What would you do for those you love? Imagine being forced to leave everything behind, venturing into a new world where you sell your body for sex in the hope of providing for your family. You leave for a garment factory job with the hope of sending money home, but learn the conditions are unlivable. If you want a better future, or perhaps just survive, it seems the only solution is to have sex for a paycheck. Thousands of Cambodian girls, teens, and women work in the sex industry. This session explores the feasibility of a mHealth SRH education intervention targeted at reducing their HIV risk. In 2013, the number of mobile subscribers reached 20 million, 5 million more than the population. This affords a new, unique medium of private, inexpensive information dissemination. If you are interested in social justice, global health, and innovative solutions, this presentation is for you!

1. Mobile Phone Use among
Female Entertainment Workers
in Cambodia: An Observation
Study
BRENT TATOMIR, MPH
Touro University CALIFORNIA

2. Special Thanks to…
 Advisors: Carinne Brody, DrPH and Siyan Yi, MD, PhD
 Touro University California
 KHANA
 SIT
 FEW Participants

3. Background
 Cambodia has reduced HIV epidemic from generalized to concentrated
 Prevalence in general pop. was 0.6% in 2013
 But, hard-to-reach, high-risk communities, such as Female Entertainment
Workers (FEW), may not be receiving the prevention and care they need
 Prevalence among FEW in Cambodia was 9% and 23% in 2009 and 2007,
respectively

4. Phone Use in Cambodia
 United Nations Development Program report
 2,597 youth aged 15–24 drawn from all 24 provinces in Cambodia
96% declared that they had access to a phone
 68% reporting that they owned a personal mobile phone
 The percentage of Cambodians who own at least one
smartphone was 39.5% in 2015, almost doubling the 2013 figure.
 Social media accessed from mobile devices jumped an impressive 32% in
the last year.
In Cambodia, about 80% of the traffic is driven by Facebook and YouTube
 Cambodia is the first country in the world where the number of mobile phone
users has surpassed the number of fixed landlines

5. Research Aim
 In order to develop a testable mHealth intervention using text
or voice messages in Cambodia, the aim of this study was to
qualitatively explore FEW phone use, specifically identifying
potential challenges and strategies through an ethnographic
observational study.

6. Methods
 STUDY SITE, SAMPLING & TRAINING
 All training, recruitment, observation and interviewing occurred in Phnom Penh
under the supervision of KHANA
 15 participants were randomly sampled from an updated list of FEW with which
KHANA works
 All outreach workers (OW) and researchers were trained for three days in basic
ethnographic observation study methods and privacy assurance.
 TOOL DEVELOPMENT AND MEASUREMENT
 Both the observation tool and the interview questionnaire were designed by
KHANA staff
 Notes on phone use, perceptions of mobile safety and privacy and health
messaging comfort were included.

7. Methods
 OBSERVATION
 8-hour observations of FEW
 Observed by 5 outreach workers
 Non-participatory style with comprehensive note taking
 INTERVIEW
 1-hour interviews with FEW
 Interviewed by the same OW
 Topics used to identify common themes and behaviors

8. Results - Table 1: Phone Ownership Information
Demographic category Demographics n
Lock/Passcode on Phone No 10
Yes 5
Comfort with receiving health
information text messages very comfortable 7
comfortable 4
somewhat comfortable 3
somewhat uncomfortable 1
very uncomfortable 0
Typical mode of communication
through mobile phone, n=13 phone's text message 6
does not message 4
app to voice message 2
app to text message 1
Preference for receiving health
information on your mobile
phone (number who ranked as
best), n=? voice call 15
Facebook messenger 11
text message 9
voice message 9
Phone Type Normal 8
Smart 7
Phone Carrier, n=19 Smart 13
Cellcard 4
Metphone 2
Privacy No past issues with phone 12
Past issues with phone 3
No concerns for the future 13
Concerns for the future 2
Demographic category Demographics n
Texting language n=17 Khmer 12
Romanized Khmer 3
English 2
Other 0
Behavior Unchanged 12
Changed because of
observation 3
Day Typical 13
Atypical 2
Phone Use Typical 14
Atypical 1
Number of SIM cards, n=24 1 8
2 5
3 2
more than 3 0
Phone Sharing No 9
Yes 6
Information Sharing, n=14 Yes 9
No 5
Likelihood of letting others use
your phone very likely 0
likely 1
somewhat likely 8
not likely 4
never 2
Frequency of others using your
phone >10 times a day 0
7-10 times a day 1
3-6 times a day 3
<3 times a day 6
Never 5

9. Results – Table 2: Observation Data
Type of Phone Use
Number of
Participants who did it
at least once (n=15)
Total frequency of
use over 120-hours of
observation (n=265) Proportion
n for
duration
of activity
Average
duration of
activity (mins)
Phone call 15 121 45.3% 106 6.57
Check the time 15 32 12.0%
Go on Facebook (FB) 6 31 11.6% 28 13.85
Check the text message from
KHANA 15 29 10.9%
Non-KHANA texting 8 16 6.0%
Listen to music on mobile 5 7 2.6% 5 14.6
FB post/look at a photo 3 6 2.2%
Play a mobile game 7 5 1.9% 5 15.6
FB newsfeed/news 4 4 1.5% 4 26.5
Go on Youtube 2 3 1.1% 2 9.5
Take a photo 1 2 0.7%
FB chat/messenger 2 2 0.7% 1 5
FB watch video 1 2 0.7% 2 4
FB game 2 2 0.7% 1 5
FB call/voice chat 2 2 0.7% 2 6
Look at phone's background 1 1 0.4%
Use LINE app 1 1 0.4%

10. Results – Graph 1: Call Communication & Graph 2: Texting Communication
Client
35%
Friend
26%
Boyfriend
14%
Family
9%
Mother
6%
Brother
4%
Moto Driver
3%
Husband
2%
Sister
1%
Phone Call Communication, n=105
Smart Phone
Company
56%
Boyfriend
25%
Friend
19%
Non-KHANA Texting Communication
n=16

11. Results – Table 3: Literacy Test
Frequency of each point on Scale
Question 0 1 2 3 4
1. Reading ability for: “Having a trusted doctor that you see once a year can improve your
health.”
3 0 0 0 12
2. Reading ability for: “Exercise is good for health.” 3 0 0 0 12
3. Writing ability for: “In the past year, have you met with a medical doctor at a hospital or
clinic?”
2 0 1 4 8
Scale
0 – cannot read any of this message
1 – can read less than half of this message
2 – can read half of this message
3 – can read more than half of this message
4 – can read all of this message

12. Results –
Table 4:
Observer Notes
Activities Observed Response Frequency
Phone Sharing Yes 3
No 12
Leave phone Yes 11
No 4
Locations where phone was left On Mattress 4
On Bedroom Table 4
In bag 1
TV 2
Time phone left Average= 36.5 minutes
Add data to phone Yes 4
No 11
Change SIM card Yes 1
No 14
Time to reading first KHANA text message Average= 16.8 minutes
Time to reading second KHANA text message Average= 24.8 minutes
Time to compose response to second KHANA text
message Average= 30.1 minutes
Text message sharing Yes 3
No 12
Ask for help deciphering the text Yes 3
No 12
Receive help to compose a response Yes 2
No 13
Interpretation
Felt normal being observed

13. Implications
 1. What mode of communication do FEWS use most?
 2. Can texting change behaviors?
 3. Are FEWs literate enough to communicate through texts?
 4. Are FEWs interested in receiving health-related text messages?
 5. Are there privacy and phone-sharing issues when it comes to receiving
health-related text messages?

14. Limitations
 Inter-Observer variability
 May be due to training or different ethnographic observation skill levels
 Hawthorne effect
 Language barriers in tool translation and development

15. Conclusion
 This study suggests that texting is a part of normal phone use, although
not as frequently used as voice calls or Facebook.
 FEW were interested in health messages and were not overly concerned
about privacy issues.
 Challenges to providing a mHealth intervention may include linguistic,
confidentiality and technological barriers.
 However, texting may be a useful tool for health behavior change within
the FEW population in Cambodia.

16. Thanks for Listening!