target, including a map of their daily routines complete with key opportunities to reach them and specific, tailored messages that needed to be addressed in nutrition and maternal health.
Ideation involved an intensive co-design workshop with diverse stakeholders including representatives from garment factories, experts in healthy living and communications, designers, innovators, nutritionists, and a midwife. Through discussion sessions with the design team, 150 diverse ideas were then honed down to 13 for prototyping.
We engaged pregnant workers, new workers, single workers, HR staff, line leaders, food vendors, doctors and nurses in iterative prototyping with several factory visits, continually testing, refining, and eventually dropping some ideas. As ideas narrowed and gained focus, prototypes became sharper and processes were refined: we were finally ready.
The final products were interventions targeting three existing opportunities: the food vendors who sell breakfast and lunch every day; the workplace infirmaries, which are staffed with nurses and doctors to provide care for workers; and the ringtone vendors surrounding factories who supply media to workers on a regular basis.
For the food vendors, we would influence change not only through training, but through a contest between vendors, where workers would be engaged and empowered to vote on their favorite vendors. Through campaigns, workers would learn more about nutrition and hygiene and food vendors would be incentivized to follow through on what they learn in training so as to get more customers.
The new infirmary service would start with a foundation of training, covering everything from basic care and infection control to nutrition and maternal and newborn health, and follow-up on-the-job coaching and mentoring. This would be reinforced by new branding for the service, to encourage workers to seek out care, as well as new communications materials for use with workers, including a decision-support app called Healthy Mother to support monthly counseling visits for pregnant workers.
Finally, the ring tone vendors would become media partners for reaching workers. CARE would develop video dramas similar to the Thai dramas workers purchase regularly, which would be firstly entertaining, but would also deliver key critical messages identified for maternal health and nutrition. These would be ‘sold’ on a buy-one-get-one-free basis by the ring tone vendors, who would receive promotional materials to draw attention to their services and grow their client base.
HCD and other participatory design approaches take a lot more time than traditional intervention design. However, the amount you learn about the target group’s needs, desires, and habits makes the extra time worth it. Iterative prototyping of ideas allows you to test ideas without investing too many resources in them and to continually engage your target group to ensure that what you are doing is actually relevant and appropriate. If you discover it isn’t, you can make changes before launching.
The result? Relevant solutions with much greater impact.
Photo credits: Erika Pineros