Evaluation and mechanism analysis of HIV prevention programme using resilience framework among female sex workers: A randomised controlled trial.

BACKGROUND: Evidence shows traditional sexual harm reduction for female sex workers (FSW) based on health behaviour theories is effective but short-lived. This study aimed to evaluate and understand the effectiveness of a resilience-promoting programme in improving psychological health and, ultimately, safe sex practice. METHODS: A randomised controlled trial was conducted at three Hong Kong-based non-governmental organisations. 127 sex workers were recruited and randomly assigned to the intervention or control groups. The former received a six-session resilience-promoting programme designed to improve self-esteem, self-efficacy and coping skills, whereas the latter had the usual care. Between-group differences in psychological outcomes and condom use were tested using the intention-to-treat, with ANOVA and chi-square tests, measured at baseline, post-intervention and 3-month follow-ups. Multiple mediation analysis was used to examine how the intervention worked through resilience factors. RESULTS: Significant between-group improvements in adaptive coping (F 1,119 = 5.82, p < .05) and reduction in psychological distress (F 1,118 = 5.00, p < .05) were seen at post-intervention and 3-month follow-ups, with significant time × group interaction changes suggesting the changes occurred at different rates between the two groups. Condom use during the last transactions had increased in the intervention group and the rate of consistent condom use during transactions improved in the intervention group at follow-ups (χ 2 = 4.35, p < .05). Self-esteem and resilience significantly mediated the effect of intervention at reducing psychological distress. CONCLUSIONS: These findings suggest that resilience improves the psychological health and general wellbeing of Chinese FSWs.

Uptake of human papillomavirus (HPV) vaccination in Hong Kong: Facilitators and barriers among adolescent girls and their parents.

The present study is aimed at assessing the feasibility of delivering the HPV (human papillomavirus) vaccine to girls through a school-based program in Hong Kong, as well as to examine the facilitators and barriers associated with their participation. We approached 1,229 eligible girls aged 9 to 14 at eight schools in Hong Kong to join the program and then delivered the bivalent HPV vaccine at 0 and 6 months over the course of one school year. The students and their parents completed separate questionnaires to indicate their decision on whether or not to participate, and to assess their knowledge of cervical cancer and the HPV vaccine. The overall vaccine uptake was 81.4% (1,000/1,229) for the first dose and 80.8% (993/1,229) for the second dose. Parents and students were given separate questionnaires and asked whether or not they would like to participate in the vaccination program. 87.1% (1,010/1,160) of parents and 84.9% (974/1,147) of students indicated that they would join the program. The reasons associated with parents' decision not to vaccinate their daughters primarily included concerns around side effects and safety. Multivariate regression analysis showed that parents who thought that the vaccine would protect their daughter from getting cervical cancer (OR = 3.16, 95% CI = 1.39-7.15, p < .01), and those who reported having a doctor's recommendation (OR = 4.54, 95% CI = 1.05-19.57, p < .05) were more likely to join the program. In contrast, parents who had never heard of the vaccine (OR = .15, 95% CI = .03-.71, p < .02), those who were willing to pay more than HK$2,000 for the vaccine (OR = .39, 95% CI = .19-.81, p < .05), or had a preference to access it through a private clinic (OR = .44, 95% CI = .26-.75, p < .01) were significantly less likely to allow their daughter to join the program. Delivery of the HPV vaccine with high uptake rate in a school setting is feasible in Hong Kong. Engaging key stakeholders including school administrators, teachers and community physicians, and providing relevant information on safety and vaccine effectiveness to parents were important to the success of the program.

Translation and Validation of a Condom Self-Efficacy Scale (CSES) Chinese Version.

The English version of the Condom Self-Efficacy Scale (CSES) was translated, back-translated, and tested among a representative sample of the Hong Kong general population. It then underwent reconsolidation, confirmation, and validation following standard procedures. Construct validity was performed by exploratory factor analysis and item-scale correlation. Independent t-test and effect size were used to identify the score differences between consistent and non-consistent condom users. The factor loading scores of 14 items ranged between 0.749 and 0.884. Cronbach's alpha for the traditional Chinese version of CSES (CSES-TC) was 0.96 for the overall scale. The CSES-TC was highly correlated with self-reported condom use among the 265 participants who indicated they had been sexually active in the past 12 months. The CSES-TC demonstrated satisfactory psychometric properties in terms of validity, reliability, and sensitivity. This scale can be used as an instrument to measure condom use efficacy for condom promotion and intervention purposes.

Psychological health and HIV transmission among female sex workers: a systematic review and meta-analysis.

Current HIV prevention interventions for female sex workers (FSWs) have tended to target the cognitive factors in changing their behaviors, yet little attention has been paid to the psychological factors that influence the behavior of women in sex work. This review aimed to explore the associations between the psychological health of FSWs and HIV risk. A total of eight studies published in English before July 2013 were identified and reviewed. FSWs had reported psychological issues, including depression, suicidal thoughts as well as lower quality of life, and the pooled prevalence of probable depression was as high as 62.4%. The majority of studies showed that higher scores in psychological health problems were associated with increased HIV risk behavior, in particular inconsistent condom use, or sexually transmitted infections. Among the five studies which measured symptoms of depression, four documented that higher depression scores were significantly associated with inconsistent condom use among FSWs with their clients and/or partners. Meta-analysis using a fixed-effects model was performed to examine the association between depression and inconsistent condom use and found that higher scores in depression were significantly associated with inconsistent condom use (odds ratio = 2.57, p < .001). This review contends that future HIV preventive interventions should take psychological health of FSWs into consideration.

Resilience in work-related stress among female sex workers in Hong Kong.

The literature on positive psychology and resilience demonstrates that individuals utilize their personal strengths and environmental resources to facilitate positive adaptation. Using a qualitative approach, we investigated how these frameworks operated as self-protective strategies for female sex workers to maintain their psychological and physical well-being under stressful socioeconomic and work-related conditions. Twenty-three female sex workers in Hong Kong participated in in-depth interviews. We used the grounded theory approach for data analysis. The informants reported negative feelings in response to financial burden, clients' demands, threats to physical health, and stigma. Some female sex workers showed their resilience by being able to rationalize their role, believe their ability to make a change in life, and stay optimistic. They adopted strategies including emotional regulation and acceptance of their responsibility and limits to cope with stressful life events. The results help us understand the role of positive psychology and resilience in this vulnerable population.

Evaluating the effectiveness of personal resilience and enrichment programme (PREP) for HIV prevention among female sex workers: a randomised controlled trial.

BACKGROUND: Female sex workers (FSWs) are often considered as the vector, if not reservoir, of HIV and other sexually transmitted infections. Building upon the existing evidence on the role of psychological health in sexual health, the aim of this protocol is to describe a trial investigating the effectiveness of the Personal Resilience and Enrichment Programme (PREP), a resilience-promoting intervention that targets at psychological well-being i.e. self-esteem, self-efficacy and coping, to facilitate adaptation and ultimately safe sexual practices among FSWs, which could be an innovative strategy in controlling the spread of these infections. METHODS: A total of 132 FSWs will be recruited and randomly assigned to either the intervention or usual care (control) groups in a multi-centred randomised controlled trial. Based on the resilience framework, this intervention is comprised of six weekly sessions focused on the awareness, expression and management of emotions, identifying roles and personal strengths, and effective problem-solving skills. Complex intervention assessment on both intervention process and effectiveness will be adopted when the primary outcome reduction of sexual risk behaviour and other psychological outcomes include their perceived stress, self-esteem, self-efficacy, coping overall resilience, and psychological distress will be measured at baseline, post-treatment and 3-month post-intervention and differences assessed by ANOVA. The relationship of resilience factors, psychological health and HIV preventive behaviours will be evaluated using structural equation modelling. DISCUSSION: It is anticipated that this study will increase our understanding of the relationships between individual resilience attributes, positive adaptation, psychological health and sexual health practices. If successful, this programme will provide an innovative direction for HIV prevention by applying the personal resilience factors to promote both psychological well-being and safe sex for this high risk population. TRIAL REGISTRATION: ChiCTR-PRC-13003091.