The results will be presented in the following manner: the demographic description of the survey data will be followed by a summary of the health behaviors of the beer promoters. Thereafter we include a discussion of beer promoters’ experiences with, and their preferences for, health care institutions. The quantitative results will be illustrated by qualitative examples where the results concur, and with contrasting examples where they differ. While the qualitative focus group data were collected before the surveys were conducted, we have chosen to present and discuss the results together in order to avoid redundancy and for purposes of comparison of both forms of data. Differences between countries will also be illustrated, though the numbers were not large enough to demonstrate statistical significance.
Summary of health behaviors
The health behaviors of the beer promoters in the survey are listed in supplementary file Table
4. The women commonly reported having sex outside of their primary relationship. While only 18.2% admitted to frequent sexual relations outside of their primary relationship (more than once per month), a further 34.1% stated they had extramarital sex at least once per year. These sexual activities were common amongst all four nationalities of beer promoters.
Table 4
Health Behaviors of Beer Promoters
43. Sex outside of marriage: | 1 | 30 (33.3) | 15 | 41 | 17 | 103 (26.4) |
2 | 13 (14.4) | 36 | 20 | 14 | 83 (21.3) |
3 | 35 (38.9) | 31 | 26 | 41 | 133 (34.1) |
4 | 12 (13.3) | 18 | 13 | 28 | 71 (18.2) |
44. Sex with clients: | 1 | 32 (35.6) | 7 | 78 | 22 | 139 (35.6) |
2 | 18 (20) | 14 | 12 | 21 | 65 (16.7) |
3 | 32 (35.6) | 39 | 6 | 40 | 117 (30.0) |
4 | 8 (8.9) | 40 | 4 | 17 | 69 (17.7) |
45. Money for sex: * 1 missing value for Cambodia | 1 | 28 (31.4) | 7 | 82 | 24 | 141 (36.2) |
2 | 16 (18.0) | 3 | 7 | 17 | 43 (11.1) |
3 | 35 (39.3) | 20 | 11 | 32 | 98 (25.2) |
4 | 10 (11.2) | 70 | 0 | 27 | 107 (27.5) |
46. Drunk beer with clients: | 1 | 18 (20) | 4 | 58 | 5 | 85 (21.8) |
2 | 9 (10) | 5 | 25 | 18 | 57 (14.6) |
3 | 37 (41.1) | 42 | 14 | 39 | 132 (33.8) |
4 | 26 (28.9) | 49 | 3 | 38 | 116 (29.7) |
47. Suspected or known sexually transmitted infection: | 1 | 39 (43.3) | 17 | 86 | 33 | 175 (44.9) |
2 | 14 (15.6) | 25 | 10 | 29 | 78 (20.0) |
3 | 23 (25.6) | 46 | 4 | 35 | 108 (27.7) |
4 | 14 (15.6) | 12 | 0 | 3 | 29 (7.4) |
48. Used injection drugs: | 1 | 68 (75.6) | 90 | 87 | 96 | 341 (87.4) |
2 | 5 (5.6) | 7 | 7 | 2 | 21 (5.4) |
3 | 9 (10) | 3 | 6 | 1 | 19 (4.9) |
4 | 8 (8.9) | 0 | 0 | 1 | 9 (2.3) |
49. Had an abortion: *Problem with category - should not be 4. | 1 | 39 (43.3) | 40 | 89 | 48 | 216 (55.4) |
2 | 17 (18.9) | 49 | 7 | 39 | 112 (28.7) |
3 | 21 (23.3) | 10 | 4 | 13 | 48 (12.3) |
4* | 13 (14.4)* | 1* | 0 | 0 | 14 (3.6) |
50. Sex with men for money to supplement income: | 1 | 36 (40) | 20 | 89 | 24 | 169 (43.3) |
2 | 15 (16.7) | 13 | 8 | 19 | 55 (14.1) |
3 | 29 (32.2) | 39 | 3 | 36 | 107 (27.4) |
4 | 10 (11.1) | 28 | 0 | 21 | 59 (15.1) |
51. Drunk from drinking at work: | 1 | 21 (23.3) | 13 | 77 | 41 | 152 (39.0) |
2 | 23 (25.6) | 11 | 16 | 30 | 80 (20.5) |
3 | 29 (32.2) | 48 | 6 | 26 | 109 (27.9) |
4 | 17 (18.9) | 28 | 1 | 3 | 49 (12.6) |
52. Beer promotion work provide enough money * 2 missing values for Vietnam | 1 | 32 (35.6) | 8 | 28 | 15 (15.3) | 83 (21.4) |
2 | 21 (23.3) | 11 | 22 | 16 (16.3) | 70 (18.0) |
3 | 27 (30) | 41 | 19 | 41 (41.8) | 128 (33.0) |
4 | 10 (11.1) | 40 | 31 | 26 (26.5) | 107 (27.6) |
The beer promoters were questioned about sex work on 3 different items “sex with clients” (Item 44), “receiving money for sex” (Item 45), and “sex with men to supplement their income” (Item 50). Over one third denied any sex work on these three items (35.6%, 36.2% and 43.3% respectively). The frequency of women who admitted that they “sometimes” (at least yearly) or “often” (at least monthly) engaged in sex work was generally higher: responses of “sometimes” or “often” on the three items addressing this issue were 47.7%, 52.7% and 42.5% respectively. Sex work was most common in beer promoters from Laos and Vietnam, and least common amongst the Thai beer promoters.
More than half the survey participants from Cambodia, Laos and Vietnam and 11% in Thailand had had an abortion at some point in their lives. (Note that in the Cambodian and Laotian surveys the response category of 4 or “often” was mistakenly included in the survey although it should not apply to this question).
The beer promoters surveyed were questioned about drinking beer with clients (item 46) and getting drunk at work (item 51). Drinking beer with clients was common amongst all beer promoters except those from Thailand. Women reported “sometimes” or “often” drinking beer with clients: 70% in Cambodia, 91% in Laos, 77% in Vietnam and only 17% in Thailand. Similarly, reports of getting drunk at work “sometimes” or “often” were highest in Laos (76%) and Cambodia (51.1%) followed by Vietnam (29%) and Thailand (7%).
About one third of the beer promoters reported that they “sometimes” or “often” knew or suspected that they had a sexually transmitted infection, though again this proportion varied by country: Laos 58%, Cambodia 41.2%, Vietnam 38% and Thailand only 4%.
Injection drug use was uncommon in all countries: only 7.2% of women admitted to “sometimes” or “often” using injection drugs and its use was most common in the Cambodian cohort (18.9% of women states “sometimes” or “often” using drugs).
When questioned if their work as beer promoters provided enough money to live on about one fifth stated that it “never” did though again the responses varied by country from Cambodia (35.6%) and Thailand (28%) to Vietnam (15.3%) and Laos (8%).
Barriers and facilitators to accessing sexual and reproductive health services
The potential barriers or facilitators to accessing sexual and reproductive health care services for beer promoters in these four Southeast Asian capital cities can be categorized under three major conceptual structures: institutional factors, work factors, and personal factors.
Institutional factors
There were several key factors that were common barriers preventing access for beer promoters to the institutions providing sexual and reproductive health care services in these four Asian capitals. These include financial barriers, location/ transportation issues, the environment of the institution, and service factors.
Financial barriers and health care insurance
Cost of the health care services was an important issue for these beer promoters as their financial resources were often stretched very thin. In the survey, 71.8 percent agreed or strongly agreed that cost was a very important factor in choice of health care institution (item 13). One third to one half could not afford to go to the health care institution that they preferred (item 22). The Cambodian and Vietnamese beer promoters quoted below reflect on the challenges they had balancing their own health with the financial needs of their families. Purchasing health care services meant giving up funds for other important requirements such as food, rent and family support. As a result, they would often avoid costly health care services.
If I go to [NGO name], I would like to use the Norplant and they wrote on the board that cost $50. And I do not have ability to pay for that because it is very expensive. For the beer seller like me, I have only the money to pay for the house rent, eating, send to my children and spend on other things. I do not have money for that. (Cambodia, FG BP 1)
You know that we come here to work to earn money and send money home, if we go to doctors, we don't have money for the time we go and we also have to spend money for doctors… Only when I have serious disease, I go to doctors because going to doctors takes much money. (Vietnam, FG BP 3)
In addition to regular fees of some of the health care institutions, this beer promoter from Laos noted that to get good service, sometimes gifts need to be provided to the doctors and nurses. As a poor beer promoter from the countryside, she was both unaware of this practice and unable to afford it.
Big city people know what to do when they go to the hospital. They always give doctors/nurses some gifts and they are looked after very well. People from countryside don’t quite know the system and they also don’t have extra money so they don’t know what to do. (Laos, FG BP 3)
The beer promoter from Laos quoted above was somewhat unique in her experience among her cohorts from her country. Only 4 percent of Laotian beer promoters agreed or strongly agreed that money or gifts improve the service of health care providers (item 20), though overall about one third of the beer promoters did agree with this statement.
Financial issues underpin the hierarchy of resort [
25], the progression of strategies used to resolve their health problems, most commonly shared by respondents. For most, the first step was the local pharmacy where they can obtain inexpensive medication without a physician’s prescription. If the medication did not adequately address the problem, the beer promoter resorted to the next, generally more expensive and more technologically sophisticated service, continuing until her needs have been satisfied. As one Laotian informant shared:
First, I go to the drugstore and buy medicine without prescription followed by using clinic service and finally going to the hospital if the health problem is still there. (Laos, FG BP 2)
As noted earlier, with the exception of those from Thailand, only about one third of the beer promoters had access to health insurance. For a few Cambodian and Vietnamese women, the employer provided this benefit: For my company, they have insurance. If we are sick, but not serious condition, we can go to the company clinic. If we are serious, we can go outside and have a receipt for them. (Cambodia, FG BP 4). If you work for long time at a permanent job like us, you will have contract and you will have health insurance. (Vietnam, FG BP 4)
The majority of beer promoters in the study, however, had no health insurance either because it was not provided by their employer or because they were part-time employees and it was not available to them. Government insurance was accessible for some Thai and Vietnamese beer promoters, but as migrants to the city it was not easy for them to use this insurance. Public health insurance schemes in those two countries are linked to service provision in residents’ natal communities, limiting its utility under conditions of migration.
Interviewer: Do you know about voluntary health insurance? Patients with voluntary health insurance only pay 5% to 10% of their hospital fees.
Respondent: Of course we know, but it requires a permanent address here while all of us are migrants. We only can buy health insurance at our hometown with a permanent address and we have to register at one hospital near our home to be examined. (Vietnam, FG BP 3)
For the beer promoters with health insurance, sometimes the health care institutions that were available to them were not desirable: The social security hospital is not providing good services, and doctors don’t care about us, long waiting. Actually we selected the clinic that is close to our home, convenient and clean. (Thailand, FG BP 3)
The Vietnamese key informant quoted below noted that while the government had policies to provide health care insurance, many beer promoters lacked labour contracts and thus were not protected by these laws and policies.
Most girls doing massage services, or working as beer promoters do not have labor contracts so they do not have social insurance or health insurance. Therefore, they do not have the opportunity to be examined in health centers or hospitals although our nation has laws to require these units to send their staff to health centers and have periodic health examinations. Besides, our nation also has laws to require heads of companies or restaurants, etc. to buy health insurance and social insurance for their staff but they usually don't buy so if beer promoters want to have their health checked, they must pay money themselves. (Vietnam, KI 2)
Thus, the cost of health care prevents beer promoters from accessing reproductive health care services. While health insurance would improve access, the complexities of government policies and lack of enforcement makes it difficult for poor beer promoters from the countryside to access health care insurance even if it exists.
Location/transportation factors
The location of the health care institution is often a key factor to whether or not beer promoters decide to access the services. In the survey 72.3 percent stated that location was important in their choice of health care institution, and the majority of beer promoters from all four countries held this opinion (item 14). In addition, almost a half of all the beer promoters and 74 percent of the Laotian beer promoters in particular agreed or strongly agreed that the cost of transportation was a key factor in accessing health care (item 24). Many beer promoters chose to seek care in institutions that are close to home as they are hesitant to spend money on transportation. This Thai beer promoter reflects on her priorities in choosing where to obtain health care:
Similar to the others, I usually go to a clinic because it is close to home, convenient and has quick services. (Thailand, FG BP 1)
Location and lack of transportation are an issue for this beer promoter in Laos. She felt she was better off in the countryside.
I don’t have a vehicle so it is very difficult for me to go to the health care provider. I am also shy to discuss my health problems with other people. I don’t have permanent address or even an identity card. It was not this difficult in my home town. (Laos, FG BP 3)
While convenience of location was a factor for beer promoters from all countries, some beer promoters were fortunate enough to be serviced by clinics that provided free or subsidized transportation. This transportation facilitated care and health education for some women:
That hospital always comes and collects all of us to receive the treatment and to understand about what we can do to take care of our health. (Cambodia FG BP 3)
Environmental factors
In addition to financial barriers and location/transportation issues, the environment of the clinic had an impact on accessibility to reproductive health care services. In particular, the beer promoters needed quick appointments, and often avoided health care institutions with long waits. In the survey, 44.7 percent of the beer promoters agreed that they would go elsewhere if there was a long wait (item 17). This varied from one third of the group in Laos to over a half of the Thai beer promoters. When questioned again if they would be willing to wait more than two hours for an appointment (item 29), 43.1 percent stated they would not mind (85.5 percent for Cambodia). Waiting was a common experience for beer promoters. Generally, the private health clinics had shorter waiting times than the government hospitals.
The government hospital is very crowded and it has a long waiting time; almost 50 people before me. (Thailand, FG BP 4).
Another key factor for choice of institution was the perceived cleanliness: eighty four percent of the beer promoters agreed or strongly agreed that cleanliness affected their choice (item 30). Some beer promoters preferred the private clinics as they were thought to be cleaner. This Vietnamese key informant summarized the strengths of the private clinics for beer promoters: Private clinics are open in order to earn money from patients so they usually meet all demands of patients such as fast, convenient, clean, friendly doctors and nurses. (Vietnam, FG KI 2)
Confidentiality was considered “very important” for 84.4 percent of surveyed beer promoters; only 5.4% disagreed or strongly disagreed (item 25). This Vietnamese beer promoter felt that the shorter waiting time and increased confidentiality of the private clinic was worth paying for: In private clinics we have to pay more money, but we don't have to wait for a long time and information is kept in secret, nobody knows who we are. (Vietnam, FG BP 4)
Not all agreed about the benefits of private clinics. This beer promoter from Laos preferred the quality of service and anonymity of the hospital: I am not confident to go to clinics. It seems okay during the medication, but the symptoms come back later. I also feel shy to tell doctor at clinic my problem person to person. Without witness, who will be responsible if something goes wrong? I am also afraid that I will meet the doctor from clinic in public and of course I will be recognized with my health problem. At hospitals, there are many patients and I am quite positive that the doctor will not remember my face as he/she sees many sick people every day. (Laos, FG BP 3)
In summary, the environment of the health care institution affects access of beer promoters to reproductive health care services. In particular, waiting times, cleanliness and confidentiality are important factors to these women.
Service factors
There are several factors related to the service provided by the health care institution that have an important impact on access to sexual and reproductive health care services for these women. One of the most significant was the friendliness and attitudes of the health care providers. More than 85 percent of the beer promoters felt that friendliness of the providers was an important issue (item 15) and few beer promoters disagreed (3.1percent). Over 85 chose the health care institution based on the caring attitudes of the providers (item 27). Health care provider skills were also perceived as important by over 84 percent (item 26). Health care provider explanations were deemed important by close to 85 percent (item 32). Female health care providers were preferred for reproductive health exams by over 70 percent (item 19), though this varied by country with Cambodian beer promoters having the strongest preference (84.4 percent), and Thai the least (56 percent). Conversely, Cambodian beer promoters were more likely to agree that male providers were more skilled than female providers, than beer promoters from other countries (item 33).
A minority of beer promoters agreed that they had been treated badly by health care providers in the past (item 28), though this varied from six percent in Laos to 40 percent in Thailand. It was not unusual to be shouted at, or treated with disrespect by health care providers. Some of the beer promoters perceived this was worse if they were dressed in their working clothes, as the health care providers stigmatized them for their work and their lower social status. Below are several examples of what women experienced:
Respondent 1: Each hospital provides a different quality of service, but how doctors react toward patients are pretty much the same. Some are very kind while some others seem to be very impolite.
Respondent 2: Doctors/nurses will talk to rich people very nicely. Those who are poor are ignored. (Laos, BP FG 2)
Attitude [of health care providers] may affect my decision [about choice of hospital]. They did not take good care of me. (Thailand, FG BP 4)
I have to say that we are beer promoters, we work in this environment, but we are also people. We also know how to hate, love, be angry, etc. And we get diseases or not, we are still people. Some doctors, they say and behave to us very softly and gently so that even when I don’t want to be checked, I let them examine me. But there are also some doctors, truthfully, we can’t smell them. They shout at us “examine or go home” or “wait out there”. In this situation, even if I have disease, I will not seek examination or treatment. (Vietnam, FG BP 2)
The doctors at [Name of Institution] said bad words. The doctor said that when we have sexual relationship, why don’t we call them to see? (Cambodia, FG BP 4)
This last example demonstrates the deep stigma some providers have against women who may be involved in sex work. This stigma was not unique to Cambodian health care providers. The Vietnamese key informant quoted below described how hospital training sessions are organized to improve communication and staff attitudes, but are not always effective.
I know some hospitals organize training sessions for their staff about communication ways to patients and their attitudes, behaviors to patients and patients’ relatives but most of these training sessions are not well-organized and staff usually come there to chat, they don’t pay much attention to the topics of the session. This leads to bad attitudes of some doctors to patients in hospitals. Many of them shout at patients and disregard patients. Besides, it is also noted that a small number of doctors receive extra money from patients that if patients don’t give them money, they will not behave and examine them well. These things make people have bad opinions about doctors and so make beer promoters - sensitive people - be afraid of going to doctors. (Vietnam, KI 3)
Another very important service that facilitates access to health care services for beer promoters is evening or weekend clinic hours. The beer promoters are often not able to go to the clinics during working hours, and many work late and are not willing to get up early to wait in a clinic to be seen. This Vietnamese beer promoter summarized her and her colleagues’ desires for health care institutions:
Of course, we always hope to have a centre with cheap price, convenience, the open time is from morning till midnight because sometimes it is difficult for us to arrange time for going to doctors. Besides, doctors must have good expertise and warm attitude to welcome us. (Vietnam, FG BP 2)
In addition to improving staff attitudes and after hours availability, several beer promoters commented on the availability of supplies and medication as an issue.
The hospital which is near my house does not have enough materials, but the far one demands more money. I just want them to have enough materials when we go. I don’t want to move to another hospital. (Cambodia, FG BP 4)
Finally, Cambodian and Laotian beer promoters noted that some NGO health care institutions provide incentives to encourage beer promoters to avail themselves of services. For example, one Cambodian NGO gives prizes to women who attend their clinic. A Laotian NGO provides beauty services and games for the beer promoters to make them feel more comfortable. These places encourage beer promoter clientele and thus facilitate their attendance for their health care needs as well.
Thus staff attitudes, clinic opening times, and medication availability can act barriers or a facilitators for beer promoters to access sexual and reproductive health care services. Another potential facilitator of service access is incentives to attract beer promoters. In addition to these institutional factors, however, the challenge of taking time off from work impacted on beer promoters access to health care services.
Work factors
One of the most common barriers to accessing reproductive health care services for beer promoters reported by both beer promoters and key informants was lack of time. Over one third agreed that they could not get time off of work to access health care (item 23). This varied from 25 percent for the Laotian beer promoters to 45 percent of those from Thailand and Vietnam. Many found that they were discouraged by their employers to take time away from work in order to seek health care. For example, this Cambodian beer promoter pointed out that the owner would cut their pay, and may not believe them if they requested time off to see a health care provider: When we want to have our health checked up, the company owner does not have time for us. If we want to go out, they will cut off our salary from 5 or 3 dollars. Sometimes we want to go to get the health care services, we ask for permission. But they think that we tell lies and we want to go somewhere else. (Cambodia BP FG1)
A Thai key informant noted that the working hours of beer promoters also prevent them from seeking health care: They don’t have enough time: they are working in the night time and wake up very late so they can’t go to the hospital. (Thai KI 4)
Not all beer promoters agreed that time was an issue for them. One Laotian beer promoter stated: Time is not a problem. We are allowed to go to health care services anytime we want to. (Laos BP FG5)
A key informant who also worked as a health care provider in Laos noted that this was not the case, however, for the beer promoters she treated: The beer promoters have a very limited time to visit my clinic for treatment in sexual and reproductive health as they spend much of their time working. (Laos KI 3)
In Vietnam, one key informant summarized: Beer promoters and sex workers are managed by their employers about time, if they go to health centers or hospitals, it will take them lots of time and this doesn’t please their employers. (Vietnam FG KI 1)
Thus in general, time was an important factor associated with work that limited beer promoters from all four countries to access sexual and reproductive health care services. There was not universal agreement about this, but for many beer promoters, taking time off of work for their health was not encouraged by their employers. Many also did not want to lose income by taking off time from work to seek health care services.
Personal factors
There were several personal factors that beer promoters from across the region experienced that affecting their willingness to seek sexual and reproductive health care services. These can be characterized as shyness and fears, lack of knowledge, and support from family and friends.
Shyness and fears
Women from all four countries stated that sometimes they avoided getting reproductive health care services because they were “shy”. Of the beer promoters surveyed, close to a third agreed that they avoided care because of shyness (item 18), though in Thailand the shy women were close to half the cohort at 46 percent. Over 22 percent of the beer promoters agreed they avoided being examined because they were afraid (item 21). In the focus groups, “shyness” appeared to have a variety of meanings including a fear of being examined, a fear of others seeing the beer promoter in the clinic and a fear of the equipment itself. Below are several examples of how the women describe their shyness and fears:
But some of us are shy and do not want to let the doctors to check us, even me for the first time. They are afraid to let the doctors to see their vagina. (Cambodia, FG BP 1)
Most women/girls are too shy to go to the hospital. They buy medicine from the pharmacy to take hoping to stop their pain without consulting a doctor. (Laos, FG BP 2)
Interviewer: Why do you think that women don’t go to see the doctor?
Respondent 1: Shy.
Respondent 2: I was afraid also. If some things happen, I cannot tolerate.
Respondent 3: I was afraid of the medical equipment. (Thailand, BP FG 4)
While a few of the key informants who worked as health care providers stated that the beer promoters who came to see them were comfortable sharing their health problems, this Vietnamese key informant noted that: They [beer promoters] usually hesitate going to big hospitals as they are afraid of seeing acquaintances there and afraid other people may recognize their identity, so they often go to private clinics or health centres which are far from their working place and they usually come there at the time they think there are a few customers. (Vietnam, FG KI 2)
Thus shyness and fears of examination and being recognized by others are common themes amongst the beer promoters in these four countries. Another significant personal factor affecting their access to reproductive heatlh care is lack of knowledge.
Lack of knowledge
Beer promoters lack knowledge of both their sexual and reproductive health needs and the services available to them. This is sometimes a barrier in accessing health care services. Key informants are particularly aware of this knowledge gap.
Most of the women come to this clinic because of sexually transmitted diseases; I think they should learn how to practice safe sex behaviors. They do not go out with their clients all the time, but they have their boyfriends and are not using condoms. Also they lack the knowledge about family planning. It is easy for them to get pregnant because they are still young and sexually active. (Thailand, KI 2)
I think barriers to sexual and reproductive health care services of beer promoters are their limited knowledge of sexual and reproductive health care. They also don’t know much about these services that hospitals provide. Due to limited knowledge, they are easily influenced by other beer promoters, and they can follow advice of their colleagues. They also may not know how to prevent diseases, especially sexually transmitted diseases. (Vietnam, KI 3)
Support of family and friends
Recommendations of friends was an important factor in choice of health care institution for close to 60 percent of the surveyed beer promoters (item 16). However, in the focus groups there was some discussion amongst the beer promoters about the cooperation of their partners and the support they received from their families when they were ill. Many did not inform their families about symptoms or seeking care unless they were very unwell. Families generally encouraged them to seek health care. Partners may encourage the woman to seek care while avoiding treatment themselves - unless the partner has many symptoms. The Cambodian beer promoter quoted below commented on the challenges beer promoters experience, due to the lack of cooperation from partners.
One problem, sometimes her family pushes her to see doctor but the partner did not go with her. When we have vaginal discharge, if we were treated and partner did not go for treatment, we can infect each other. So the problem is the partner did not want to see doctor. He said that he is lazy to see doctor, only ask for medicines. (Cambodia, FG BP 1)
On the other hand, friends can facilitate access to health care services by making recommendations of where to seek care, as the Thai beer promoter described:
Interviewer: Do your friends influence you to choose the hospital?
Respondent: Yes, they do. If they told this hospital is good service, we will go. (Thailand, FG BP 2)
Thus friends and family can act as a support to the beer promoter, recommending health care services and encouraging access to services. Sometimes family acts as a barrier to health for beer promoters; in particular, uncooperative male partners who choose not to be treated can negatively impact on the beer promoters’ health status.