With the Millennium Development Goals (MDGs) expiring at the end of 2015, world leaders have agreed to seventeen Sustainable Development Goals (SDGs) which will guide global development policy and planning up to 2030.

To advance the global health goal (Goal 3: Ensure healthy lives and promote well-being for all at all ages) further progress needs to made in ensuring universal access to affordable and appropriate healthcare [1]. Achieving this requires reaching those employed in the informal sector who are largely excluded from any protections provided by national labour laws and regulations [2–4]. The informal workforce is estimated to comprise of one-half to three-quarters of non-agricultural employment in low- and middle income countries. Their lack of formal employer-employee relationships makes them a difficult population to reach and they are often the last to be enrolled into social protection and health insurance schemes [2–4]. Irregular incomes also contribute to informal workers being reluctant to join insurance schemes, such as community based insurance, or leads to defaults on contributions [4, 5]. Yet, job insecurity and poor working conditions often leaves informal workers particularly vulnerable to catastrophic health shocks [6]. Women comprise a large proportion of the informal employment sector and are particularly vulnerable due to their employment conditions. Women often work in the lowest paying informal jobs, employment conditions often prevent them from meeting their maternal health needs and their working conditions often subject them to physical as well as emotional and sexual abuse [5]. The Lao People’s Democratic Republic (PDR) is a lower-middle income country situated in Southeast Asia and is undergoing rapid socio-economic change, including the emergence of a large, informal but uninsured, urban workforce [4, 7–9].

Female beer promoters, a relatively new phenomenon in Lao PDR, are part of the growing informal urban workforce. Their exact number is not known, but unofficial estimates suggest that there are 8,000 to 10,000 women working in the bars, beer shops and nightclubs, as beer promoters in Vientiane Capital City [10]. Beer promoters are differentiated from beer sellers and are employed by both international and national breweries to promote the sales of beer in restaurants and other establishments [10]. They are predominantly young, female and attractive and often required to wear revealing, branded uniforms of the brewery. The working conditions of the beer promoters mean that they are vulnerable to harassment and sexual abuse compounded by broader gender and social norms [10].

Using beer promoters in the informal sector as an example, the present study draws on the work of the French theorist, Pierre Bourdieu [11–14], to provide insights into the processes and experience of informal work and access to health. Using the conceptual tools of Bourdieu [11–14], we examined how the interactions between informal employment and the healthcare system and access to social, cultural and economic capital shaped health seeking practices.

Bourdieu [11] proposed three concepts that are fundamental to understanding how individuals cope with imposed social structures: habitus, field, and capital. For Bourdieu [11] social practice is an effect of actions and interactions of agents struggling in social spaces (fields) over resources at stake and the power to set out the “rules of the game” in order to survive and pursue wealth, profit, power and distinction [15]. These practices and interactions are shaped through habitus that is, a personal set of cognitive and embodied dispositions that guide how people act and the sum of a person’s economic, social, cultural and symbolic capital. Habitus develops through socialisation experiences and thus, particular dispositions more or less reflect particular social fields with people who move through similar social contexts acquiring similar habitus [11, 13]. It is also about power relations, and in particular about those power relations that exist between social classes and that appear in the complex interactions and practices embodied in a particular habitus [13, 15].

Ethical approval was obtained from the National Ethics Committee for Health Research, Ministry of Health, Lao PDR. Verbal consent was obtained from each participant prior to interviews and was approved by the Ethics Committee. The participants were assured of privacy and confidentiality. Participants were informed that their participation was voluntary and that they could withdraw from the interview any time without notice and without consequences. The interviewers explained the purpose of the study and procedures and checked participant understanding. Participants were reimbursed 50,000 kip in cash (The exchange rate at the time was USD1 = 8000 Lao kip) as a token of appreciation for their time to participate in the study. Participants were not aware of this until after the interview had concluded.

Most of the participants in this study were young women from modest backgrounds. For the study participants their health was important and a source of capital for everyday life, enabling them to be productive. Importantly, good health was seen a contributing to beauty, an important factor in their work. Respondents reported frequent but low-risk illness episodes rather than chronic or severe episodes of poor health.

All of the young women interviewed financed their healthcare through their sometimes precarious wages, most were not enrolled in community based health insurance and all expressed concern in terms of chronic health care needs and continuity of care. A study in Vietnam of uninsured populations reported similar findings [20]. This lack of community-based health insurance is also reflective of relatively low levels of cultural capital in relation to literacy about health insurance related and economic capital.

The beer promoters’ health seeking practices were influenced and are similar to those described by beer promoters elsewhere [10]. health services supply and demand-side barriers. These health service supply and demand-side barriers can be mapped onto the domains of access, acceptability, affordability, appropriateness and availability and illustrate the interface between users and the characteristics of suppliers [10, 21–27]. These barriers have also been well described in the Lao PDR, especially for informal sector workers [9, 21, 28]. Access to healthcare and health seeking practices was also influenced by participants’ work and employment conditions and discussed within their social networks.

Inequities in access to appropriate healthcare can also be explained by interactions and hidden struggles over symbolic power in the fields of health and employment which contribute to reproducing social inequities [29]. A lack of confidence in navigating the complexities of the health system alongside poor working conditions and their lack of relevant capitals in the employment field, forced the beer promoters to passively accept both their employment conditions and uncertain healthcare and is corroborated by another study in Lao PDR, Cambodia and Vietnam [10]. Even where their conditions were detrimental to their health or not within their terms of employment, the beer promoters did not question these conditions or challenge the “rules of the game”. In contexts such as Lao PDR, these norms of passivity and modes of interacting with the health field are often compounded by power hierarchies between patients and healthcare workers and reinforced by broader societal inequities.

The apparently passive attitudes of the beer promoters are shaped by their habitus and their social network who usually share the same habitus [11, 29]. These social networks were to large degree homogenous, with limited symbolic capital and thus did not link them into social networks that would provide them with experiences and opportunities outside of their social class. These networks however were crucial resources in for the beer promoters in both finding work as a beer promoters and seeking healthcare. It was within the spaces of these networks, that the beer promoters shared practical information and advice on both employment opportunities and therapeutic options. In this way, both employment and illness were placed in their everyday social life - their acceptance of their work conditions and their health seeking was shaped by broader institutional structures and long-term historical trajectories of change and was enacted beneath the level of conscious reflection [30]. In this way, while to a large extent ambivalent about the nature of their informal status, the women in this study did not see themselves as victims. Rather, they were exercising agency and working to achieve their longer-term aspirations of tertiary level education and reduce the burden on their family. Their choices were framed by their circumstances and by what seemed reasonable to them, which in turn, was shaped by their habitus, the social structure of the labour market and their limited expectations of the role of employers in providing a safe workplace and social protection [11, 30, 31].

As with all studies, this research has some limitations. As an exploratory study, the research relied on qualitative methods only and interviews were only conducted in the capital city of Vientiane. Quantitative survey data combined with the qualitative data could have provided more primary data and allowed a more refined analysis. As a consequence this study does not claim to be representative of all beer promotion workers in the Lao PDR. In addition, time constraints on the research meant that beer promoters themselves were not engaged as researchers. Such engagement would not only have enhanced the research but may have contributed to changing the status quo and building the capacity of the beer promoters to advocate form their rights.

In this paper, we have suggested that Bourdieu’s concepts of field, capital, and habitus can provide insights into the processes and experience of informal work and access to healthcare.

The study has shown a need to move away from understanding inequality in access to healthcare only through frameworks that focus supply and demand-side factors and ones that focus on individual ‘choices’ and behaviours to one that embraces broader frameworks. While the conceptual work of Bourdieu has been applied in research on inequities, few studies have used Bourdieu’s concepts in research on inequities in health-care access in low and lower-middle income countries. This paper shows that the subtle and sometimes ingrained reproduction of inequities by linking agency is linked through habitus with the structure, via field and capitals.

Drawing on Bourdieu, this study suggests that the processes that limit the access of female beer promoters to appropriate healthcare services will not be achieved by improving access to financial assets, for example through work and health system mechanisms such as insurance will not be sufficient on their own. While better access to economic capital will help, interventions also need to focus on social and institutional context and to challenge the status quo. While the informal sector is an important contributor to economic growth in countries such as the Lao PDR, it should not worsen the distribution of costs and benefits, including health outcomes and generate further inequality. Further work is required to understand what incentives would encourage the employers of informal workers to provide staff with basic protection mechanisms through contracts, minimum number of agreed hours, breaks, smoke-free workplaces and access to adequate healthcare. Further work is also required to better understand the causal mechanisms that produce and reproduce inequalities and the complex interactions of the social determinants, agency and power within the social institutions. Finally, while the challenges of reversing inequalities in access to healthcare are similar to those of other disenfranchised populations, young women, such as the beer promoters in this study, are often not a priority and their needs can easily be overlooked [32]. Yet failing to progress the well-being of young, informal workers is likely in the long-term to be detrimental to the economic well-being of nations.