The Joint Commission mandates that hospitals seeking accreditation have a process to define and address disruptive behavior. Leaders at Maimonides Medical Center, Brooklyn, New York, took the initiative to create a code of mutual respect that not only requires respectful behavior, but also encourages sensitivity and awareness to the causes of frustration that often lead to inappropriate behavior. Steps to implementing the code included selecting code advocates, setting up a system for mediating disputes, tracking and addressing operational system issues, providing training for personnel, developing a formal accountability process, and measuring the results.

BackgroundIn Cambodia, HIV prevalence is concentrated in key populations including among female entertainment workers (FEWs) who may engage in direct or indirect sex work. Reaching FEWs with sexual and reproductive health (SRH) services has been difficult because of their hidden and stigmatized nature. Mobile-phone-based interventions may be an effective way to reach this population and connect them with the existing services. This article describes study design and implementation of a randomized controlled trial (RCT) of a mobile health intervention (the Mobile Link) aiming to improve SRH and related outcomes among FEWs in Cambodia.MethodsA two-arm RCT will be used to determine the effectiveness of a mobile-phone-based text/voice messaging intervention. The intervention will be developed through a participatory process. Focus group discussions and in-depth interviews have been conducted to inform and tailor behavior change theory-based text and voice messages. During the implementation phase, 600 FEWs will be recruited and randomly assigned into one of the two arms: (1) a control group and (2) a mobile phone message group (either text messages [SMS] or voice messages [VM], a delivery method chosen by participants). Participants in the control group will also receive a weekly monitoring survey, which will provide real-time information to implementing partners to streamline outreach efforts and be able to quickly identify geographic trends. The primary outcome measures will include self-reported HIV and sexually transmitted infections (STI) testing and treatment, condom use, contraceptive use, and gender-based violence (GBV).DiscussionIf the Mobile Link trial is successful, participants will report an increase in condom use, linkages to screening and treatment for HIV and STI, and contraception use as well as a reduction in GBV. This trial is unique in a number of ways. First, the option of participation mode (SMS or VM) allows participants to choose the message medium that best links them to services. Second, this is the first RCT of a mobile-phone-based behavior change intervention using SMS/VMs to support linkage to SRH services in Cambodia. Lastly, we are working with a hidden, hard-to-reach, and dynamic population with which existing methods of outreach have not been fully successful.Trial registrationClinical trials.gov, NCT03117842. Registered on 31 March 2017.Electronic supplementary materialThe online version of this article (10.1186/s13063-018-2614-7) contains supplementary material, which is available to authorized users.

Introduction Adolescent childbearing has been viewed as a social, political, and public health priority since the 1970s. Research has primarily focused on the negative consequences of teen pregnancy; less research has explored factors associated with healthy pregnancy and birth experiences in this population. Methods Using open-ended and qualitative techniques, researchers performed individual interviews with fifteen adolescent mothers (15–19 years of age) recruited from a Women’s and Children’s Clinic in Southern Louisiana, who had experienced a healthy pregnancy and bore a full-term, normal birth weight infant. We used a resiliency framework to identify factors that may have supported positive health outcomes despite risks associated with low-income and/or marginalized minority status. Results A total of 15 mothers of multiple racial/ethnic identities were included in the analysis. Mothers discussed potential protective factors that we classified as either assets (internal factors) or resources (external factors). Mothers demonstrated strong assets including self-efficacy and self-acceptance and important resources including familial support and partner support during pregnancy which may have contributed to their resiliency. Discussion Ensuring access to social and structural supports as well as supporting adolescent-friendly health and social policies may be key to promoting healthy maternal and infant outcomes among young women who become pregnant.

Background: The HIV epidemic in Cambodia is strongly and disproportionately concentrated among key populations. One important hard-to-reach key population is the expanding community of female entertainment workers (FEWs). HIV as well as other sexual and reproductive health (SRH) outcomes including sexually transmitted infections (STIs), contraception, and gynecologic health are also substandard among FEWs. To address these concerns, a mobile health intervention (mHealth) using short message service (SMS) and voice message (VM) services-the Mobile Link project-was constructed. This paper aims to describe the development of this mHealth intervention that used participatory methodologies and to illustrate how these findings can be useful in future mHealth projects. Methods: This intervention development process used an iterative, participatory approach. Twenty-seven focus group discussions (FGDs) covering SRH topics were designed and conducted and implemented across four provinces in Cambodia. Additionally, six in-depth interviews (IDIs) were conducted with FEWs living with HIV in Siem Reap and Phnom Penh. Data from the FGDs and IDIs were analyzed using content and matrix analysis methods to identify prioritized themes for messages. Two data validation workshops were organized to present the prioritized themes to FEWs and outreach workers (outreach workers) for validation. The workshops included activities stimulating participation such as listening to sample messages in order to determine health priorities as well as message tone and style. Results: The findings from the qualitative research provided guidance on how to tailor the intervention to the FEW community in terms of the tone, timing, content and delivery mode of the messages. Participants preferred a friendly, professional female voice for VM. Participants revealed that health priorities such as gynecologic issues (vaginal infections/irritation) and cervical and breast cancer, were emphasized more than HIV and family planning. Participants also reported a number of misconceptions about contraception, particularly around oral contraceptives and intrauterine devices, and STI transmission. Participants expressed the need to build trust in outreach workers and linkages, affirming the emphasis on the link within the Mobile Link project. Lastly, from the IDIs, FEWs living with HIV highlighted wanting supportive/messages to address depressive feelings that may stem from their perceived stigma. Conclusions: Utilizing participatory methodologies was demonstrated to be useful in intervention content creation and program implementation. As a result of this intervention development process, the research team gleaned lessons that may be applicable to future mHealth projects including the idea of adding some layers of choice to mHealth interventions for further tailoring at the individual level and the importance of human contact and trusting relationship. mHealth, 2019

Background: Female entertainment workers (FEWs) in Cambodia work in predominantly alcoholbased venues and therefore may face occupational risks. Studies have suggested that FEWs are pressured to consume alcohol while at the workplace, which may have adverse health outcomes. This study aims to explore the experiences of alcohol use among FEWs in Cambodia. Methods: Twenty-seven focus group discussions (FGDs) with FEWs were conducted across five sites in four provinces in Cambodia. FGD participants were FEWs who worked at entertainment venues, including karaoke TV bars, beer gardens, and massage parlors, as well as women who worked as on-call or street-based sex workers, and women across entertainment venues who were parenting. Results: The authors modified a conceptual model to create a framework based on the major themes identified within the FGDs on autonomy in alcohol use among FEWs. The framework and thematic components highlight the continuum of autonomy from pressured or coerced alcohol use to, economically or socially rational alcohol use to voluntary alcohol use. Factors that impacted alcohol use across the spectrum include experiencing an economic shock, needing to maintain a livelihood, experiencing psychological distress, having the desire to thrive in employment environment and drinking socially for personal enjoyment. Conclusion/Importance: Much of the motivation behind alcohol use is related to the need for economic security. For women who do not have other employment or income-generating options, individual behavior change programing is unlikely to be effective. Structural changes are needed to improve the health and safety of FEWs in Cambodia.