Income loss and gender-based violence during the COVID-19 pandemic among female entertainment workers in Cambodia: a cross-sectional phone survey.

BACKGROUND: In Cambodia, female entertainment workers (FEWs) are disproportionately affected by global and local disasters, such as the COVID-19 pandemic. To prevent the spread of COVID-19, the government imposed tight restrictions, including closures of entertainment venues, such as karaoke bars, beer gardens, nightclubs, or massage parlors, leading FEWs to face economic and social disruptions. This study aims to assess the relationship between income loss during the pandemic and gender-based violence (GBV) among FEWs in Cambodia to inform future disaster response programs. METHODS: We conducted a phone survey in August 2021 with 369 randomly sampled FEWs from a national organization's email list. We used a structured questionnaire to ask the participants about job and income loss, food security, mental health, access to health services, and GBV. We fit a linear regression model to examine the differences in GBV experience between FEWs who lost all their income and those who lost partial income due to the COVID-19 pandemic. Key covariables comprised the number of dependents, smartphone ownership, internet access, food security, and mental health. Multivariable linear regression analysis was conducted. RESULTS: The mean age (31.6 vs. 30.6), years of formal education (6.3 vs. 6.3), marital status (24.2 vs. 23.8 never married), and the number of children (1.3 vs. 1.1) of women reporting having lost all income were not significantly different from those who experienced partial income loss. Overall, GBV experiences were significantly higher in FEWs who lost all income than in those who lost partial income (62.9% vs. 47.4%, p = 0.03). Controlling for the number of dependents, smartphone ownership, and food security, the adjusted odds ratio for GBV was significant in the adjusted model (AOR = 1.23 (1.08-1.40), p = 0.001) indicating that those who experienced total income loss were more likely to experience GBV than those who experienced partial income loss. In addition, they were significantly less likely to be food secure (p = 0.04), less likely to own a smartphone (p = 0.02), and had more dependents (p < 0.001). CONCLUSION: Disaster response programs should consider the implications of safety measures and government support for both formal and informal workers regarding safety, food access, and mental health support. Food assistance programs should target the most vulnerable informal sector workers during crises.

A Mobile Intervention to Link Young Female Entertainment Workers in Cambodia to Health and Gender-Based Violence Services: 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 abuse, and gender-based violence (GBV) than the general female population. Reaching FEWs with health education and linking them to services has been difficult because of their hidden and stigmatized status. OBJECTIVE: This study evaluated the efficacy of the Mobile Link intervention in improving FEWs' health by engaging and connecting them to existing HIV, sexual and reproductive health, and GBV services. METHODS: A randomized controlled trial was conducted between March 2018 and June 2019 in the capital city and 3 other provinces in Cambodia. FEWs in the intervention arm received automated twice-weekly Short Message Service messages and voice messages with health information and direct links to outreach workers. The control group received the existing standard care, including free HIV and STI counseling and testing and a toll-free helpline staffed by trained counselors. We used a stratified random sampling method to select participants from 5 study sites in the 4 selected provinces. Initially, we randomly selected 600 participants from a list of 4000 FEWs by age group (18-24 and 25-30 years) 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 assessed through a face-to-face structured interview. We also measured secondary outcomes, including contact with outreach workers, escorted referral service use, forced drinking, and GBV experiences. Intervention effects were modeled using repeated measures, multilevel mixed-effects logistic regression. RESULTS: A total of 1118 participants were recruited and enrolled in the study. We included 218 FEWs in the intervention arm and 170 FEWs in the control arm in the per protocol analyses after removing 730 dropouts. Evidence of positive intervention effects was detected for the following secondary outcomes: contacting an outreach worker (at 30 weeks: adjusted odds ratio [AOR] 3.29, 95% CI 1.28-8.47), receiving an escorted referral (at 30 weeks: AOR 2.86, 95% CI 1.09-7.52; at 60 weeks: AOR 8.15, 95% CI 1.65-40.25), and never being forced to drink at work (at 60 weeks: AOR 3.95, 95% CI 1.62-9.60). Over time, no significant differences between intervention and control groups 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 but did not show an effect on primary outcomes. Reduced forced drinking at work was also significantly more extensive in the intervention group than in the control group. Longer-term messaging may increase access to services and impact FEWs' health outcomes in the future. TRIAL REGISTRATION: Clinicaltrials.gov NCT03117842; https://clinicaltrials.gov/ct2/show/NCT03117842. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-018-2614-7.

"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.

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.

"We Cannot Avoid Drinking": Alcohol Use among Female Entertainment Workers in Cambodia.

Background: Female entertainment workers (FEWs) in Cambodia work in predominantly alcohol-based 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.

Factors associated with condom use with non-commercial partners among sexually-active transgender women in Cambodia: findings from a national survey using respondent-driven sampling.

BACKGROUND: Globally, the prevalence of HIV among transgender women is much higher than that of the general adult population. This can be explained by the persistently low rate of consistent condom use among this population. This study was therefore conducted to explore factors associated with consistent condom use among sexually-active transgender women in Cambodia, specifically with their non-commercial partners. METHODS: Data used for this study were collected as part of the National Integrated Biological and Behavioral Survey 2016. Participants were recruited from the capital city of Phnom Penh and 12 other provinces with high burden of HIV using the Respondent-Driven Sampling (RDS) method. Face-to-face interviews were conducted using a structured questionnaire. Weighted multivariate logistic regression analysis was conducted to explore independent factors associated with consistent condom use. RESULTS: This study included 1202 transgender women who reported having anal sex with at least one male partner not in exchange for money or gifts in the past three months. The mean age of the participants was 26.0 (SD = 7.0) years. Of the total, 41.5% reported always using condoms with male non-commercial partners in the past three months. After adjustment, the likelihood of consistent condom use was significantly higher among participants who resided in an urban community (AOR = 1.7, 95% CI = 1.1-2.6), had attained at least 10 years of formal education (AOR = 1.8, 95% CI = 1.2-2.7), perceived that they were likely or very likely to be HIV infected (AOR = 2.9, 95% CI = 2.0-4.1), reported drinking alcohol two to three times per week (AOR = 3.1, 95% CI = 1.1-8.3), reported using amphetamine-type stimulants (AOR = 1.9, 95% = 1.1-3.8) or other drugs (AOR = 7.6, 95% CI = 1.5-39.5), and reported inconsistent condom use with male commercial partners in the past three months (AOR = 4.3, 95% CI = 1.8-10.4) compared to that of their respective reference group. CONCLUSIONS: This study confirms the low rates of condom use, particularly in non-commercial relationship, among transgender women in Cambodia. To address these concerns, efforts towards education about effects of multiple, concurrent relationships, and inconsistent condom use should be reinforced among transgender women.

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.

Prevalence of and factors associated with utilization of herbal medicines among outpatients in primary health centers in Cambodia.

BACKGROUND: Traditional, complementary and alternative medicine (TCAM) is seen as a way to provide healthcare in both developed and developing countries across the world. In Cambodia, there is a long tradition of using TCAM. However, scant studies have been conducted on the extent of Cambodian TCAM use and how it interacts with allopathic health care to date. In this study, we examined the prevalence of and factors associated with utilization of herbal medicines among patients with chronic diseases in primary health care settings in Cambodia. METHODS: A cross-sectional survey was conducted in 2015 with outpatients receiving treatment and care for chronic diseases in two urban and two rural primary health centers purposively selected from Phnom Penh, Kampong Cham and Siem Reap. Every eligible patient was randomly selected at the health centers using a systematic sampling procedure. I-CAM-Q was used to measure TCAM use. A multivariate logistic regression model was constructed to identify factors associated with herbal medicine use. RESULTS: In total, 1602 patients were included in this study, of whom 77.7% were female, and 51.2% were recruited from urban primary health centers with a mean age of 46.5 years (SD = 15.2). Of total, 27.0% reported at least one consultation with a TCAM provider in the past 12 months. The most common modality of TCAM used was herbal medicine (89%). Herbs were obtained at drug or folk stores (36.9%), from herbalists directly (28.5%) or from their own gardens (18.6%). Of herb users, 55.2% reported that herbs were somewhat helpful. After adjustment, herb users were significantly more likely to be female (AOR = 1.42, 95% CI = 1.12-2.67), have completed less schooling (AOR = 0.66, 95% CI = 0.45-0.96), were unemployed or homemakers (AOR = 0.23, 95% CI = 0.13-0.52) and have a gastrointestinal illness (AOR = 0.49, 95% CI = 0.39-0.62). CONCLUSIONS: Herbal medicines are broadly used among chronic disease patients in Cambodia. Understanding TCAM use in the general population will support health care practitioners and policy makers to make informed decisions about the use of TCAM. Integration of TCAM into the primary health system should be further explored.

Sex with sweethearts: Exploring factors associated with inconsistent condom use among unmarried female entertainment workers in Cambodia.

BACKGROUND: Despite the success in promoting condom use in commercial relationships, condom use with regular, noncommercial partners remains low among key populations in Cambodia. This study explores factors associated inconsistent condom use with sweethearts among unmarried sexually active female entertainment workers (FEWs). METHODS: In 2014, the probability proportional to size sampling method was used to randomly select 204 FEWs from entertainment venues in Phnom Penh and Siem Reap for face-to-face interviews. Multivariate logistic regression analysis was conducted to examine independent determinants of inconsistent condom use. RESULTS: Of total, 31.4% of the respondents reported consistent condom use with sweethearts in the past three months. After adjustment, respondents who reported inconsistent condom use with sweethearts remained significantly less likely to report having received any form of sexual and reproductive health education (AOR = 0.49, 95% CI = 0.22-0.99), but more likely to report having been tested for HIV in the past six months (AOR = 2.19, 95% CI = 1.03-4.65). They were significantly more likely to report having used higher amount of alcohol in the past three months (AOR = 1.29, 95% CI = 1.01-1.99) and currently using a contraceptive method other than condoms such as pills (AOR = 4.46, 95% CI = 1.34-10.52) or other methods (AOR = 9.75, 95% CI = 2.07-9.86). CONCLUSIONS: The rate of consistent condom use in romantic relationships among unmarried FEWs in this study is considerably low. The importance of consistent condom use with regular, non-commercial partners should be emphasized in the education sessions and materials, particularly for FEWs who use non-barrier contraceptive methods.

Non-communicable diseases and related risk behaviors among men and women living with HIV in Cambodia: findings from a cross-sectional study.

BACKGROUND: There is a growing concern for an increasing burden of non-communicable diseases (NCDs) in people living with HIV. This concern is evident especially in developing countries where dietary and lifestyle risk factors associated with NCDs are becoming more prominent. This study explored the prevalence of diabetes mellitus, hypertension, and hyperlipidemia and related risk factors in men and women living with HIV in Cambodia. METHODS: This cross-sectional study was conducted among 510 adult people living with HIV randomly selected from one city and four provinces in Cambodia. A structured questionnaire was used to collect data on socio-demographic characteristics, health behaviors, medical history, and antiretroviral therapy (ART). Anthropometric and biological measurements were performed. Descriptive statistics were used to calculate proportions and means of the measured variables. An independent Student's t-test was used for continuous variables. Chi square test or Fisher's exact test was used for categorical variables to explore gender differences. RESULTS: Prevalence of diabetes mellitus, hypertension, and hyperlipidemia was 9.4, 15.1, and 33.7%, respectively. The prevalence of hyperlipidemia was significantly higher among men compared to women. Mean systolic and diastolic blood pressures were also significantly higher among men. Regarding risk factors, 17.3% of participants were overweight, and 4.1% were obese. Tobacco and alcohol use was common, particularly among men. Fruit and vegetable consumption was considerably low among both men and women. Physical activity levels were also low. About 40% of participants reported having a job that involved mostly sitting or standing; 46.3% reported engaging in moderate activities; and 11.8% reported engaging in vigorous activities during leisure time. A significantly higher proportion of men compared to women engaged in vigorous activities both at work and during leisure time. CONCLUSIONS: The prevalence of diabetes mellitus, hypertension, and hyperlipidemia among men and women living with HIV in Cambodia is considerably high. Related risk factors were also common. Given the comorbidity of NCDs and HIV, policy and programmatic interventions are required, including integration of NCD screening into HIV programs. Distinctions in the levels of diseases and in health behaviors between men and women suggest that interventions need to be tailor-made and gender-specific, targeting their respective diseases and behaviors.

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

In Cambodia, despite great achievements in reducing the prevalence of HIV in the general population, reducing new HIV infections among young at-risk women remains a challenge. This study was designed to examine the prevalence of risky behaviors of sexually active female youth in Cambodia and to explore risk factors associated with engagement in transactional sex. We surveyed sexually active female youth aged 10-24 enrolled at risk "hotspots" in eight provinces in Cambodia. We collected data on demographic factors, sexual behavior, and factors hypothesized to be associated with transactional sex. Multivariable logistic regression was used to identify associations between demographic and sexual behavior and transactional sex. Of the 280 respondents, the mean age was 21.2, and 48.1% had been paid for sex in the past year. After adjustment, at-risk females who were never have been married (adjusted odds ratio (AOR) 3.40, 95% confidence interval (CI) = 1.65-6.97), have completed less than 6 years of school (AOR 3.26, 95% CI = 1.60-6.66), have 1 or more parents who had died (AOR 4.34, 95% CI = 2.00-9.38), be a heavy alcohol drinker (AOR 3.58, 95% CI = 1.78-7.18), have used a condom with their boyfriend during last sexual encounter (AOR 3.50, 95% CI = 1.68-7.32), and have ever had an HIV test (AOR 3.51, 95% CI = 1.68-7.32) were more likely to engage in sex work. Our findings suggest that prevention strategies for female youth at risk of engagement in sex work should include upstream structural interventions that aim to encourage girls' education and empowerment. In addition, tailored sex education and behavior change messaging about the risks of heavy drinking, condom use with romantic partners, and the importance of frequent HIV testing for at-risk youth and sex workers should be designed and delivered to youth currently engaging in sex work.

HIV risk and psychological distress among female entertainment workers in Cambodia: a cross-sectional study.

BACKGROUND: In Cambodia, there has been an increase in entertainment work as a result of the breakdown of the traditional brothel-based sex industry, presenting new challenges to addressing the health issues and needs of people working in the entertainment industry. This study aims to identify factors associated with psychological distress among female entertainment workers (FEWs) in Cambodia. METHODS: A two-stage cluster sampling method was used to randomly select 657 FEWs from entertainment establishments in Phnom Penh and Siem Reap in April and May 2014 for interviews using a structured questionnaire. Psychological distress was measured using the General Health Questionnaire (GHQ-12), and multivariate logistic regression analysis was conducted. RESULTS: Almost half of FEWs (43.2 %) had a higher level of psychological distress (GHQ-12 > 3), while 19.5 % reported having suicidal thoughts, and 7.3 % reported having attempted to commit suicide in the past 3 months. Controlling for confounding factors, women with a higher level of psychological distress were significantly more likely to rate their overall health (AOR = 1.88, 95 % CI 1.20 to 2.94) and quality of life (AOR = 2.39, 95 % CI 1.47 to 3.87) as poor. They were also significantly more likely to have suicidal ideation (AOR = 2.41, 95 % CI 1.45 to 3.76), rate their HIV risk as higher than the general population (AOR = 0.48, 95 % CI 0.31 to 0.74), have been forced to drink at work (AOR = 1.77, 95 % CI 1.19 to 2.62), have had clients requesting not to use a condom (AOR = 3.48, 95 % CI 1.14 to 10.62), be not able to find condoms when they needed it (AOR = 0.64, 95 % CI 0.45 to 0.93), have had a family member who said hurtful things to them during childhood (AOR = 1.84, 95 % CI 1.24 to 2.75), and have had a parent or guardian who had been physically abused (AOR = 1.93, 95 % CI 1.34 to 2.82). CONCLUSIONS: FEWs in Cambodia experience high levels of psychological distress, which likely stems from both past negative experiences and current working conditions. For women that are experiencing psychological distress, intervention programs aimed at improving mental health should specifically address substance use, condom availability and negotiation skills, and suicide risk.

Improving prevention and care for HIV and sexually transmitted infections among men who have sex with men in Cambodia: the sustainable action against HIV and AIDS in communities (SAHACOM).

BACKGROUND: The prevalence of HIV and sexually transmitted infections (STIs) among key populations in Cambodia continues to rise. To address this issue, KHANA, the largest national HIV organization in the country developed and implemented the Sustainable Action against HIV and AIDS in Communities (SAHACOM) project. This study aims to determine the impacts of the SAHACOM on sexual behaviors and the uptake of HIV/STI services among men who have sex with men (MSM) in Cambodia. METHODS: We compared outcome indicators at midterm (n = 352) and endline (n = 394). Surveys were conducted in 2012 and 2014 in Battambang and Siem Reap provinces. A two-stage cluster sampling method was employed to select the study sample for structured interviews. RESULTS: The midterm and endline samples were similar. The average number of sexual partners in the past three months decreased significantly from 6.2 to 4.0 (p = 0.03). The proportion of MSM who reported paying for sex with men in the past three months also decreased significantly from 19.0 % to 9.7 % (OR = 2.0, 95 % CI = 1.3-3.0). No significant change was found in condom and lubricant use in all types of relationships. Regarding STIs, 28.1 % of MSM at midterm reported having at least one STI symptom in the past three months compared to 6.1 % at endline (OR = 4.6, 95 % CI = 2.9-7.4); out of them, 14.1 % of MSM at midterm sought treatment compared to 20.7 % at endline (OR = 2.6, 95 % CI = 1.1-6.9). The proportion of MSM who reported using illicit drugs in the past three months also decreased significantly from 12.2 % to 5.1 % (OR = 2.4, 95 % CI = 1.4-4.2). However, the proportion of MSM who reported having been tested for HIV in the past six months decreased significantly from 94.1 % to 77.1 % (OR = 2.9, 95 % CI = 1.8-3.6). CONCLUSIONS: Findings from this study indicate that the SAHACOM was effective in improving sexual behaviors and related health outcomes among MSM under the project. However, it could not increase condom use and HIV testing rates among this key population. Tailored intervention programs are needed to improve condom use and HIV testing among MSM in Cambodia.

The impact of a community-based HIV and sexual reproductive health program on sexual and healthcare-seeking behaviors of female entertainment workers in Cambodia.

BACKGROUND: In Cambodia, despite great successes in the fight against HIV, challenges remain to eliminating new HIV infections and addressing sexual reproductive health (SRH) issues in key populations including female entertainment workers (FEWs). To address these issues, the Sustainable Action against HIV and AIDS in Communities (SAHACOM) project has been implemented since late 2009 using a community-based approach to integrate HIV and SRH services. This study evaluates the impact of the SAHACOM on sexual and healthcare-seeking behaviors among FEWs in Cambodia. METHODS: A midterm and endpoint comparison design was utilized. Midterm data were collected in early 2012, and endpoint data were collected in early 2014. A two-stage cluster sampling method was used to randomly select 450 women at midterm and 556 women at endpoint for face-to-face interviews. RESULTS: Compared to women at midterm, women at endpoint were significantly less likely to report having sexual intercourse in exchange for money or gifts in the past three months (OR = 2.1, 95 % CI = 1.6-2.7). The average number of commercial sexual partners in the past three months also decreased significantly from 5.5 (SD = 13.3) at midterm to 3.6 (SD = 13.9) at endpoint (p = 0.03). However, women at endpoint were significantly less likely to report always using condom when having sexual intercourse with clients in exchange for money or gifts (OR = 2.6, 95 % CI = 1.5-4.5). Regarding sexually transmitted infections (STIs), women at endpoint were significantly less likely to report having an STI symptom in the past three months (OR = 1.8, 95 % CI = 1.4-2.3) and more likely to seek treatment for the most recent STI symptom (OR = 1.6, 95 % CI = 1.1-1.9). Furthermore, women at endpoint were significantly more likely to be currently using a contraceptive method (OR = 1.4, 95 % CI = 1.1-1.8) and less likely to report having an induced abortion (OR = 1.4, 95 % CI = 1.1-1.7) during the time working as a FEW. CONCLUSIONS: The overall findings of the study indicate that the SAHACOM is effective in reducing sexual risk behaviors and improving the access to SRH care services among FEWs in Cambodia. However, several unfavorable findings merit attention.

Factors associated with recent HIV testing among high-risk men who have sex with men: a cross-sectional study in Cambodia.

BACKGROUND: Despite remarkable success in the fight against HIV, HIV prevalence in many countries remains high among key populations including men who have sex with men (MSM), and HIV testing rates is relatively low among this hard-to-reach population. This cross-sectional study explores factors associated with recent HIV testing among MSM in Cambodia. METHODS: This study was conducted in 2014 and included 384 MSM randomly selected from two provinces of Battembang and Siem Reap, using a two-stage cluster sampling method. A structured questionnaire was used for face-to-face interviews to collect data on socio-demographic characteristics, HIV testing history, sexual behaviors, HIV testing attitudes, and HIV knowledge. Multivariate logistic regression analysis was performed to identify factors independently associated with recent HIV testing. RESULTS: Mean age of the participants was 23.4 (SD = 5.2). Of total, 83.6 % had been tested for HIV at least once in their lifetime, and 65.1 % had been tested for HIV in the past six months. After controlling for other covariates, MSM who had been tested for HIV in the past six months were significantly more likely to regard themselves as female (AOR = 2.29, 95 % CI = 1.06-5.37), have received some form of HIV education in the past six months (AOR = 3.97, 95 % CI = 1.91-8.26), perceive that they were at higher HIV risk compared to the general population (AOR = 2.48, 95 % CI = 1.14-4.86), have been diagnosed with an STI in the past six months (AOR = 3.19, 95 % CI = 1.02-9.24), report using a condom at last sexual intercourse with a man or woman (AOR = 2.24, 95 % CI = 1.06-3.13), and report using a condom at last sexual intercourse with a boyfriend (AOR = 2.17, 95 % CI = 1.04-5.31). CONCLUSIONS: This study highlights the common practices of risky sexual behaviors and relatively low rate of recent HIV testing among MSM in Cambodia. HIV education and social marketing should be expanded and tailored for MSM, specifically addressing the risk of unprotected anal intercourse and the importance of regular HIV testing for early enrolment in the care and treatment cascade.

Evaluating attitudes among healthcare graduate students following interprofessional education on opioid use disorder.

CONTEXT: Provider-enacted stigma is a barrier for people with substance use disorder (SUD) who interface with the healthcare system, and it has been shown to lead to worse healthcare outcomes. This has given urgency to the need for stigma reduction interventions such as education- and contact-based approaches. The positive effect of interprofessional education (IPE) in reducing graduate health students' stigmatizing attitudes on opioids has been examined before, and we contribute to the existing literature by examining the attitudes across the following four health disciplines-osteopathic medicine, physician assistant (PA) studies and public health, pharmacy, and nursing-following a single half-day IPE event focused on opioid use disorder (OUD). OBJECTIVES: We aimed to determine whether attitudes could be affected by the IPE event by assessing attitudes utilizing an adapted version of the Alcohol and Alcohol Problems Perceptions Questionnaire (AAPPQ) before and after the IPE event. METHODS: A total of 647 students across the four previously mentioned health disciplines participated in the IPE event. Attitudes were compared between the pre/post groups utilizing unpaired t tests, and a summative "all-attitudes" score was generated, with higher scores being associated with improved attitudes toward individuals with an OUD. Linear regression was performed controlling for program type, gender, and previous OUD exposure (personal, professional, and education). RESULTS: We found that the pre/post summative attitudes scores improved an average of 2.81 units (SD 0.87, p=0.001, CI 1.09-4.52) for the entire cohort of graduate health students (56.9 vs. 66.6, p<0.0001) and for all attitudinal subscales (role adequacy, role legitimacy, role support, task-specific self-esteem, and work satisfaction). Students from PA programs had significantly higher attitude scores than other programs, and there were differences in degree type on attitude scores, with an average decrease of 1.89 units in attitude scores (SE 0.38, p<0.0001, CI -2.64 to -1.16). We found that students with previous exposure to OUD had higher pre-IPE event scores than those without, and knowing someone impacted by an SUD was a significant predictor of increased attitude scores, by an average of 3.82 units (SE 0.27, p<0.0001, CI 3.49-4.16). However, students without previous exposure to OUD had equal attitude scores post event to those who had previous exposure to OUD through education, personal experience, or training. CONCLUSIONS: Our findings suggest that an IPE intervention and panel discussion may improve attitudes toward people with OUD in healthcare trainees, which is consistent with previous research that shows the beneficial effect of education and contact in reducing stigma. Degree type and knowing someone who has been impacted by an SUD are also significant predictors of attitude scores. IPE events are useful in targeting a public health issue by encouraging collaboration between different health professionals at early stages of their training, and preclinical educational efforts can affect therapeutic attitudes.

Connecting Female Entertainment Workers in Cambodia to Health Care Services Using mHealth: Economic Evaluation of Mobile Link.

BACKGROUND: Mobile Link is a mobile phone-based intervention to increase access to, and use of, health care services among female entertainment workers in Cambodia who face higher risks for specific diseases and gender-based violence. A multisite randomized controlled trial showed that Mobile Link connected female entertainment workers with outreach workers for information and escorted referrals after 6 months but did not lead to statistically significant improvements in HIV and sexually transmitted infection testing, contraceptive use, and condom use. OBJECTIVE: This study aims to conduct a 3-part economic evaluation of Mobile Link to understand its costs, value, and affordability. METHODS: We conducted cost, cost-effectiveness, and budget impact analyses of Mobile Link using cost and outcomes data from the Mobile Link trial and other sources. For the cost analysis, we estimated the total, per-person, and incremental costs of Mobile Link compared with usual care. Using probabilistic decision-analytic models, we estimated the 1-year cost-effectiveness of Mobile Link from payer and combined payer and patient perspectives by converting selected primary and secondary outcomes from the trial to disability-adjusted life years (DALYs) averted. Finally, we estimated the financial costs of scaling up Mobile Link's messaging and outreach services to 70% of female entertainment workers in 5 years. RESULTS: The incremental costs of Mobile Link were US $199 from a payer perspective and US $195 per person from a combined payer and patient perspective. With an average of 0.018 (95% predicted interval -0.088 to 0.126) DALYs averted, Mobile Link's cost-effectiveness was US $10,955 per DALY from a payer perspective (US $10,755 per DALY averted from a payer and patient perspective). The costs of Mobile Link would have to decrease by 85%, or its effectiveness would have to be 5.56 times higher, for the intervention to meet the upper limit of recommended cost-effectiveness thresholds in Cambodia (US $1671 per DALY averted). The 5-year cost of scaling Mobile Link to 34,790 female entertainment workers was estimated at US $1.64 million or US $46 per person per year. CONCLUSIONS: This study provided a comprehensive economic evaluation of Mobile Link. We found that Mobile Link is not likely to be cost-effective unless its costs decrease or its effectiveness increases. Scaling up Mobile Link to more female entertainment workers is estimated to cost less than the costs of the trial. Given the importance of linking female entertainment workers to essential services, future research should focus on enhancing the effectiveness of Mobile Link or developing new mobile health interventions for this population. TRIAL REGISTRATION: ClinicalTrials.gov NCT03117842; https://clinicaltrials.gov/study/NCT03117842.

Redeeming qualities: exploring factors that affect women's use of reproductive health vouchers in Cambodia.

BACKGROUND: One approach to delivering healthcare in developing countries is through voucher programs, where vouchers are distributed to a specific population for free or subsidized health care. Recent evaluations suggest that vouchers have the potential to extend coverage of priority health services to the poor in developing countries. In Cambodia, a reproductive health voucher program was implemented in January 2011. This study aims to explore women's early experiences accessing health services with their vouchers at accredited clinics. METHODS: This qualitative exploratory study used focus group methodology to gather information from five groups of older (>25 years) and four groups of younger (18-25 years) women who were eligible for the voucher program in three rural provinces. Focus groups were digitally recorded, transcribed and translated from Khmer into English. Data analysis was an iterative process, which comprised of open coding to find commonalities that reflected categories or themes and axial coding to relate initial themes to each other. Next, a basic framework for analysis was formed by integrating the themes into the framework. RESULTS: Two overarching themes were identified in the data: 1) factors that facilitate voucher use and 2) factors that inhibit voucher use. Within each of these themes, three subthemes were identified: 1) pre-existing factors, 2) distribution factors, and 3) redemption factors. Overall, women expressed positive feelings towards the voucher program, while several areas for program improvement were identified including the importance of addressing pre-existing demand-side barriers to using reproductive health services, the need for more comprehensive counselling during voucher distribution, and the persistent cost of unofficial payments expected by midwives after delivery irrespective of voucher use. CONCLUSIONS: Early information from program beneficiaries can lead to timely and responsive changes that can help to maximize program success. This study highlights the importance of tailoring voucher programs to specific community needs, a strategy that can lead to better program uptake.

"If it wasn't forced upon me, I would have given it a second thought": Understanding COVID-19 vaccine hesitancy in an outlier county in the Bay Area, California.

While the San Francisco Bay Area counties rank very low in vaccine hesitancy and high in vaccination rates when compared to national numbers, Solano County has the most residents who are hesitant (6.3%) and the least who are fully vaccinated (51.6%) among Bay Area counties, according to the CDC. No studies to date have been able to provide the in-depth, localized information that would inform county-level public health interventions. This study aims to explore reasons and consequences for remaining unvaccinated in Solano County. Using a qualitative in-depth interview approach, we conducted 32 interviews with unvaccinated adults from Solano County. We used a grounded theory approach to our analysis. Using the socio-ecological model as a framework, we found that reasons for not getting vaccinated were primarily structural (mistrust of public information) and individual (bodily autonomy, personal choice) while consequences were primarily interpersonal (discrimination and stigma from friends, family, and employers). An overarching theme was that the vaccine rollout and messaging felt like an encroachment on personal choice and the feeling of being forced created more mistrust. Participants reported feeling like their decisions made them minorities among their colleagues, friends and family and that they were not persuaded by groupthink or by their relationships. Future public health responses to epidemics and pandemics might consider if a vaccine mandate is the best approach for reaching all county residents.

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.