Abstract
Community research into women’s experiences in the indoor commercial sex industry illustrated an urgent need for sexually transmitted infection (STI) and HIV education, prevention, testing, and treatment and culturally appropriate services to support the sexual and reproductive health of commercial sex workers (CSWs). This work also revealed that a high number of immigrant—primarily Asian—women are involved in the indoor sex industry. In response, the authors developed a community–academic research partnership to design and implement a blended outreach research program to provide STI and HIV prevention interventions for indoor CSWs and their clients. This Community Health Worker Model HIV Prevention and Health Promotion Program incorporated health education, primary care referrals, STI testing using self-swab techniques, and a point-of-care HIV screening test. Here the authors report on program implementation, design, and the experiences of participants and team members and provide research and vaccination recommendations for future work in this area. This work work affirms that community-based service providers can be a key entry point for indoor CSWs to access health care and sexual health promotion and education and may be a solution to missed opportunities to provide culturally and contextually appropriate education and services to this population.
Keywords
Introduction
In Canada, approximately 80% of women working as commercial sex workers (CSWs) do so within indoor sex establishments such as massage parlors and escort agencies (Hanger, 2006). Little is known about their sexual and reproductive health experiences as research and health service delivery has primarily focused on street-level sex work (Lowman, 2000; Shaver, 2006). Preliminary research indicates that indoor CSWs in Canada may experience significant risk for sexually transmitted infection (STI) and HIV (Benoit & Miller, 2001; Jeal & Salisbury, 2007; Nemoto, Iwamato, Wong, Nhung Le, & Operario, 2004; Remple, Johnston, Patrick, Tyndall, & Jolly, 2007). These risks are compounded by gender-based violence (Bungay, Halpin, Halpin, Johnston, & Patrick, 2012), criminalization of prostitution (Lowman, 2000; Pivot Legal Society, 2004; Shaver, 2006), and barriers to appropriate health promotion, education, and testing services (Asian Society for the Intervention of AIDS [ASIA], 2003; Nguyen, Venne, Rodrigues, & Jacques, 2008). As such, there is an urgent need to better understand the health experiences of CSWs and for targeted interventions to promote and protect their health.
Within our urban Western Canadian locale, there is an extensive indoor commercial sex market that operates under the guise of licensed businesses, and estimates suggest that several hundred such sex venues exist (Remple et al., 2007). In 2003, the nonprofit organization ASIA undertook pilot work within local massage parlors that illustrated an urgent need for STI and HIV education, prevention, testing, and treatment and culturally appropriate services to support CSW sexual and reproductive health. Their work indicated that a high number of immigrant women, largely from Asian countries, work in these venues (ASIA, 2003), an important finding given that in 2008 immigrants accounted for 14.2% of all new HIV cases in Canada (Public Health Agency of Canada, 2009).
In response to ASIA’s (2003) research, we created a community–researcher partnership between ASIA staff and community health workers (CHWs), university-based health researchers, and health and social service practitioners. This partnership, named the “Outreach and Research in Community Health Initiatives and Development Project” (ORCHID), combines outreach, service delivery, and research with the primary aim of promoting and protecting the health of CSWs. The initial ORCHID activities, which have been described in detail elsewhere (Remple et al., 2007), emphasized building collaborative relationships among team members; capacity building among CHWs with current or previous sex work experience to provide outreach services to CSWs, including health education and referral services and health appointments accompaniment; and undertaking of further needs assessment to inform future interventions for STI and HIV prevention among indoor CSWs. Here we report on one aspect of our activities, namely, the design and implementation of a CHW Model HIV Prevention and Health Promotion Program that expanded the health education, primary care referrals, and health appointment accompaniment services to include STI testing using self-swab techniques and a point-of-care (POC) HIV screening test. 1 Additionally, we detail the experiences of CSWs within this program and generate recommendations for further work to protect CSW health.
Method and Strategies
Program Design
The CHW model approach is predicated on the goals of community empowerment, increased access to services, and delivery of culturally competent, cost-effective care (Andrews, Felton, Wewers, & Heath, 2004; Witmer, Seifer, Finocchio, Leslie, & O’Neil, 1995; World Health Organization, 2007). Integral to this approach is the integration of CHWs. Although multiple definitions exist, we identified CHWs as people who are part of the communities in which they work—ethnically, linguistically, and experientially (Love, Gardner, & Legion, 1997). Within a CHW model, CHWs provide outreach services and act as connectors between health care providers and community members (e.g., CSWs) who frequently lack access to care (Witmer et al., 1995). CHW model approaches have demonstrated effectiveness on an international level in addressing structural barriers in health care and promoting CSW skills in HIV prevention (Jana, Basu, Toheram-Borus, & Newman, 2004; Swendeman, Basu, Das, Jana, & Rotheram-Borus, 2009), as well as in providing peer counseling, condoms, resource information, and health care and social service referrals (e.g., Janssen, Gibson, Bowen, Spittal, & Petersen, 2009; Stadler & Delany, 2006). Drawing on the preestablished success of the ORCHID outreach model, our initial CHW outreach team included six women with sex work experience and eight ASIA volunteers, most of whom were fluent in Mandarin, shared Asian ancestry with CSWs, and were immigrants to Canada (as described in Remple et al., 2007). Within our CHW Model HIV Prevention and Health Promotion Program, five community-based researchers (CBRs) were added to outreach teams. As recommended in similar research projects that incorporate CHW service delivery (Terpstra, Coleman, Simon, & Nebeker, 2011), CBRs assumed research responsibilities, including data collection and STI and HIV testing to ensure that CSWs would not perceive any restriction on CHW service provision should they decline research participation. One CBR was a registered nurse who provided frontline support to CBRs and CHWs.
In response to the identified needs and evidence regarding appropriate HIV prevention initiatives (ASIA, 2003; Swendeman et al., 2009), we offered six services: health education, health and social service (e.g., immigration, legal, income assistance) referrals and accompaniment to appointments, condom and lubricant distribution, POC HIV testing, and self-collected vaginal swabs for human papillomavirus (HPV), chlamydia, and gonorrhea. Consistent with ASIA’s mandate to promote the health of Asian communities by decreasing the impact of HIV/AIDS through multilingual, culturally appropriate services that support equity in access to care, we developed a program that was accessible to Asian women. We did not restrict service for any woman who requested or required services.
Clinical Partnerships, Policies, and Protocols
The integration of testing services into ORCHID activities required expansion of our clinical partnerships, particularly with regard to the testing and reporting requirements and treatment referrals associated with STI and HIV. Investigative and clinical team members collaborated with our provincial center for disease control (CDC) to develop testing and reporting protocols that incorporated pre- and posttest counseling, informed consent, documentation for testing, and partner notification and follow-up care. These policies and protocols were crucial given that provincial policy guidelines recommend use of the POC HIV test by licensed health care professionals (British Columbia Centre for Disease Control, 2007); four of the five CBRs were not licensed health care professionals, although all were experienced in the field of STI and HIV education and prevention. Additionally, the POC HIV test is considered an initial test and all reactive tests require confirmatory laboratory testing.
These protocols assisted our engagement in evidence-based best practices regarding the use of POC testing that were congruent with those recommended by the CDC (see British Columbia Centre for Disease Control, 2007). CBRs underwent an in-depth HIV pre- and posttest counseling course developed in partnership with nurse educators from the CDC, as well as additional training on the STI and HIV testing procedures. CHW training was also expanded from the original sessions (see Remple et al., 2007) to include supplemental instruction regarding HIV screening in order to enhance their understanding of the POC test and their abilities to provide health education to CSWs about testing. Translated safer sexual practices educational materials, health care referrals, more comprehensive STI testing and treatment, confirmatory HIV testing, and legal advice were provided by partnering agencies and sexual health clinics.
Implementation
CHWs first visited sex venues that we had accessed in exploratory work via a targeted sampling approach, which involved community consultations with CSWs, venue managers, health care providers, and community-based organizations providing support services to CSWs (see ASIA, 2003; Remple et al., 2007). In accessing new venues, CHW teams developed initial relationships with CSWs and managers and explored CSW interest in participating in our program. If managers were supportive of the program, CBRs accompanied CHWs as part of the outreach team to provide services and undertake research activities in a private location within the venue. If managers were unsupportive, a situation that occurred only once, arrangements were made to meet outside of the workplace. Each woman who accessed our services was given three “vouchers” with ORCHID contact information to be shared with coworkers in order to facilitate access to services by women who were unable to meet with CHWs.
Women who self-identified as working within the indoor sex industry, were 18 years of age or older, and were able to participate in languages spoken by members of the CHW–CBR teams (primarily English and Mandarin) were eligible to participate. No women younger than the age of majority are employed because of employment restrictions within these venues. CHWs worked collaboratively with CSWs to determine their service provision needs and provided services accordingly. CSWs who did not wish to participate in research activities were still provided health education, referral, and social support services by CHWs.
Participating CSWs were asked to complete a sociodemographic survey that included demographic data (Table 1), sex work characteristics (Table 1), and specific health-related data (Table 2). On receiving pretest counseling, they provided a blood sample (one drop from a finger poke) to test for HIV, as well as two self-collected vaginal swabs to test for chlamydia and gonorrhea. Because of fiscal constraints, only 60 participants self-swabbed for HPV. All self-collected samples were analyzed at the CDC lab and results provided to the CBR nurse to facilitate treatment and follow up when indicated.
Participant Characteristics
Sixteen participants classified as Other were from non-China Asian countries, four participants identified European countries as their country of origin, two were from the United States, and the others were from African countries.
Health Experiences, Practices, and Access to Services
Using research principles associated with an interpretive descriptive research approach (Thorne, 2008), 18 women at six different venues were invited to participate in focus groups. Focus groups were an appropriate data collection method as we wanted to capture women’s analysis of their experience of testing that included their own experiences as well as debates or discussion regarding the pros and cons of the service (Thorne, 2008). Two focus groups were conducted in Mandarin via a translator and the rest in English. A semistructured interview guide was constructed to explore CSW perspectives on the merits and negative aspects of testing with our outreach teams. CBRs maintained field notes about their observations regarding participant HIV and STI testing, noting participants’ comments during testing paying particular attention to women’s concerns about testing and related results as well as positive and negative comments about the testing procedures. Focus group transcripts were transcribed, checked for accuracy, and in combination with field notes, uploaded to NVivo 7™. Data were analyzed using an interpretive thematic approach. Four members of the investigative team including a CHW and a CBR reviewed interview results independently. Team meetings to discuss results were held, and we collaboratively constructed a thematic code scheme that reflected women’s experiences with the services provided by the CHW–CBR teams, their perspectives of the positive and negative aspects of testing, and related influential factors (Sandelowski & Barroso, 2003; Thorne, 2008). Descriptive statistics were produced from surveys using SPSS 17™.
All participants provided informed consent verbally, and the study was undertaken with ethical approval granted by the University of British Columbia Research Ethics Board and Simon Fraser University’s Office of Research Ethics. Participants received a small financial stipend as an honorarium.
Findings
Between 2006 and 2009, ORCHID CHW visited 32 indoor sex venues. Visit frequency ranged between one and four visits per month. A total of 129 CSW from 17 establishments were enrolled into the program. As per ASIA’s mandate, immigrant women accounted for 62% of participants, the majority of whom were born in China (Table 1). Most women were fluent in English. Approximately 24% required translation services provided by CBR-CHW teams, the majority of which was done in Mandarin. On average, women had engaged in sex work for less than 3 years and provided services to 12 men per week. Women worked the equivalent of full-time hours although their income usually depended on the number of clients and type of services offered versus being paid a salary by the venue. Among the 11 women who were not employed in massage parlors, women’s homes and clients’ residences were the common sites for work.
Women were receptive to the services provided by CHW–CBR teams. Their interest in being able to access STI and HIV testing at their workplace was a major contributing factor to engaging with the research aspect of our program and functioned as a critical step in developing rapport, providing health education, and improving women’s access to other health services. To best illustrate how the capacity of CHW–CBR teams to offer testing services interrelated with other health promotion activities, we organized our analysis of the program into two interrelated themes: (a) testing experiences and (b) health education and promotion.
Testing Experiences
As illustrated in Table 2, 9.5% of the women reported never having been tested for STI and 12.5% had never had an HIV test. Of our 129 participants, 113 agreed to gonorrhea and chlamydia screening using self-collected vaginal swabs and to HIV screening. Ten women tested positive for chlamydia, one tested positive for chlamydia and gonorrhea, and no participants screened positive for HIV (POC testing does not detect acute infections and therefore these results are to be interpreted cautiously). Of the 60 women who self-swabbed for HPV, 30 tested positive. All women testing positive for STI were referred to a primary care provider for treatment and follow-up; CHW or CBR team members often accompanied participants to provide translation services and emotional support.
Women who reported never or rarely testing (e.g., less than once per year) for STI or HIV provided several reasons for this, including not wanting to be tested by their primary care provider, lack of awareness of sexual health clinics, language barriers, knowledge deficits regarding need for testing, and challenges with scheduling because of work and other life commitments. The testing services offered by ORCHID addressed many of these barriers. For instance, women appreciated the flexibility of being offered testing at their workplace:
The service you provide is very good and convenient for us. We have busy schedules and some work every day. We can’t go to the [clinic]. (FG-4)
In addition to the convenience of onsite testing, participants noted that self-swabs and POC were less invasive, more “comfortable,” and “less painful” than traditional modes of testing. Women recognized that the specific self-swabs offered were not comprehensive of full STI screening and that POC HIV screening was not confirmatory. They considered these tests as a first step and noted that if further testing was necessary, they now felt more prepared to undergo it. This preparation for further testing and/or access to other health services was primarily because of the CHW–CBR health education activities regarding sexual health promotion, including risk reduction and information for accessing nonjudgemental health services. Participants also expressed that the initial testing offered by ORCHID provided them some “peace of mind,” particularly the POC test, as results were available within minutes:
The test [POC] was excellent, fast and easy. When I go to the doctor I have to wait too long. It’s scary . . . [With your test] I don’t have to worry. I already know if I am OK or not. If it takes long, I’m nervous. (FG-6)
Testing with CHW–CBR teams was considered preferential to testing with “outsiders” as participants could avoid disclosing their sex work involvement to their primary care provider. Approximately 90% of women stated that their primary care provider was unaware they engaged in sex work (Table 2). CHWs and CBRs were perceived as nonjudgmental and knowledgeable about women’s sexual practices. The statement “we trust you. Because you already know the kind of work we do, we do not need to hide anything” was consistently noted within all focus groups. Most women reported fear of discrimination, judgment, or a lack of attention to health issues unrelated to sex work as reasons for not disclosing their sex work activity to their care provider:
I feel embarrassed to go to family doctors and request a HIV test . . . They would think that “how come you have AIDS? You must have some secret.” If you go to a doctor and ask for whole body exam, or specifically ask for HIV test, your doctor will see you differently right away. (FG-4)
Women also noted that by not disclosing their sex work activity to their physician, they could maintain separation between their “normal” lives and their experiences as CSWs:
I don’t tell him [my doctor] ’cause outside I’m normal, but inside I still work. (FG-7)
In other instances, their decision not to tell was related to their attempts to prevent friends and family members from learning about their work as they shared the same care provider.
Health Promotion and Education
As part of pretest counseling, CHWs and CBRs explored with women the appropriateness for testing, their readiness to test, their current access to health care services, and their social support systems. It was during these discussions that CHW–CBR teams identified women’s particular health education needs about STI and HIV transmission and responded in the moment, as noted in this excerpt from CBR field notes:
[When talking about why she may want testing] She was very concerned about HIV transmission, even via hand jobs. We spent time speaking about the risks involved in different kinds of sexual acts, mostly in relation to HIV transmission but also in terms of other STI’s. (Field note)
Although most women reported consistent condom use (Table 2), pretest counseling revealed that several women experienced condom breakage. In response, CHW–CBR teams provided critical health education about correct condom placement and strategies to reduce risk of breakage, such as use of lubricant. Also, CHWs used their experiential knowledge to help women learn how to ensure placement of condoms on clients and to position themselves in ways that permitted monitoring client behavior should one try to remove a condom. This was important given the reported instances of clients who attempted to secretly remove condoms (Table 2).
In discussing the significance of more comprehensive STI testing and potential need for confirmatory HIV testing, we were able to offer support and education concerning how women navigated sexual health issues with their family physicians. Additionally, we were able to support women’s access to health services. More than 25% of women did not have health insurance (Table 2). CHWs and CBRs provided vital information and referrals to assist women in obtaining medical services plan coverage.
Our outreach provided an opportunity for change in CSW health care–seeking behavior as it encouraged future testing for many CSWs who felt reassured regarding their health by ORCHID testing:
Good idea . . . I am safe; my body is safe . . . I feel secure . . . For health, I want to check once every half a year. (FG-6)
CHWs also provided social support in their ability to listen and appreciate experiences of participants. As one woman noted,
Even if we feel fine [no worries about health] when you visit us, it is still great to talk with you. I like that you visit us often. (FG-7)
Although testing experiences were overwhelmingly positive, a few participants expressed preference to receive HIV and STI testing from a family doctor and/or in a clinical setting regardless of reluctance to disclose the nature of their work:
[Participant] was resistant to HIV test. She said that it is not because she has HIV, but that she just not want to hear a positive result in the parlor. She wants to do it at her GP. (Field note)
If I had the choice between the community-based outreach workers and a family doctor, I would choose to visit a family doctor because [they] will keep everything confidential. (FG-4)
Confidentiality was considered an issue with CHW–CBR teams because of the potential for women to be visited by different team members. Although we assured confidentiality among the teams, as the project progressed we learned it was critical to explore the comfort of participants with being visited by different team members. For participants expressing concern, we strove to ensure the same team members were able to visit them consistently.
Some participants also expressed concern regarding cleanliness (e.g., clinic environments being perceived as cleaner) and assumptions that physicians were more credible in performing tests to ensure accuracy of results:
When you are in the [clinic] and you have tests, everything is very clean . . . Also, when the doctor does the test, I feel more comfortable because I know that it is being done correctly. (FG-6)
For others, their uncertainty involved the efficacy of POC HIV testing, questioning whether it was as accurate as testing requiring venipuncture and blood draw. Women were concerned that POC testing was somehow “not as good” because it required a small amount of blood and results could be available in minutes:
I am suspicious whether this method is accurate or not because . . . this test only requires tiny amount of blood. I was not very convinced. Also the result of the test was seen in less than a minute . . . (FG-4)
Learning about women’s perceptions of testing onsite provided us with important opportunities for health education and supported us to facilitate clinic visits and accompany CSWs when requested.
Discussion
Within our community–academic partnership, we responded to an urgent need to develop understanding of women’s work and sexual health practices within a relatively invisible indoor sex industry and to implement an expanded program of services to promote CSW health. The implementation of a CHW model approach to a HIV prevention intervention expanded the ORCHID project’s outreach activities, built capacity among CHW, and addressed key aspects of CSW barriers to HIV and STI testing, all of which were of direct benefit for women’s health. Repeat visits by CHW–CBR teams facilitated the development of trusting and supportive relationships with participants, and CHWs were able to provide health education drawing on their expert knowledge that was contextually relevant and meaningful for participants. Participants were actively involved in managing their health and interested in health promotion and education activities particularly when these were provided at their work in a nonjudgmental manner and in their preferred language. These factors, in addition to the convenience of onsite and rapid testing methods, contributed to the acceptability of POC HIV and self-obtained STI tests among the majority of participants. Additionally, given the goal of community empowerment, the health education provided as part of the testing services contributed to enhanced CSW capacities to protect their health and improved women’s access to health care.
The benefits of HIV and STI testing outside of traditional health care settings has been well documented (e.g., Liang et al., 2005; Puro et al., 2004; Spielberg et al., 2005). Research comparing POC with standard HIV testing suggests that POC testing has resulted in increased HIV test uptake in outreach settings (Antonia-Gaddy et al., 2006; Wurcel, Zaman, Zhen, & Stone, 2005), in test volume (Greenwald, Hall, & Skolnik, 2006), as well as in receipt of results to 95% to 100% of study participants (Kendrick et al., 2005; Metcalf et al., 2005). Researchers have also demonstrated that self-swab specimen collection contributes to increased uptake of STI testing, particularly among young women (Holland-Hall, Wiesenfeld, & Murray, 2002; Rose, Lawton, Bromhead, MacDonald, & Lund, 2007). There are concerns that offering limited testing services (e.g., POC HIV testing in absence of other testing or limited STI testing) may have a negative impact on other testing (see Shima et al., 2006). However, our research illustrates that by offering onsite testing in combination with empowering health education activities that facilitate access to services, outreach CHW model approaches can contribute to increase health care access and testing uptake.
It is important to acknowledge that our results show a preference among some women to receive testing in more formal health care settings. This underscores the need for comprehensive assessment of women’s preferences and needs to ensure contextual appropriateness of interventions to promote health. Although our results are promising and other researchers have illustrated the benefits of empowering health education interventions among CSWs for STI and HIV prevention (Ghose, Swendenman, & George, 2011; Swendeman et al., 2009), further longitudinal work to assess the interventional outcomes of our program is needed.
Conclusions
The expansion of ORCHID project activities illustrated that the implementation of, and partnerships between, a variety of service delivery models can help promote a broad range of access to STI and HIV care and that community-led health promotion programs that work to supplement deficiencies within the health care system are well situated to address health issues among underserved or otherwise marginalized populations.
The CHW model in particular, can serve to supplement access for populations often overlooked in health programming through availability of multilingual and culturally sensitive services by peers, testing outside of clinical settings, and rapid and self-testing techniques. As a result, there are several recommendations that we put forth that have relevance to our specific urban locale and potentially other centers and programs aimed at protecting the health of CSWs in indoor settings. First, it is essential that partnerships between outreach programs and existing clinical services be forged. POC and self-swab testing do not represent the full spectrum of care to promote women’s sexual health and may work most effectively when CHWs can support appropriate and seamless transitions into nonjudgemental health care. We also recommend the integration of translators into the CHW teams and that CHW receive extensive training and support to carry out their specific activities. Policy and programming to support free and voluntary HPV vaccination may also be critical given the high incidence of HPV in the small sample obtained. In undertaking a CHW model approach that integrates research and service, it is important that research activities be undertaken in an ethical manner that does not limit CSW access to services. In many studies, CHW often engage in data collection. We put forth that separation of CHW and CBR roles may guarantee that care is not perceived to be dependent on research participation and, as demonstrated here, support uptake of services independent of the research. Finally, it is of significance to note the high levels of postsecondary education reported among the CSW participants. Further study to investigate barriers to employment is warranted with an aim to address potential inequities because of immigration status. This research is critical to inform policy to support enhanced economic opportunities for women.