Socio-demographic characteristics and access to economic, social and cultural capital
The majority of the female beer promoters recruited into the study were 18 years of age and had worked as beer promoters for more than one year (n = 17). Eleven of the respondents were from Vientiane while 13 had migrated to Vientiane Capital City from other provinces. The majority were single (n = 22), had completed high school (n = 18), 14 were in higher education at the time of the research and four worked in additional jobs in the informal sector as well as working as beer promoters. All of the participants were ethnic Lao, the dominant ethnic group. While not in the lowest economic strata, participants needed their income from their work to either support their study and associated living expenses or to take care of their family. Many of the respondents reported that they struggled balancing their commitments as beer promoters and those of being students or working elsewhere and complained of often being tired. The income from their informal work was used to help them gain cultural capital through university or to support their family and most of them reported that in this way it also helped to reduce the financial burden of their family.
The value of their social networks was not very high and consisting of family relations, ties in the close neighbourhood or at work or in their higher education institution. Two had written contracts with the company as they had worked with the company for more than a year. Participants reported that they were organized into teams of work with each team consisting of seven to eight beer promoters and a supervisor. Usually they were picked up by the beer company each evening and dropped off at pre-identified places, which changed on a regular basis. At the end of their shift they were again picked up by the beer company and dropped off at their homes, providing a level of protection late at night. Not all beer companies had a van to pick the girls up and take them to work regardless of the location of their houses. Some of the girls lived far away from the company or beer shops and had to come to work on their own, often coming home late at night and in the dark. Most of the respondents reported that while at work they were generally not allowed to drink beer with their clients. Many felt that the conditions of their work negatively affected both their physical and mental health. Common complaints were back pain, stomachache, headache and tiredness and some said they had lost weight.
Seeking and accessing healthcare
For minor illnesses such as cough, fever, headache or stomach problems, self-medication being the first line of treatment, often in consultation with family and friends. The quote below reflects a commonly reported practice:
We need to consult with family and relatives about where to get good treatment, especially consulting with relatives who have more experience in utilising the different health services. (Beer promoter, 22 years old)
Where self-medication did not resolve the issue, the next step was typically presenting at a small private clinic, which in Lao PDR, are typically owned and managed by sole operator medical officers who also work in the public sector. The public health system was often seen as the place of last resort when other treatment options had not worked or when the symptoms were perceived to be severe or the cost of treatment was uncertain but expected to be high or in health emergencies. The following quote helps to highlight a common sentiment, with public facilities and hospitals (which are public) only being seen as places to go when very sick:
The services in the public hospitals are not so good and the services are slow, some staff do not speak nicely. If the patients do not know the health staff, they do not treat patients well. So, why if I am not severely ill, why would I go to the public facilities? However, the hospitals have more medicine and equipment. If we are getting severely sick, we have to go to the hospitals as we do not have any choice.
The medical costs plus access to financial resources were mentioned as the most important determinants in the health-seeking process. Almost all of the participants worried about their financial and job security and for more than routine medical needs said that they would need to borrow money to cover the costs. Almost all (n =20) had no health insurance and were responsible for their own healthcare costs. Two had partial insurance coverage and two were insured through their family’s insurance. Some were reimbursed approximately 50 % of the cost of healthcare on presentation of a receipt from the hospital but this was unusual. None of the participants had access to a work-sponsored fund where they could borrow money to cover medical costs. In such cases or in the case of chronic disease, the young women in this study reported they would need to borrow money from people in their social networks.
The indirect costs of medicine and loss of income, concerns about being replaced and losing their job if they were absent, inconvenient opening hours in relation to the beer promoters’ work and other commitments, the unpredictability of informal payments, perceived poor quality of care and long waiting times were also important supply and demand-side factors that often acted as barriers to using public healthcare services. The quotes below are illustrative of some of the barriers and help to highlight the interactions between human, social and economic capital and access to healthcare:
Mostly, I go to the drugstores or clinics because the services are better than the services in the hospital, not a long waiting time. In the hospitals, the health staff tell us to go to this place or to go to another place and it is confusing. The health staff do not welcome us and they do not speak nicely and sometimes we ask them a question, but they do not tell us or take good care of us. If we do not have money, they will not take care of us. And comparing the prices of the private clinics and the public, the prices are quite similar. And in the hospitals we have to give the tips to the health staff. So, it is better to go to clinics and the services are good and close to my house. (Beer Promoter, 19 years)
The health staff at the public hospitals are not so good as they are tired and there are many clients at the public hospitals. Sometimes, they get angry if we keep asking questions and they do not speak nicely with the patients. Sometimes, I think that they are tired with the examination of the patients, so they are not in so good a mood. Sometimes, I have to wait for long time, for example, I was in the queue, and then, other patients jumped in front of me. If we do not know anybody, we have to wait for a long time. (Beer Promoter, 19 years)
In the hospital, the billing system is complex because the billing system is not performed at one place. For example, I went to hospital A. I had to bring the registration book to examine in one room, then to the finance section. After that, I went to be examined in the room upstairs, after that I went to the finance office or cashier. Firstly, I did not know that I have to be examined upstairs, so I waited in downstairs until someone told me that the examination room was upstairs and I had not seen it. I think patients get easily confused for their first time to the hospital. (Beer Promoter, 19 years)
Even with education, most of the participants did not know about community based health insurance, were not confident in navigating the healthcare system and as young women, felt unable to ask questions or assert themselves in the health setting encounter. Typically, they reported that in the medical encounter they did not reveal their position as beer promoters because they felt that this would create stigmatising attitudes from the healthcare staff, and in particular, that they would be perceived as sex workers.
The lack of knowledge related to navigating the health system as well as work-based struggles of maintaining their beer promotion duties induced feelings of anxiety, which contributed to self-medication as the first line of treatment. To overcome feelings of anxiety and uncertainty, common tactics deployed by participants were to rely on their own previous experience and the experience and knowledge in their social networks. Social networks were the first point of information on what the problem might be, which pharmacist or healthcare provider to consult, which treatment to take and to find out if anyone had contacts in any of the public health facilities that could help guide them through the systems. Where they did feel the need to use a public facility, it was usually where someone in their social network knew someone in a particular facility, albeit someone with limited seniority. While most respondents felt they could afford the medicine they purchased from the drugstores for routine, non-severe health issues, many worried about the cost of on-going care. Work condition barriers included lack of work-based insurance, concerns about taking time off, anxiety about maintaining their employment and no worker organizations to advocate for the rights of informal workers. The quotes below are illustrative and help to highlight the interactions between social and economic capital and how social networks can potentially be used to raise funds:
“If I became very sick, I could not afford to pay. If I am admitted to the hospital, my parents will pay, however, if my parents did not have the resources, they would have to borrow from relatives and friends. If I am severely ill and a long-term illness, we have to borrow from relatives, sometimes, we have to deposit some precious things or valuable things with lenders such as car, house or land. After recovery, we will find some money and repay the lenders. I could not borrow from the Beer Company, and we do not get any insurance from them.” (BP, 19 years)
If I am getting so sick that I have to be admitted to the hospital for long time, there will be a high cost of hospital admission, high cost of medicines, and I do not have the money to afford to pay. The company does not take care of the health expenses and I would have to ask my family or friends (Beer promoter, aged 22 years)
Work and employment conditions and the symbolic power of economic capital
The brewery management, the management and clients of the restaurants and other establishments where the beer promoters work, have more economic and symbolic power than the young, female beer promoters. The brewery management set the hours of the beer promoters’ work and their conditions. Some worked for up to eight hours while others worked less. With an inconsistent income, they relied on tips from customers. Most the respondents said that were allowed to take up to three days unpaid leave if needed but if they were absent for more than this, they would probably lose their position, and have double their daily wage subtracted from their pay for the days in which they were absent (i.e. if they were absent for 5 days they would lose 10 days’ pay). Some of the beer promoters said that they were often required to undertake non-paid work for the owner or manager of the establishment where they were deployed. This included for example, cleaning or waiting at tables. While not part of their agreement, the beer promoters did not consider refusing to do this additional, unpaid work was an option.
All of the respondents reported working in poor working conditions including exposure to loud and constant noise, bright lights, second-hand smoke, and tiredness from lack breaks, standing in high heeled shoes for long periods of time and eating at irregular times, as the following illustrate:
In our work we are often exposed to [tobacco] smoke, noisy and we stand for long hours, eat at the wrong time and sleep late. (Beer promoter, 21 years)
“I have to stand out for long time and I have some leg pain and pain in my feet as I wearer high shoes. (Beer promoter, aged 19 years)
Most of the beer promoters said that they were not allowed drink beer with clients, and while some of the clients might be rude or inappropriate, they were expected to avoid any conflict with the clients. Sometimes as more beer was consumed the behaviour of the clients was reported to become increasingly inappropriate including harassment which varied from verbal abuse (from male and female clients) to unwanted touching and sexual propositions. Many felt that the female guests often looked down on them, assuming they were promiscuous and engaged in commercial sex. The beer promoters reported tolerating these behaviours and always being polite to the venue’s customers. All of the beer promoters interviewed said that their role was to serve beer to the venues customers but they were not allowed to sit or drink with clients, were expected to avoid the conflicts with clients and they had sometimes experienced difficulties with clients. The quotes below provide examples of how the unequal structures of power were manifested and how the beer promoters try to manage this:
In terms of client, some of them look at me with not good feeling, especially the female clients, because they may think that we are working like a prostitute. But I don’t care about their perceptions; I just smile at them because I or we know ourselves, that as beer promoters, we have our honor, no matter what they think about us. I can move to another table if I feel not good with a client. Sometimes after work, I wait for the company car to take me home, some men call me and ask me to go with them at night, and I answer ‘No, thanks’. If they still call, I don’t care, I keep a little smile and not look at them. Sometimes, men say that “Girl, I can take you out of here but not to your home, OK? Come on, come with me, girl”. Mostly we all do the same - no argument. (Beer promoter, 19 years)
A man touched my bottom, I kept quiet with angriness inside, and he spoke out very loud among his friends and many clients like this: “girl, I am sorry I touched your bottom”. Everybody heard that and I was so shy. And I suddenly answered out loud like this: “That is fine brother, but I really don’t like it. If you really want to do that, please be a man and ask nicely and I may allow you perhaps; otherwise, I or other people may think that you have no manners or have never been to school”. Then, his friend apologized to me instead of him because he was drunk. I also added more “That is OK to drink and get drunk, but please stay aware”. Doing like that is really wrong. I am just a girl, but he is a lot older than me and he has work, I don’t want to say much more than this”. That was the moment I was really angry, but felt good to let them know. As I said, I try to talk nicely with them, as to keep a good image of the company who hire me. (Beer promoter, 20 years)
Sometimes, as the male guests try to touch me on my hands; if it is by accident it is OK, but if they intend to touch me, either my hand or my waist, then I must try and avoid that table. I have to avoid an argument. Some women don’t like it when I serve and their boyfriends look at me; some women even say “That’s OK, leave the bottles here, I can serve my boyfriend, and I will call you when the beer is running out. You can go to serve any other table now”. I think I know what they feel, but I am not sure they know how I feel if they say like that. But it is normal to me now. I just think that I am good-looking. Sometimes men ask me to go with them, but I don’t go and I don’t care. I have the company car to take me home and it is safe. (Beer promoter, 19 years)
Given the beer promoters were economically dependent on their work as beer promoters, they rarely complained about their work conditions. Their informal status and anxiety about losing their job, further weakened possibilities of challenging the status quo, far removed as they were, from the aegis of formal regulations governing standards of work that protected those at the higher end of the production chain. In this way, while at work, the beer promoters experience non-respectful and sometimes even harmful treatment, that further contributed to reproducing social inequities. While the beer promoters acknowledged the detrimental effect their work conditions had on their health, their gender, class, age, position in the social hierarchy in the field of work and their life experience, shaped their habitus and understandings of what was reasonable or possible, and respondents did not overtly try to challenge the conditions of their employment or the appropriateness of behaviour of some of the clients.
Habitus and social networks
The passive attitudes and acceptance of health system and work conditions that prevent them from seeking appropriate healthcare are not only because of anxiety and uncertainty but also their habitus. As young, single women, struggling to make ends meet and juggling varying demands, their experiences and those of other in their social networks who are from similar social strata, experience discrimination by employers, negative attitudes from healthcare workers and sustained neglect by the government which has shaped their expectations of work and healthcare.
The help of people within their social networks was sought to mobilise, when required, the required finances for healthcare, to get information about which providers to go to for which ailment, and to accompany them to health facilities to help them navigate the system, as shown below:
Last year I had a fever, sore throat, difficult swallowing and I went to the close private clinic with my parents and my mother asked advise from our neighbors about which private clinic they suggested to go to a private clinic of a doctor working at the private clinic and at the big hospital. My mother also knew that doctor. (Beer promoter, 19 years)
The same social networks were used to identify employment opportunities and find out which were the best beer companies to work for. Almost all of the participants in the study for example, were introduced to the work of beer promotion through people in their social network:
I have friends working with the Beer Company, so they persuaded me to work as a beer promoter (Beer promoter, 21 years)
I wanted to earn some money myself and reduce my family’s expenditure, so I consulted my sister then my sister took me to apply at the company because my sister knew a beer promoter there and that they could do this job without any problem (Beer promoter, 19 years)
The members of this network however, usually share the same habitus based on similar experiences of both the healthcare systems and informal work. Furthermore, while participants reported that these social networks were very helpful in securing work and introducing them to people who could help guide through the process of applying for work or seeking healthcare, there is a risk that dependent relationships of power and patronage develop.