Factors associated with sex work among at-risk female youth in Cambodia: a cross-sectional study

Development and validation of contextual measures of sexual harassment perceptions, experiences, and coping for women employees in Ethiopian hospitality workplaces

Background

Sexual harassment among female employees in the hospitality industry is a complex phenomenon, and it has ramifications for employment, psychological, physical, and reproductive health. Nevertheless, our interpretation is constrained by a lack of agreement on its definition and measurement. As a result, hospitality workplaces require accurate tools that provide a detailed understanding of sexual harassment and inputs for action to limit adverse outcomes. Thus, this study aimed to develop a reliable and valid measure of female hospitality employees’ perceptions, experiences, and coping features concerning sexual harassment.

Methods

Item development, scale development, and scale evaluation were all parts of the design process. Following a round of feedback from the expert group, qualitative results, and a comprehensive literature review on related themes, item pools were created for the first version of the questionnaire. Pre-testing, survey administration, item reduction, and transformation of extracted latent factors of individual items into a unified and measurable construct were also performed. Field testing included five cognitive interviews with women who had experienced sexual harassment, a pre-test study of 30 women, and a survey of 345 women who worked in hospitality workplaces. Finally, tests for dimensionality, reliability, and validity were conducted.

Results

In Bahir Dar, Ethiopia, 345 women working in the hospitality workplaces, with a mean age of 24.31 ± 4.30 years, took part in this study. The robust maximum likelihood estimation approach was used to do confirmatory factor analysis. The model’s stability was determined by calculating the goodness of fit and the factorial invariance. Subsequently, the validity was confirmed. The findings supported the validity and reliability of the questionnaires designed for the target group. Therefore, the questionnaires can be used as research instruments.

Conclusions

The sexual harassment perceptions, experiences and coping scales provide a locally verified method for assessing sexual harassment in Ethiopia by government authorities and local and international non-governmental organisations, which aid in providing necessary services and the evaluation of efforts aimed at improving workplace safety, workplace health, and psychosocial well-being.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00828-z.

Using Social Ecological Theory to Identify Factors Associated With Risky Sexual Behavior in Cambodian Adolescent Girls and Young Women Aged 10 to 24 Years: A Systematic Review

There is an increase in risky sexual behavior (RSB) in Cambodian female youth aged 10 to 24 years, which can contribute to detrimental sexual and reproductive health due to the increased risk of acquiring sexually transmitted infections, unintended pregnancies, or abortions. Bronfenbrenner’s social ecological model was used to identify factors at personal, microenvironment, and macroenvironment levels potentially associated with RSB. A systematic literature review employing PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted to search 8 databases for articles published between 1994 and 2019. A risk of bias tool was applied for methodological quality of the 4 included studies. RSB is associated with multiple factors including sexual debut at young age, alcohol and substance abuse, multiple partners, living away from parents or orphan status, peer delinquency, non-use of condoms by partners, transactional sex, low education and socioeconomic status, and no access to sexual and reproductive health services. Multipronged preventive strategies operating at different levels are recommended in terms of including sex education and increasing reproductive health literacy programs at the schools and community programs for safe sex, condom use and sexual negotiation skills, and access to modern contraceptive methods.

Psychosocial correlates of self-reported HIV among youth in the slums of Kampala

Background

Human immunodeficiency virus (HIV) rates are high in Uganda (6.7%), and rates are especially high among at-risk groups such as youth living in the slums of Kampala, Uganda. The objective of this study was to assess the psychosocial correlates, particularly alcohol use, associated with HIV among youth living in the slums of Kampala, Uganda.

Methods

Analyses are based on cross-sectional survey data collected in Spring of 2014. Participants comprised a convenience sample (N = 1134) of urban service-seeking youth living on the streets or in the slums, 12–18 years of age who were participating in a Uganda Youth Development Link drop-in center (56.1% female and 43.9% male). Chi-Square Tests were used to determine differences in the proportions of alcohol use patterns between self-reported HIV-positive and HIV-negative youth. Bivariate and multivariable logistic regression were conducted to determine the associated risk factors with self-reported HIV. Institutional Review Board approvals were obtained from the Georgia State University and the Uganda National Council for Science and Technology.

Results

Among the total sample of youth (N = 1103), 10.5% (n = 116) reported being HIV-positive. There were statistically significant differences between HIV-positive and HIV-negative youth on ever living on the streets (χ² =10.14, df = 1, p = 0.002), past 12-month alcohol use (χ² =16.38, df = 1, p < .0001), ever having sexual intercourse (χ² =14.52, df = 1, p = 0.0001), ever engaging in sex work (χ² =13.19, df = 1, p = 0.0003), inconsistent condom use in the past 3 months (χ² =5.03, df = 1, p = 0.03), and ever being raped (χ² =15.29, df = 1, p < 0.0001). A higher percentage of HIV-positive youth were classified as problem drinkers, defined by the CAGE scores (21.6% vs. 13.9%, respectively). In the multivariable analysis, previously being raped (OR: 1.70; 95% CI: 1.02, 2.83) and alcohol use without problem drinking (OR: 2.14; 95% CI: 1.24, 3.69) was associated with HIV.

Conclusion

Youth living in the slums of Kampala, Uganda have a high prevalence of HIV. These youth are in dire need of interventions which address both alcohol use behaviors and sexual risk behaviors to reduce further complications of their existing health conditions, including HIV.

Using participatory methods to build an mHealth intervention for female entertainment workers in Cambodia: the development of the Mobile Link project

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.

A generation at risk: a cross-sectional study on HIV/AIDS knowledge, exposure to mass media, and stigmatizing behaviors among young women aged 15-24 years in Ghana

HIV/AIDS stigmatizing behaviors are a huge barrier to early detection and treatment of individuals with the AIDS virus. HIV/AIDS stigma and related consequences are debilitating, especially for vulnerable populations. This study sought to assess whether young women's HIV/AIDS knowledge levels and exposure to mass media (television and radio) have an influence on their stigmatizing behaviors and role as agents of stigma towards individuals living with HIV and AIDS. The data used for this study originated from the Ghana Multiple Indicator Cluster Survey 2011. Binary and multiple (stepwise) logistic regression analyses were used to examine the associations between HIV/AIDS knowledge, frequency of exposure to mass media, and HIV/AIDS stigmatizing behaviors among young women aged 15-24 years in Ghana. Of the 3573 young women, 80% of 15-19-year-olds and 76% of 20-24-year-olds had at least one stigmatizing behavior towards persons living with HIV/AIDS (PLHA). Young women with increased knowledge regarding HIV/AIDS and frequent exposure to mass media (television and radio) had lesser tendency to stigmatize or act as agents of stigma towards PLHA (proportion with at least one stigmatizing behavior per subgroup - HIV/AIDS knowledge: those with highest knowledge score 579 [70.1%], those with lowest knowledge score 28 [90.3%]; mass media: those with daily exposure 562 [73.4%], those not exposed at all 249 [89.2%]). There was a graded negative 'exposure-response' association between the ranked variables: HIV/AIDS knowledge, mass media, and HIV/AIDS stigmatizing behaviors. The significant inverse association between HIV/AIDS knowledge, frequency of exposure to mass media, and HIV/AIDS stigmatizing behaviors persisted even after adjusting for all other covariates in the multiple logistic regression models. It is extremely important to increase HIV/AIDS-related knowledge and reduce stigma among young women in Ghana through targeted HIV/AIDS factual knowledge transfer. The use of mass media for communication of issues regarding HIV/AIDS, its mode of transmission, and associated stigma should be emphasized among women in Ghana.

Mobile Link - a theory-based messaging intervention for improving sexual and reproductive health of female entertainment workers in Cambodia: study protocol of a randomized controlled trial

BACKGROUND

In 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.

METHODS

A 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).

DISCUSSION

If 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 REGISTRATION

Clinical trials.gov, NCT03117842 . Registered on 31 March 2017.

Youth paying for sex: what are the associated factors? Findings from a cross-sectional study in Cambodia

BACKGROUND

At-risk male youth in Cambodia who purchase sex are at greater risk for HIV compared to the general population. Factors associated with paying for sex among youth are poorly studied, both globally and in Cambodia. This study aimed to identify specific factors associated with transactional sex with women among most-at-risk male youth in Cambodia.

METHODS

This cross-sectional questionnaire survey was conducted with 405 sexually active male youth aged 16-24 recruited at 'hotspots' in the capital city of Phnom Penh and seven provinces. We collected data on demographic factors, sexual behaviors, HIV testing and other potential factors. Multivariable logistic regression analysis was used to identify factors associated with transactional sex.

RESULTS

In total, this study included 405 male youth with a mean age of 21.3 (SD = 2.2). Of the total respondents, 82.5% (n = 334) have ever paid for sex. After controlling for potential confounding, participants who purchased sex in the last 12 months remained significantly more likely to be older than 18 (AOR = 3.60, 95% CI = 1.26-10.62), reside in an urban area (AOR = 2.29, 95% CI = 1.24-4.20), never have been married (AOR = 9.58, 95% CI = 4.34-21.12), spend less than 2.55 USD per day (AOR = 2.22, 95% CI = 1.12-4.40), and have had more than 4.6 sexual partners in the past year (AOR = 16.73, 95% CI = 4.71-59.36).

CONCLUSIONS

This study highlights the high proportion of Cambodian male youth who paid for sex and the potential challenges to addressing this issue. While the majority of HIV prevention interventions surrounding sex work are aimed at female sex workers themselves, targeting the demand side of sex work, particularly the local demand, may be an important next step towards a sustainable HIV prevention.

Mobile phone use among female entertainment workers in Cambodia: an observation study

BACKGROUND

Text or voice messages containing health behavior change content may be an inexpensive, discreet, sustainable and scalable way to reach populations at high risk for HIV. In Cambodia, one of the important high-risk populations is female entertainment workers (FEWs). This ethnographic study aims to explore typical phone use, examining patterns and behaviors that may influence the design of future mHealth interventions.

METHODS

The study consisted of one 8-hour non-participant observation session for 15 randomly sampled FEWs. Observations focused on capturing normal daily use of mobile devices. Observation checklists were populated by observers during the observations and a post-observation survey was conducted. Findings were discussed with Cambodian HIV outreach workers and HIV research fellows and their interpretations are summarized below.

RESULTS

In this ethnographic study, all 15 participants made calls, checked the time and received research-related texts. More than half (n=8) of the participants engaged in texting to a non-research recipient. About half (n=7) went on Facebook (FB) and some (n=5) listened to music and looked at their FB newsfeed. Fewer played a mobile game, posted a photo to FB, went on YouTube, used FB chat/messenger, watched a video on FB, played a game on FB, used FB call/voice chat, looked at their phone's background or used the LINE app. Fewer still shared their phones, left them unattended, added airtime or changed their SIM cards. When participants received a research text message, most did not share the text message with anyone, did not ask for help deciphering the message and did not receive help composing a response. Notable themes from observer notes, HIV outreach workers and researchers include reasons why phone calls were the most frequent mode of communication, examples of how cell phone company text messages are used as a form of behavior change, literacy as a persistent barrier for some FEWs, and FEWs' high interest in receiving health-related messages and less concern about privacy and phone-sharing issues than expected.

CONCLUSIONS

This study suggests texting is a part of normal phone use although not as frequently used as voice calls or Facebook. Despite the less frequent use, FEWs were able to send and receive messages, were interested in health messages and were not overly concerned about privacy issues. Texting and voice messaging may be useful tools for health behavior change within the FEW population in Cambodia.

Prevalence of HIV and Associated Risks of Sex Work among Youth in the Slums of Kampala

Purpose. The purpose of this study is to examine the prevalence of and risk factors for engaging in sex work among youth living in Kampala, Uganda. Methods. Analyses are based on a cross-sectional study (N = 1,134) of youth aged 12-18 years, living in the slums of Kampala, conducted in Spring of 2014. The analytic sample consisted of only sexually active youth (n = 590). Youth who reported engaging in sex work were compared to youth who did not report sex work. Multivariable analyses were conducted to examine factors associated with sex work. Results. Among the youth who had ever had sexual intercourse (n = 590), 13.7% (n = 81) reported engaging in sex work. Self-reported HIV prevalence was 13.9% among the total sample (n = 81) and 22.5% (n = 18) among youth engaged in sex work. Engaging in sex work was associated with being female (AOR 10.4; 95% CI: 3.9, 27.4), being an orphan (AOR 3.8; 95% CI: 1.7, 8.4), ever drinking alcohol (AOR 8.3; 95% CI 3.7, 19.0), and experiencing any rape (AOR 5.3; 95% CI: 2.9, 9.5). Discussion. The reported prevalence of sex work is high among youth in the slums of Kampala and is associated with high HIV prevalence, ever drinking alcohol, previously being raped, and being an orphan.