Using qualitative and community-based engagement approaches to gain access and to develop a culturally appropriate STI prevention intervention for foreign female entertainment workers in Singapore

Abstract

BackgroundThere is an increasing global movement of foreign female entertainment workers (FEWs), a hard-to-reach population vulnerable to HIV/STIs. This paper described the needs assessment phase before intervention implementation where the socio-organisation, sexual risk behaviours and access to health services of foreign FEWs in Singapore were explored. We also highlighted how qualitative inquiry, census enumeration technique and community-based engagement approaches were used to gain access and to develop a culturally appropriate STI prevention intervention.MethodsIn-depth interviews, observations, informal conversational interviews, mystery client and critical incident technique were used. We estimated the size of FEW population using the census enumeration technique. The findings were used to inform intervention development and implementation.ResultsWe estimated 376 Vietnamese and 330 Thai FEWs in 2 geographical sites where they operated in Singapore. Their reasons for non-condom use included misconceptions on the transmission and consequences of STI/HIV, low risk perception of contracting HIV/STI from paid/casual partner, lack of skills to negotiate or to persuade partner to use condom, unavailability of condoms in entertainment establishments and fear of the police using condom as circumstantial evidence. They faced difficulties in accessing health services due to fear of identity exposure, stigmatisation, cost and language differences. To develop the intervention, we involved FEWs and peer educators, and ensured that the intervention was non-stigmatising and met their needs. To foster their participation, we used culturally-responsive recruitment strategies, and ensured that the trial was anonymous and acceptable to the FEWs. These strategies were effective as we achieved a participation rate of 90.3%, a follow-up rate of 70.5% for the comparison and 66.8% for the intervention group. The interventions group reported a significant increase in consistent condom use with a reduction in STI incidence compared to no significant change in the comparison group.ConclusionsThe qualitative inquiry approaches to gain access, to foster participation and to develop a culturally appropriate intervention, along with the census enumeration technique application to estimate the FEW population sizes has led to successful intervention implementation as well as safer sexual behaviour and STI incidence reduction.Trial registrationClinicalTrials.gov, NCT02780986. Registered 23 May 2016 (retrospectively registered).Electronic supplementary materialThe online version of this article (10.1186/s12992-018-0358-5) contains supplementary material, which is available to authorized users.

Access to HIV-prevention in female sex workers in Ukraine between 2009 and 2017: Coverage, barriers and facilitators

“…Our results identified an encouraging trend underscoring the importance of facilitators that operate on a community organisation level. In congruence with previous literature [17,[57][58][59], our findings strongly imply that collective agency of the Ukrainian FSW community via NGO membership largely facilitated access to the basic PP, as most PP recipients were clients of an NGO. Knowledge of HIV transmission routes was higher amongst PP recipients across all years, which may be attributable to consultations with social workers and the distribution of HIV awareness-raising materials, two components that were consistently included in the PP.…”

“…We observed a high level of stigma (54%) amongst PP recipients who feared their HIV status being exposed in 2009, however we did not observe meaningful between-group differences. Previous studies have deemed stigma to be one of the most salient barriers to HIV prevention [17,52,53], fuelled by other factors on different structural levels such as criminalisation [15,[54][55][56] on the macrostructural level and a lack of community empowerment on the community organisational level [17,57,58].…”

Access to HIV-prevention in female sex workers in Ukraine between 2009 and 2017: coverage, barriers and facilitators

“…We observed a high level of stigma (54%) amongst PP recipients who feared their HIV status being exposed in 2009, however we did not observe meaningful between-group differences. Previous studies have deemed stigma to be one of the most salient barriers to HIV prevention [17, 52, 53], fuelled by other factors on different structural levels such as criminalisation [15, 54-56] on the macrostructural level and a lack of community empowerment on the community organisational level [17, 57, 58].…”

Structural determinants of HIV/STI prevalence, HIV/STI/sexual and reproductive health access, and condom use among immigrant sex workers globally

“…Qualitative studies revealed economic marginalization (i.e. accepting increased pay for unprotected sex) [40,46] (Box 5, Supplementary Digital Content, http:// links.lww.com/QAD/C119), language barriers [41], and fear of police using condoms as evidence [29,41] as macrostructural barriers to condom negotiation and use. In work venues, gaps in condom availability [29], client/aggressor violence [46], and stealthy condom removal by clients [31,41,51] posed pervasive barriers to condom use.…”