Md. Irfan Hossain
Abdullah Al Mahmud
Ashish Bajracharya
Ubaidur Rob
Laura Reichenbach
Publication Date
September 1, 2017

This evaluation of Business for Social Responsibility (BSR)'s HERhealth model, conducted by the Evidence Project/Population Council, offers evidence and recommendations for effective programming to improve the health of women workers in garment factories in Bangladesh and elsewhere. The report presents findings from: a pre- and post-intervention quantitative study of female factory workers from 10 factories; a qualitative study with factory managers, service providers, and implementing partners; and self-administered retention assessments of Peer Health Educators (PHEs) from 6 factories in Dhaka, Gazipur, and Narayanganj districts of Bangladesh. (See Related Summaries below for baseline findings.)

Organisers explain that Bangladesh's ready-made garment (RMG) sector employs a predominantly female workforce, and has had a major impact on women's autonomy and economic empowerment. Alongside potential financial benefits, however, female factory workers face a myriad of health issues, many of which aren't adequately addressed by traditional workplace health programmes. BSR's HERhealth model, one pillar of BSR's HERproject, seeks to improve the health-related knowledge, behaviours, and access of low-income working women through strengthening factory clinics, engaging factory management in the issue of worker health, and training peer health educators (PHEs).

The HERhealth intervention is 18 months long and delivered via PHEs (recruited and trained by BSR) through a series of workplace trainings; training content is tailored to the Bangladeshi context, based on the identified health needs of that factory, from needs assessment in each factory. In participating factories, six 3-hour trainings, with a one-hour follow up one month later, were offered on topics including menstrual hygiene, sexually transmitted infections (STIs) and HIV/AIDS, nutrition, family planning (FP), early detection of breast and cervical cancer, and occupational safety and health (OSH). Training modules were provided to female factory workers in groups of 10-40, depending on factory size. Since some of the topics contained sensitive material, female trainers conducted the trainings for PHEs and ensured confidentiality of the sessions. PHEs were taught to communicate effectively through careful listening, to encourage active participation from factory workers, and to use a non-judgmental tone when delivering the modules. Modules were designed to be interactive and involved group activities for each topic, including the use of flipcharts, drawings, and diagrams. When appropriate, role-play was used to illustrate concepts. After each module, female factory workers were given a short assessment to test their knowledge from the day's activities. Most factory programmes in Bangladesh also included efforts to link improvements in health awareness among factory workers with health services, through strengthening factory-based clinics.

The Evidence Project/Population Council conducted an implementation science study to evaluate the effectiveness of the HERhealth intervention for increasing knowledge and service uptake among female workers and HERhealth's impact on business outcomes from factory management's perspective. The study hypothesis was that better health knowledge and practices would improve the workers' health status, resulting in less absenteeism and an accompanying business return for the factory.

The breakdown of factories that took place in the 38-month study is as follows: 4 intervention factories (two large and two medium-sized), where HERhealth was implemented between 2015 and 2016; 2 post-intervention factories (one large and one medium-sized), where HERhealth activities were completed (and BSR involvement had ended) before 2015 and the start of the study; and 4 comparison factories (two large and two medium-sized), where HERhealth would not be implemented before the completion of the evaluation. Systematic random sampling was used to draw a sample of female factory workers of reproductive age (18-49 years old) from each of the selected factories. Respondents were interviewed on a range of sexual and reproductive health (SRH), maternal and child health, FP, and other health knowledge, access, and utilisation issues. The total sample for the baseline survey was 2,165 and for the end line survey was 1,953.

In short, the study found that:

  • The HERhealth intervention had a positive impact on knowledge and behaviour related to menstrual hygiene, in part because of the intervention's facilitation of relationships between factories and menstrual products suppliers, which made it possible for factories to offer reduced-cost sanitary pads to workers. Among the workers at intervention factories, there was a steep and highly significant increase in the use of sanitary pads between baseline and end line (49 percentage points; from 23% percent to 72%).
  • A positive impact was observed on workers' knowledge of STIs and HIV/AIDS, knowledge of recommended antenatal care, and use of contraception. The observed differences indicating that the change in knowledge in the intervention factories is greater than the changes in control factories suggest that this positive outcome may be attributable to the HERhealth intervention. For example:
    • The STI awareness of workers from intervention factories increased from baseline (28%) to end line (75%), an increase (47 percentage points) that was found to be highly significant (p-value <0.001).
    • Workers from intervention factories reported greater awareness of HIV/AIDS (95%) and HIV/AIDS prevention measures (88%) than both post-intervention and control factory workers at end line. Workers from intervention factories also showed a significant increase (6 percentage points; from 89% to 95%) in HIV-related knowledge from baseline to end line.
    • Workers in intervention factories reported a change in knowledge regarding at least 4 antenatal care (ANC) visits during pregnancy (18 percentage points; from 48% to 66%), while workers in control factories reported a decrease in knowledge for this indicator (3 percentage points; from 46% to 43%).
  • Between baseline and end line, use of any FP methods or any modern FP methods increased only among the workers in intervention factories (5 percentage points, from 65% to 72%, for any FP method, and 5 percentage points, from 56% to 61%, for any modern FP method). A significant decrease among workers from control factories in use of any FP method (3 percentage points; from 70% to 67%) and any modern FP method (6 percentage points; from 61% to 55%) suggests that the positive outcomes observed at intervention factories may be attributable to the HERhealth intervention.
  • Factory managers reported observing positive effects on workers' health-related knowledge, awareness, and behaviours, particularly related to hygiene and nutrition. They were generally supportive of the intervention, saying that they have found the PHE model to be very effective, and seemed to understand the value of healthy workers for improving business outcomes. They mentioned, in particular, decreased absenteeism as a result of improved worker health and were also generally appreciative of the positive impact of offering low-cost sanitary pads.
  • To capture the perceptions of health service providers regarding HERhealth in their factories, a total of 18 health service providers were interviewed from intervention and post-intervention factories (on average, 3 in each factories). The study also interviewed implementing partners (BSR and Change Associates) to collect their views towards HERhealth. They shared their views on factors such as project implementation, achievement of objectives, effectiveness, sustainability, and challenges. For example, one problem identified by implementing partner respondents was a shortage of training rooms that allow female workers to sit and talk comfortably with privacy, and have enough space to use and display training materials.
  • Periodic knowledge retention tests revealed variable performances of the PHEs, depending on the topic. The assessments found that PHEs performed highest on the round 3 topics (Preventing STIs and HIV/AIDS) and round 6 topics (Occupational Safety and Health). In all 5 assessment rounds, PHEs at intervention factories showed significantly better retention performance than those at post-intervention factories, where the intervention had previously been implemented. This provides evidence of the need to maintain the knowledge and skills of PHEs and to continue regular HERhealth activities.
  • Results show that family planning products like oral pill, condom, injectable, and intrauterine devices (IUDs) were not provided by participating factory clinics, highlighting an area for future investment and revision in the HERhealth intervention.

The report presents several recommendations for improving the sustainability of the HERhealth model:

  • Extend training content and duration: Many of the female factory workers who were exposed to the HERhealth programme recommended more training on health-related issues.
  • Engage male workers: Factory managers suggested that sensitising male workers could support positive changes in their spouse's knowledge and behaviour.
  • Regular follow up: Particularly in the context of high turnover in this sector, regular follow up by the implementing agency with factories where the HERhealth intervention has been completed is important to ensure positive impacts are sustained.

Posting from Kate Gilles to the IBP Knowledge Gateway, November 8 2017; and Evidence Project/Population Council website, November 8 2017. Image credit: BSR