Recomendados
Recomendados
Mais conteúdo relacionado
Mais procurados
Mais procurados (20)
Semelhante a Empowerment with Sex Workers for HIV Prevention in India
Semelhante a Empowerment with Sex Workers for HIV Prevention in India (20)
Mais de The Bixby Center on Population and Reproductive Health
Mais de The Bixby Center on Population and Reproductive Health (20)
Último
Último (20)
Empowerment with Sex Workers for HIV Prevention in India
- 1. Opening Slide (change photo) GlobalHealth Institute Dallas Swendeman, Ph.D., M.P.H. Co-Director, Center of Expertise on Women’s Health, Gender & Empowerment, University of California Global Health Institute (UCGHI) Associate Professor, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA Affiliated Faculty, Department of Epidemiology, UCLA Fielding School of Public Health
- 3. 6/3/19 3 Women’s Health, Gender and Empowerment COE Establishing UCGHI as global health thought leaders COE Leadership Team Co-Directors: Ndoal Prata, UCB Dallas Swendeman, UCLA Directors of Programs: Melissa Smith, UCSB, Education & Training Ushma Upadhyay, UCSF, Research & Dissemination Jennifer Wagman, UCSD, Community Engagement & Signature Project
- 4. Durbar - A Community-led Structural Intervention
- 5. Dr. Jana, an occupational health doctor, negotiated a contract with political parties & police to support sex workers to use condoms, advocate for their rights and support their families High status advocate Removed structural barriers Changed social group relations Built skills & competencies
- 6. Durbar - The Sonagachi Project • W.H.O. Model Program • Model for Project Avahan • Gates Foundation funded scale-up of HIV prevention in India
- 7. Kolkata’s Sonagachi “red light area” - 2001 Timeline of Research & Training Activities 1998-2003: Replication Trial 2005-2007: Mixed-methods Rx - In-depth interviews - Random Household Survey 2007: AIIS Fellowship - Participant-observation of social movement aspects of Durbar - Statistical analyses for dissertation 2007: Internship program - UPENN Social Work Service- Learning summer course 2010: Indo-US Bilateral R21 - ICMR & NIH collab., funded 2012 - Pilot RCT on Mobile Tech. for ART adherence 2017: PrEP Demonstration
- 8. Durbar Intervention Evolution W.H.O. Risk Appraisal - 1991 • Community mapping • Stakeholder analysis • Advocacy to implement • Risk behavior survey • Identify community leaders
- 9. Durbar - Intervention Evolution STD/HIV Intervention Project (SHIP) – 1992 •STI clinics for diagnosis, treatment & follow-up •Peer health educators •Social marketing •Stakeholder advocacy W.H.O. Risk Appraisal - 1991 • Community mapping • Stakeholder analysis • Advocacy to implement • Risk behavior survey • Identify community leaders
- 10. SHIP Did not address structural barriers or community priorities Contexts of Disempowerment Poverty Low status/value of girls & women Lack of economic opportunities Coercion, including in other work (domestic) Loss of male breadwinner
- 11. Durbar - Intervention Evolution STD/HIV Intervention Project (SHIP) – 1992 •STI clinics for diagnosis, treatment & follow-up •Peer health educators •Social marketing •Stakeholder advocacy Durbar Mahila Samanwaya Committee (DMSC / Durbar) - Sex Worker SHG – 1995 • Voice of Community • Organize & mobilize • Local chapters • Elected officers • Raise consciousness • Build community • Advocacy with SHIP W.H.O. Risk Appraisal - 1991 • Community mapping • Stakeholder analysis • Advocacy to implement • Risk behavior survey • Identify community leaders
- 12. Durbar - Intervention Evolution W.H.O. Risk Appraisal - 1991 • Community mapping • Stakeholder analysis • Advocacy to implement • Risk behavior survey • Identify community leaders STD/HIV Intervention Project (SHIP) – 1992 •STI clinics for diagnosis, treatment & follow-up •Peer health educators •Social marketing •Stakeholder advocacy Durbar Mahila Samanwaya Committee (DMSC / Durbar) - Sex Worker SHG – 1995 • Voice of Community • Organize & mobilize • Local chapters • Elected officers • Raise consciousness • Build community • Advocacy with SHIP USHA Multi-Purpose Micro-Finance Cooperative • Secure savings & lending • Reduce theft & extortion • Peer field “tellers” • Micro–enterprise loans • Profits fund community priority projects
- 13. “Sonagachi/Durbar” Empowering Interventions Community-Led Projects Micro- Finance Community Org. Peer CHWs External Change Agents - S.H.I.P Community-led Structural Intervention
- 14. Participation, Task Sharing, Partnering & Ownership by Sex Workers Empowerment Peer Educators Clinic Assistants Condom Social Marketers DMSC Chapter Officers Self-regulatory board Reps Clinic Assistants Diverse Work Roles for “CHWs” Micro-banking Reps
- 16. School for Sex Workers’ children
- 17. Empowerment from Development Investment Perspective Agency -individual -collective Resources -economic -social -health Achieve- ments -outcomes * N. Kabeer (1999). Resources, Agency, Achievements: Reflections on the Measurement of Women's Empowerment. Development and Change, 30: 435- 464.
- 19. Kar- Common Strategies of Women’s Empowerment Programs •Empowerment training & leadership dev. •Media use, support & advocacy •Public-education & participation •Organizing partnership: associations, cooperatives & coalitions •Work/job training & micro-finance - Econ •Enabling services & assistance •Rights protection & social action/reform Kar, S.B., Pascual, C.A., & Chickering, K.L. (1999). Empowerment of women for health promotion: A meta-analysis. Social Science & Medicine, 49, 1431-1460.
- 20. Sex Workers show solidarity after 9/11 Durbar - a Social Movement of Sex Workers
- 21. 21 Social Movement, Identity & Behaviors The Durbar “Master Frame” § “Sex work is valid work” § “Sex workers are human beings” § “Sex workers deserve to protect themselves” Designed to shift self-perceptions: § from “prostitute,” “fallen woman,” “victim” § to “worker,” “human being,” “sister”
- 22. “Only rights can stop the wrongs” Employs rights-based frames: Human Rights • “Three R’s: Respect, (self) Reliance, Recognition” Worker’s Rights § HIV/STIs as occupational health & safety hazards • “Sex work is work, we demand worker’s rights” Women’s (& girls) Rights § empowerment • gender & class-based economic & social exclusion
- 23. Sex Worker or Prostitute… Do Labels matter?
- 24. 24 Social Movement, Identity & Behavior “Sex Worker” identity § Linked to constellation of behavioral expectations: • Negotiate condom use to protect self • Visit clinics & adhere to treatment • Solidarity with “sisters” • Self-reliance & Self-respect § Re-frames decision-making • Sex workers • Clients • Power Brokers (madams, police, political parties)
- 25. 25 UCLA Replication Study - Rationale High HIV prevalence among sex workers in Mumbai, Delhi, & Chennai § 50%-90% § ~ 10% in Calcutta May reflect the impact of the “Sonagachi Project.” § Condom use by sex workers rose from 3% to > 80% since established in 1992.
- 26. 26 Replication Study Rationale & Objective Little evidence under controlled conditions that Sonagachi Project is responsible for: § increased condom use § low HIV prevalence § community empowerment Sonagachi Project and UCLA collaborated on a replication study
- 27. Collaborative Replication Trial Brothel-based sex workers in “red light areas” Control (n=110) •STD Clinic Standard Care Site Assessments Baseline 5-month follow up 10-month follow up Interventio n (n=110) •STD Clinic Plus CLSI 15-month follow up Site Site Site
- 29. West Bengal
- 30. Study Sites
- 31. 31 Demographics Mean age 26 (range - 18 to 50) § 25% <=20 years, 25% >=30 years § Most working in sex work >7 years 3/4 self-employed § < 5 “Adhiya” (50/50 split) § 25% “Chukri” (Bonded) 1/2 partnered & have children § 1/3 married § 1/2 steady partner/boyfriend • 1/2 lived with husband or partner Low Literacy and Education § 11% primary education (only 2 secondary) § 74% illiterate Low substance use § 1/3 used alcohol, < 3% injected drugs
- 32. 32 HIV/STI Risk Almost all risk from vaginal sex § < 25% reported oral or anal sex Low substance use § 1/3 used alcohol § < 3% injected drugs High lifetime STI exposure § 60% exposed to Syphilis (VDRL test) § 40% sought treatment in past Low baseline STI prevalence § < 10% 1/2 reported some condom use § 40% every time (at baseline)
- 33. Figure 2. Percentage of condom use by intervention condition * Indicates a statistically significant intervention effect (p<0.05) based on the compariosn of slopes of the two groups over time. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Baseline Wave 1 Wave 2 Wave 3 Time points Percentageofcondomuse Intervention group Standard care group *
- 34. Indicators of “Empowerment” Knowledge & Attitudes -Know STD symptom -Condoms Prevent STDs -Condoms Prevent AIDS -At risk for STDs SEX BEHAVIOR SELF-EFFICACY -Most important condom decision maker -Can refuse a client -Ever refused a client WORKPlACE AUTONOMY -Can change contract ECONOMIC EMPOWERMENT -Save money -Other income MOBILITY & SOCIALIZING -Go with sex workers outside of work -Participate in social functions SEX WORKER 'CONSCIOUSNESS' -Sex work is valid work -Help other sex workers -Want more education/training -Disclosed profession
- 35. Summary Empowerment Index for HIV/STD Prevention 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Baseline Wave 1 Wave 2 Wave 3 Time points EmpowermentMeasure Intervention group Standard care group *
- 36. Condoms Prevent STDs 0 0.25 0.50 0.75 1.00 0.23 0.42 0.61 0.79 0.98 OVTIME STDPREVC INTV = 0 INTV = 1 23.2 (7.69, 70.3) 0.86 ^ (0.45, 1.64) 78% 88% 96% 96% 80% 72% 77% 77%
- 37. Most Important Condom Decision Maker 0 0.25 0.50 0.75 1.00 0.11 0.30 0.49 0.68 0.87 OVTIME CONDECD INTV = 0 INTV = 1 24.7 (11.0, 55.6) 0.3 (0.16, 0.63)
- 38. Verbal Abuse by Literate 0 0.25 0.50 0.75 1.00 0.082 0.253 0.423 0.594 0.764 OVTIME VERBABUS INTV = 0 INTV = 1 54 (6.14, 477) 1.9 (1.03, 3.51)
- 39. Predictors of Empowerment & Intervention Effect • Who benefited more from the intervention? • Lower education, not self-employed, and older women. • Educated and self-employed women had higher baseline empowerment • Less room to improve (“ceiling effects”) • Older women have lower baseline empowerment • Income decreases with age and is associated with higher baseline empowerment • Implications for negotiating power & alternative work • Male partners (“Babus”) associated with higher empowerment • Security, power, and negotiation
- 40. Opening Slide (change photo) GlobalHealth Institute Thank You!