“Feeling clean”: stigma and intravaginal practices among female entertainment workers in Cambodia

Background Intravaginal practices (IVPs), methods used by women most often to manage vaginal hygiene and address perceived disruptions to vaginal health, may increase the risk of contracting human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). This qualitative study explores the social, professional, and peer context surrounding IVPs, the experiences of self-cleaning or getting cleaned from a health professional, and the perceived impacts of IVPs among female entertainment workers (FEWs) in Cambodia. Methods In 2017, we conducted 27 focus group discussions from four provinces, and 16 follow-up semi-structured in-depth interviews with purposively selected participants in two provinces. Data collection occurred over three weeks, with concurrent data transcription and translation. The data from the transcripts were analyzed using Dedoose, an online, open-access qualitative analysis software. Two researchers independently labeled sections of transcripts associated with broader categories and subcategories based on the initial content analysis matrix and created codes. This process continued iteratively until a final coding schema and conceptual model was created. Results We found that IVPs are widely practiced among FEWs in Cambodia and are associated with internalized and enacted stigma. Stigma was an overarching theme that impacted the sub-themes of (1) messages about cleaning, (2) the cleaning process, and (3) the impact of cleaning. Experiences of enacted stigma and internalized stigma permeated conversations about IVP, including feeling pressured by peers to keep themselves clean, practicing internal cleaning after transactional sex, and being called dirty by health providers. Conclusions FEWs who practice IVP talk about it in the context of their lived experiences stigma and discrimination. Highly stigmatized practices such as IVP among FEWs may benefit from a harm reduction approach that emphasizes positive changes without judgment, coercion, or discrimination.

A Mobile Intervention to link Female Entertainment Workers in Cambodia to Health and Gender-based Violence Services: Randomized Controlled Trial (Preprint)

BACKGROUND Female entertainment workers (FEWs) in Cambodia experience a greater prevalence of human immunodeficiency virus (HIV), other sexually transmitted infections (STIs), psychological distress, substance use, and gender-based violence (GBV) than the general population. Reaching FEWs with health education and linking them to services has been difficult because of their hidden and stigmatized status. OBJECTIVE This study evaluates the Mobile Link intervention, aiming to improve FEWs’ health by connecting them to health services using automated twice-weekly short message services and voice messages with health information and direct links to outreach workers. METHODS The randomized controlled trial was conducted between March 2018 and June 2019. We employed a stratified random sampling method to select participants from five study sites. Initially, we randomly selected 600 participants from a list of 4000 FEWs by age group and study site using a random number generator and enrolled them in person. The primary outcome measures included self-reported HIV and STI testing, condom use, and contraceptive use, which we assessed through face-to-face structured interviews. We also measured secondary outcomes, including contact with outreach workers, escorted referral services use, forced drinking, and GBV experiences. Intervention effects were modeled using repeated measures, multilevel mixed-effects logistic regression. RESULTS We included 218 FEWs in intervention and 170 FEWs in control arms in the per-protocol analyses after 212 removing dropouts. Evidence of positive intervention effects was detected for the following secondary outcomes: contacting an outreach worker (group by time 2 AOR 3.29, 95% CI 1.28–8.47), receiving an escorted referral (group by time 2 AOR 2.86, 95% CI 1.09–7.52; group by time 3 AOR 8.15, 95% CI 1.65–40.25), and never being forced to drink at work (group by time 3 AOR 3.95, 95% CI 1.62–9.60). No significant differences between intervention and control groups over time were observed for any primary outcomes in the fully adjusted models. CONCLUSIONS The Mobile Link intervention did not show an effect on the primary outcomes but effectively connected FEWs with outreach workers and escorted referrals. Reductions in forced drinking at work were also significantly more extensive in the intervention group than the control group. Longer-term messaging may increase access to services and impact FEWs’ health outcomes in the future. CLINICALTRIAL Clinical trials.gov, NCT03117842 . Registered 31 March 2017, https://clinicaltrials.gov/ct2/show/NCT03117842?term=NCT03117842&rank=1 INTERNATIONAL REGISTERED REPORT RR2-10.1186/s13063-018-2614-7

Improving Access to Health and Gender-based Violence Services for Female Entertainment Workers in Cambodia: Findings From the Mobile Link Randomized Controlled Trial

Background: Female entertainment workers (FEWs) in Cambodia experience a greater prevalence of human immunodeficiency virus (HIV), other sexually transmitted infections (STIs), psychological distress, substance use, and gender-based violence (GBV) than the general population. Reaching FEWs with health education and linking them to services has been difficult because of their hidden and stigmatized status. This study evaluates the Mobile Link intervention, aiming to improve FEWs’ health by connecting them to existing HIV, sexual and reproductive health, and GBV services using short message services and voice messages.Methods: This randomized controlled trial was conducted between March 2018 and June 2019. We employed a stratified random sampling method to select participants from five study sites. Initially, we randomly selected 600 participants from a list of 4000 FEWs by age group and study site and randomized them to intervention or standard care control arms. The primary outcome measures included self-reported HIV and STI testing, condom use, and contraceptive use. We also measured secondary outcomes, including contact with outreach workers, escorted referral services use, forced drinking, and GBV experiences. Intervention effects were modeled using repeated measures, multilevel mixed-effects logistic regression.Results: We included 218 FEWs in intervention and 170 FEWs in control arms in the per-protocol analyses after removing dropouts. Evidence of positive intervention effects was detected for the following secondary outcomes: contacting an outreach worker (group by time 2 AOR 3.29, 95% CI 1.28–8.47), receiving an escorted referral (group by time 2 AOR 2.86, 95% CI 1.09–7.52; group by time 3 AOR 8.15, 95% CI 1.65–40.25), and never being forced to drink at work (group by time 3 AOR 3.95, 95% CI 1.62–9.60). No significant differences between intervention and control groups over time were observed for any primary outcomes in the fully adjusted models.Conclusions: The Mobile Link intervention effectively connected FEWs with outreach workers and escorted referrals. Reductions in forced drinking at work were also significantly more extensive in the intervention group than the control group. Longer-term messaging may increase access to services and impact FEWs’ health outcomes in the future.Trial registration: Clinical trials.gov, NCT03117842 . Registered 31 March 2017, https://clinicaltrials.gov/ct2/show/NCT03117842?term=NCT03117842&rank=1

Risk factors of HIV infection among female entertainment workers in Cambodia: Findings of a national survey

Background Cambodia has been well recognized for its success in the fight against the HIV epidemic. However, challenges remain in eliminating HIV infections in key populations, including women working in entertainment establishments, such as massage parlors, karaoke bars, or beer gardens. This study explored the prevalence of HIV and identified factors associated with HIV infection among female entertainment workers (FEWs) in Cambodia. Methods This national biological and behavioral survey was conducted in 2016 in Phnom Penh and 17 provinces. We used a two-stage cluster sampling method to recruit FEWs for HIV testing performed on-site and face-to-face interviews using a structured questionnaire. We investigated factors associated with HIV infection using multiple logistic regression. Results This study included 3149 FEWs with a mean age of 26.2 years (SD 5.7). The adjusted prevalence of HIV was 3.2% (95% CI 1.76–5.75). In the multiple logistic regression model, the odds of HIV infection were significantly higher among FEWs in the age group of 31 to 35 (AOR 2.72, 95% CI 1.36–8.25) and 36 or older (AOR 3.62, 95% CI 1.89–10.55); FEWs who were not married but living with a sexual partner (AOR 3.00, 95% CI 1.16–7.79); FEWs who had at least ten years of formal education (AOR 0.32, 95% CI 0.17–0.83); FEWs who reported having abnormal vaginal discharge (AOR 3.51, 95% CI 1.12–9.01), genital ulcers or sores (AOR 2.06, 95% CI 1.09–3.17), and genital warts (AOR 2.89, 95% CI 1.44–6.33) in the past three months; and FEWs who reported using illicit drugs (AOR 3.28, 95% CI 1.20–4.27) than their respective reference group. The odds of HIV infection were significantly lower among FEWs working in karaoke bars (AOR 0.26, 95% CI 0.14–0.50) and beer gardens (AOR 0.17, 95% CI 0.09–0.54) than among freelance FEWs. Conclusions The prevalence of HIV among FEWs in Cambodia remains much higher than that in the general population. These findings indicate that differentiated strategies to address HIV and other sexually transmitted infections should be geared towards FEWs working as freelancers or in veiled entertainment venues such as massage parlors and freelance sex workers. Prevention efforts among venue-based FEWs should be sustained.

Gender-Based Violence and Factors Associated with Victimization among Female Entertainment Workers in Cambodia: A Cross-Sectional Study

Women working in the entertainment industry are confronted with various forms of gender-based violence (GBV). However, their vulnerability remains understudied, particularly in resource-limited settings. This study aims to examine the prevalence of GBV among female entertainment workers (FEWs) in Cambodia and identify factors associated with victimization. We conducted a cross-sectional study in November 2018 for the impact evaluation of a randomized controlled trial. We used a stratified random sampling method to recruit 600 FEWs from different entertainment venues in the capital city and three other provinces. Female data collectors administered a structured questionnaire, and we performed multiple logistic regression analyses. Of the total, 60.5% had experienced a form of GBV during their lifetime; of whom, 37.5% experienced the GBV in the past 6 months. The prevalence of emotional abuse, forced substance use, physical abuse, and forced sex was 51.5%, 25.0%, 20.6%, and 2.9%, respectively. Forced substance use and forced sex were mainly perpetrated by clients, physical abuse by intimate partners, and emotional abuse by others such as entertainment establishment owners or managers. FEWs victimized by clients (relative risk ratio [RRR] = 0.19, 95% confidence interval [CI] = [0.07, 0.53]) and others (RRR = 0.11, 95% CI = [0.03, 0.44]) were less likely to be married compared with victims of intimate partner violence. Factors associated with sexual harassment were working in beer gardens (adjusted odds ratio [aOR] = 2.39, 95% CI = [1.20, 4.73]) and restaurants/cafés (aOR = 1.65, 95% CI = [1.01, 2.69]), and having higher acceptance of violence against women (aOR = 1.12, 95% CI = [1.01, 1.24]). FEWs in Cambodia experience high levels and unique forms of GBV as they are confronted with different types of perpetrators. Interventions need to be tailored to fit the specific needs of FEWs. Interventions aimed at reducing client-perpetrated violence should specifically focus on forced substance use and forced sex, while physical abuse by intimate partners should also be addressed.

Female Entertainment Workers and Condom Use Negotiation in Post-100% Condom Use Era Cambodia

Beyond the monopoly environment of the early 100% Condom Use Program in Cambodia, less is known about how current female entertainment workers negotiate condom use on their own, and what factors impact that negotiation. This study aims to understand the experiences of current female entertainment workers in negotiating condom use with clients in Cambodia. Data collection occurred over a period of 3 weeks (August–September 2017) with concurrent data transcription and translation. A total of 27 focus group discussions (FGDs) were conducted in the following groups: pilot FGD (5), karaoke bar (5), massage parlor (5), beer garden (5), on-call sex workers (3), cross-venue groups exploring parenting issues (2), and street-based sex workers (2). Female entertainment workers experience a range of control over negotiating condom use with clients. Participants reported times when they were able to take direct action and successfully insist on condom use, times when they agreed to participate in condomless sex for money in the face of economic insecurity, and times when male clients sabotaged their attempts to negotiate condom use with tricks, verbal threats or threats of violence. These experiences are influenced by alcohol use, economic shocks, trust between partners, and experiences with side effects. Our findings support the development of policies that re-invigorate the structural-level condom promotion programs while also acknowledging the many individual-level factors that shape condom use such as alcohol consumption, economic insecurity, trust, and side effects.