"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.

"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.

Correction to: 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.

After publication of our article [1] we became aware that several sections of text in our Methods section were copied from a previously published article [2]. We would like to formally apologize and give credit to the authors of that article [2]: Chris Smith, Uk Vannak, Ly Sokhey, Thoai D Ngo, Judy Gold, Khemrin Khut, Phil Edwards, Tung Rathavy and Caroline Free.

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.

Correction to: 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.

After publication of our article [1] we became aware that several sections of text in our Methods section were copied from a previously published article [2].

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.

Racial Discrimination and HIV-related Risk Behaviors in Southeast Louisiana.

OBJECTIVES: We examined the relationship between cumulative experiences of racial discrimination and HIV-related risk taking, and whether these relationships are mediated through alcohol use among African Americans in semi-rural southeast Louisiana. METHODS: Participants (N = 214) reported on experiences of discrimination, HIV sexual risk-taking, history of sexually transmitted infection (STI), and health behaviors including alcohol use in the previous 90 days. Experiences of discrimination (scaled both by frequency of occurrence and situational counts) as a predictor of a sexual risk composite score as well as a history of STI was assessed using multivariate linear and logistic regression, respectively, including tests for mediation by alcohol use. RESULTS: Discrimination was common in this cohort, with respondents confirming their experience on average 7 of the 9 potential situations and on more than 34 separate occasions. After adjustment, discrimination was significantly associated with increasing sexual risk-taking and lifetime history of STI when measured either by frequency of occurrence or number of situations, although there was no evidence that these relationships were mediated through alcohol use. CONCLUSIONS: Cumulative experiences of discrimination may play a significant role in sexual risk behavior and consequently increase vulnerability to HIV and other STIs.

Use of a resiliency framework to examine pregnancy and birth outcomes among adolescents: A qualitative study.

INTRODUCTION: Adolescent childbearing has been viewed as a social, political, and public health priority since the 1970s. Research has primarily focused on the negative consequences of teen pregnancy; less research has explored factors associated with healthy pregnancy and birth experiences in this population. METHOD: Using open-ended and qualitative techniques, researchers performed individual interviews with 15 adolescent mothers (15 to 19 years of age) recruited from a Women's and Children's Clinic in Southern Louisiana, who had experienced a healthy pregnancy and bore a full-term, normal birth weight infant. We used a resiliency framework to identify factors that may have supported positive health outcomes despite risks associated with low-income and/or marginalized minority status. RESULTS: A total of 15 mothers of multiple racial/ethnic identities were included in the analysis. Mothers discussed potential protective factors that we classified as either assets (internal factors) or resources (external factors). Mothers demonstrated strong assets including self-efficacy and self-acceptance and important resources including familial support and partner support during pregnancy which may have contributed to their resiliency. DISCUSSION: Ensuring access to social and structural supports as well as supporting adolescent-friendly health and social policies may be key to promoting healthy maternal and infant outcomes among young women who become pregnant. (PsycINFO Database Record

Soccer and sexual health education: a promising approach for reducing adolescent births in Haiti.

OBJECTIVE: To explore the effect of an innovative, integrative program in female sexual reproductive health (SRH) and soccer (or fútbol, in Haitian Creole) in rural Haiti by measuring the rate of births among program participants 15-19 years old and their nonparticipant peers. METHODS: A retrospective cohort study using 2006-2009 data from the computerized data-tracking system of the Haitian Health Foundation (HHF), a U.S.-based nongovernmental organization serving urban and rural populations in Haiti, was used to assess births among girls 15-19 years old who participated in HHF's GenNext program, a combination education-soccer program for youth, based on SRH classes HHF nurses and community workers had been conducting in Haiti for mothers, fathers, and youth; girl-centered health screenings; and an all-female summer soccer league, during 2006-2009 (n = 4 251). Bivariate and multiple logistic regression analyses were carried out to assess differences in the rate of births among program participants according to their level of participation (SRH component only ("EDU") versus both the SRH and soccer components ("SO") compared to their village peers who did not participate. Hazard ratios (HRs) of birth rates were estimated using Cox regression analysis of childbearing data for the three different groups. RESULTS: In the multiple logistic regression analysis, only the girls in the "EDU" group had significantly fewer births than the nonparticipants after adjusting for confounders (odds ratio = 0.535; 95% confidence interval (CI) = 0.304, 0.940). The Cox regression analysis demonstrated that those in the EDU group (HR = 0.893; 95% CI = 0.802, 0.994) and to a greater degree those in the SO group (HR = 0.631; 95% CI = 0.558, 0.714) were significantly protected against childbearing between the ages of 15 and 19 years. CONCLUSIONS: HHF's GenNext program demonstrates the effectiveness of utilizing nurse educators, community mobilization, and youth participation in sports, education, and structured youth groups to promote and sustain health for adolescent girls and young women.

Soccer and sexual health education: a promising approach for reducing adolescent births in Haiti / Fútbol y educación en salud sexual: un enfoque prometedor para reducir los partos en adolescentes en Haití

OBJECTIVE: To explore the effect of an innovative, integrative program in female sexual reproductive health (SRH) and soccer (or fútbol, in Haitian Creole) in rural Haiti by measuring the rate of births among program participants 15-19 years old and their nonparticipant peers. METHODS: A retrospective cohort study using 2006-2009 data from the computerized data-tracking system of the Haitian Health Foundation (HHF), a U.S.-based nongovernmental organization serving urban and rural populations in Haiti, was used to assess births among girls 15-19 years old who participated in HHF's GenNext program, a combination education-soccer program for youth, based on SRH classes HHF nurses and community workers had been conducting in Haiti for mothers, fathers, and youth; girl-centered health screenings; and an all-female summer soccer league, during 2006-2009 (n = 4 251). Bivariate and multiple logistic regression analyses were carried out to assess differences in the rate of births among program participants according to their level of participation (SRH component only ("EDU") versus both the SRH and soccer components ("SO") compared to their village peers who did not participate. Hazard ratios (HRs) of birth rates were estimated using Cox regression analysis of childbearing data for the three different groups. RESULTS: In the multiple logistic regression analysis, only the girls in the "EDU" group had significantly fewer births than the nonparticipants after adjusting for confounders (odds ratio = 0.535; 95% confidence interval (CI) = 0.304, 0.940). The Cox regression analysis demonstrated that those in the EDU group (HR = 0.893; 95% CI = 0.802, 0.994) and to a greater degree those in the SO group (HR = 0.631; 95% CI = 0.558, 0.714) were significantly protected against childbearing between the ages of 15 and 19 years. CONCLUSIONS: HHF's GenNext program demonstrates the effectiveness of utilizing nurse educators, community mobilization, and youth participation in sports, education, and structured youth groups to promote and sustain health for adolescent girls and young women.

OBJETIVO: Explorar la repercusión de un programa innovador e integrador de salud sexual y reproductiva femenina y fútbol llevado a cabo en una zona rural de Haití, mediante la medición de la tasa de partos entre las participantes del programa, de 15 a 19 años de edad, y entre sus compañeras no participantes. MÉTODOS: Se utilizó un estudio retrospectivo de cohortes, que usaba los datos del periodo 2006-2009 del sistema de seguimiento de datos computadorizados de la Fundación Haitiana de Salud (HHF, una organización no gubernamental con sede en los Estados Unidos que presta servicio a las poblaciones urbanas y rurales de Haití, para evaluar los partos en las adolescentes de 15 a 19 años de edad que participaron en el programa GenNext de la HHF. Este programa es una combinación de educación y fútbol para jóvenes y se basa en las clases de salud sexual y reproductiva que el personal de enfermería de la HHF y los trabajadores comunitarios han impartido en Haití para madres, padres y jóvenes; los tamizajes de salud centrados en las adolescentes; y una liga de fútbol de verano solo para mujeres durante dicho periodo (n = 4 251). Se llevaron a cabo análisis bivariado y de regresión logística múltiple para evaluar las diferencias en las tasas de partos entre las participantes del programa según su nivel de participación (sólo el componente de salud sexual y reproductiva ["EDU"] frente a ambos componentes, salud sexual y reproductiva, y fútbol ["FU"]) en comparación con las compañeras de su municipio que no participaron . Se calcularon las razones de riesgo (RR) de las tasas de partos mediante análisis de regresión de Cox de los datos de maternidad de los tres grupos. RESULTADOS: En el análisis de regresión logística múltiple, sólo las adolescentes del grupo "EDU" tuvieron significativamente menos partos que las no participantes tras ajustar para los factores de confusión (razón de posibilidades = 0,535; intervalo de confianza [IC] 95% = 0,304-0,940). El análisis de regresión de Cox demostró que las del grupo EDU (RR = 0,893; IC 95% = 0,802-0,994), y en un mayor grado las del grupo FU (RR = 0,631; IC 95% = 0,558-0,714), estaban significativamente protegidas contra la maternidad en edades comprendidas entre los 15 y los 19 años. CONCLUSIONES: El programa GenNext de la HHF demuestra la eficacia de utilizar al personal de enfermería como educadores, la movilización comunitaria, y la participación de las jóvenes en actividades educativas y deportivas, y en grupos juveniles estructurados, para promover y mantener la salud de las adolescentes y las mujeres jóvenes.