Empowering sex workers in India to reduce vulnerability to HIV and sexually transmitted diseases☆
Introduction
The Sonagachi Project was conceived in 1992 to address vulnerability for sexually transmitted diseases (STD) and HIV infection among sex workers in red-light areas of Kolkata, India (Jana & Singh, 1995). It has since evolved to become a widely diffused model labeled an “empowerment approach” to STD/HIV prevention (Blankenship et al., 2006, UNAIDS, 2000, Wallerstein, 2006), by successfully mobilizing diverse financial resources (e.g., WHO, DFID, Gates Foundation, government), and building a social movement of more than 60,000 sex workers to sustain and expand the program to over 60 communities in West Bengal (Jana, Basu, Rotheram-Borus, & Newman, 2004). The Sonagachi Project was also a model for (and its leadership advisors to) the recent Bill and Melinda Gates Foundation funded scale-up of HIV prevention targeting high-risk groups in India (i.e., Project Avahan).
This model program intervenes at multiple levels (structural or environmental, community, social network, individual) using core strategies common to women's empowerment programs globally to address five common factors of effective, evidence-based HIV prevention programs. The common factors framework resulted from content analyses of manuals for evidence-based interventions for HIV/STD prevention (Rotheram-Borus, Swendeman, Flannery, Rice, et al., 2009). Common factors represent what every HIV/STD prevention program does, or should do, to be effective and provides a framework for multiple intermediate prevention program goals: 1) provide a frame to motivate change; 2) increase knowledge of risk and protective factors; 3) build cognitive, affective, and behavioral skills; 4) reduce environmental barriers to change; and 5) build ongoing social support to sustain change over time.
To achieve HIV/STD prevention goals, the Sonagachi project has adopted empowerment strategies common across women's empowerment programs and organizations globally, identified in Kar, Pascual, and Chickering's (1999) “EMPOWER” review and synthesis: Education and leadership development, Media use and advocacy, Public education and participation, Organizing associations and unions, Work training and micro-enterprise, Enabling services and assistance, and Rights protection and promotion (see Jana et al., 2004 and methods below for Sonagachi specific details). Together, these strategies restructure risk environments to enable or “empower” sex workers to protect their health and families' well-being (Jana et al., 1998).
Due to Sonagachi's notoriety as a model program for replication, a large body of qualitative and descriptive research has emerged to elaborate Sonagachi's underlying processes, including: program development and intervention components (Jana et al., 1998, Jana et al., 2004); community participation (Basu and Dutta, 2008, Cornish, 2006a, Evans and Lambert, 2008a); advocacy and community leadership (Cornish and Ghosh, 2007, Pardasani, 2005); challenges to stigma and oppression (Cornish, 2006b); the role of agency and contextual contingencies in sexual practices (Evans & Lambert, 2008b); and sex worker collective identity in mobilizing condom use (Ghose, Swendeman, George, & Chowdhury, 2008). However, program impacts have only been reported quantitatively for increased condom use (Basu et al., 2004) and STD treatment seeking (Gangopadhyay et al., 2005) when compared to a standard care of STD clinics, peer education, and condom promotion.
We previously reported improved condom use rates over 16 months in a Songachi intervention replication community (39%) compared to standard care control (11%), and a 25% increase in consistent (i.e., 100%) condom users compared to a 16% decrease in control; STD incidence (<10%) was too low to detect intervention effects (Basu et al., 2004). Yet, these results do not elucidate the empowerment intervention's processes and proximal impacts on other HIV/STD prevention related outcomes. This paper presents quantitative results of the Sonagachi empowerment intervention's impacts on 21 measured variables reflecting five common factors of effective, evidence-based, HIV/STD prevention programs as intermediate program outcomes. Broadening focus from condom use and STD infection to common factors of effective prevention programs enables elaboration of the ecologically driven empowerment processes, impacts, and limitations, and contributes to the practice-based evidence needed to support researchers and prevention planners to better understand ecologically oriented, multi-component, empowerment programs (Green, 2006).
Empowerment is a multi-level construct describing both processes and outcomes that aim to enhance agency with explicit attention to structure or context (Schulz, Israel, Zimmerman, & Checkoway, 1995). Empowerment has been elaborated at psychological, organizational, and community levels, and links individual self-efficacy (i.e., person-level empowerment) to participation in organizations that can influence structural factors or contexts (e.g., policies, risk environments) (Laverack & Wallerstein, 2001). Measuring “empowerment” is challenging due to the multi-level and ecological nature of the construct, and thus requires examining multiple, context dependent, outcome variables simultaneously (Alsop and Heinsohn, 2005, Israel et al., 1994, Kabeer, 1999, Laverack and Wallerstein, 2001). While an empowerment program's stated priority targets may be specific (e.g., reducing SDT or HIV infection), a program's multiple intervention strategies are intended to impact a web of proximal and distal causal factors, which can translate across a broader range of challenges and result in a generalized reduction in structural vulnerabilities and enhancement of individual agency (i.e., empowerment as an outcome). However, generalized empowerment is difficult to assess reliably and meaningfully unless grounded in measured variables in specific domains (Alsop & Heinsohn, 2005), for example, safe-sex negotiation versus general or non-specific negotiation skills. Therefore, in this paper, we conceptualize empowerment as intervention strategies and processes, and examine their impacts on measured variables of multiple outcomes linked to program goals to reduce vulnerability to HIV/STDs, using a common factors of effective HIV/STD prevention framework.
The challenges to operationalizing and measuring empowerment have also inhibited generating a strong evidence-base for empowerment program impacts, particularly quantitative results prioritized by many researchers, policy makers, and funders. In the Sonagachi example, the lack of evidence on empowerment component impacts has led to questions about whether STD/HIV services, peer education, and condom promotion are sufficient and whether empowerment intervention strategies are necessary or what value they add (Gangopadhyay et al., 2005). This paper specifically compares the impact of Sonagachi's empowerment intervention strategies (advocacy, community organizing and mobilization, rights-based framing, and micro-finance) to a standard care of STD/HIV services, peer education, and condom promotion.
Empowerment theory and practice focused on enhancing the status and agency of women is commonly addressed in development economics (Kabeer, 1999, Sen, 1990). Gender-based marginalization, exacerbated by poverty and caste/class/ethnicity-based discrimination, is evident in low levels of education and limited economic opportunities for women outside the home globally (Krieger, 2003, Sen, 1990). These factors reinforce perceptions that girls are burdens in poor households, driving the “missing women” phenomena evident in sex-ratio demographic data suggesting that girls are aborted, victims of infanticide, or otherwise neglected to result in early mortality (Krieger, 2003). These issues are particularly salient in contemporary India (Bhaskar & Gupta, 2007). Low education and lack of economic opportunities drive some women in India to sex work when abandoned by husbands, widowed, orphaned, or facing abject poverty (Gangopadhyay et al., 2005). Countervailing these trends are observations that economic opportunities for women outside the home increase negotiating power in household decision-making (Sen, 1990). Micro-finance addresses economic exclusion and vulnerability by making credit available to poor women and families (Yunus, 2005).
Household economic instability has also been found to increase HIV risk behaviors, with disproportionate impact on women (Aidala, Cross, Stall, Harre, & Sumartojo, 2005). In the sex work context, negotiating consistent condom use has economic consequences; sex workers surveyed in Kolkata who consistently use condoms experience financial losses estimated around 70% compared to less consistent condom users (Rao, Gupta, Lokshin, & Jana, 2003). Individual-level empowerment (“control perceptions” or self-efficacy), therefore, is a highly salient factor supporting condom use for groups that lack power such as women, young people, ethnic minorities, and the under educated (Albarracin, Kumkale, & Johnson, 2004).
Finally, “politicization” associated with rights-based and identity-movement empowerment strategies, like those used by the Sonagachi Project, reframe or transform self-perceptions and motivations in deprived groups, who may be “habituated to inequality,” “unaware of possibilities of social change,” “hopeless,” or “resigned to fate” (Sen, 1990). Fairness, justice, and identity are particularly salient in women's movements in India (Ray & Korteweg, 1999).
Section snippets
Intervention methods and development
The Sonagachi Project is organized into relatively distinct organizational units that emerged over time in response to community needs and that work closely together to deliver a variety of clinical services and empowerment strategies. The three primary units are an STD/HIV intervention program, a sex workers community organization, and a micro-finance cooperative. Their evolution and theory of action are described below and shown in Fig. 1.
Sample description and univariate statistics
A detailed study and sample description was published previously (Basu et al., 2004). Briefly, the mean age was 27 (SD = 7, range 18–50) with about half the sample between ages 21 and 29. Half had live-in partners and about half (46%) had children. Substance use was low; only about 1/3 reported drinking alcohol, and less than 3% (n = 5) injected drugs. Biomarkers and clinical exams indicated low current STD prevalence (<10%) but high lifetime exposure; about 60% had been exposed to syphilis; low
Discussion
Over a 16 month replication trial, the Sonagachi Project's empowerment intervention strategies (community organizing and mobilization, rights-based framing, advocacy, micro-finance) had broad impacts on factors that reduce vulnerability to HIV/STD infection, and which are common across effective HIV/STD prevention programs. Compared to a standard care of STD clinic, condom promotion, and peer education, the additional empowerment intervention strategies: 1) improved knowledge of STDs and condom
References (36)
- et al.
The necessary contradictions of ‘community-led’ health promotion: a case study of HIV prevention in an Indian red light district
Social Science & Medicine
(2007) - et al.
Implementing community interventions for HIV prevention: insights from project ethnography
Social Science & Medicine
(2008) - et al.
Mobilizing collective identity to reduce HIV risk among sex workers in Sonagachi, India: the boundaries, consciousness, negotiation (BCN) framework
Social Science & Medicine
(2008) - et al.
Empowerment of women for health promotion: a meta-analysis
Social Science & Medicine
(1999) - et al.
Sex workers and the cost of safe sex: the compensating differential for condom use among Calcutta prostitutes
Journal of Development Economics
(2003) - et al.
Housing status and HIV risk behaviors: implications for prevention and policy
Aids and Behavior
(2005) - et al.
Influences of social power and normative support on condom use decisions: a research synthesis
Aids Care-Psychological and Socio-Medical Aspects of AIDS/HIV
(2004) - Alsop, R., & Heinsohn, N. (2005). Measuring empowerment in practice: structuring analysis and framing indicators, World...
- et al.
Participatory change in a campaign led by sex workers: connecting resistance to action-oriented agency
Qualitative Health Research
(2008) - et al.
HIV prevention among sex workers in India
Journal of Acquired Immune Deficiency Syndromes
(2004)
India's missing girls: biology, customs, and economic development
Oxford Review of Economic Policy
Structural interventions: concepts, challenges and opportunities for research
Journal of Urban Health-Bulletin of the New York Academy of Medicine
Empowerment to participate: a case study of participation by Indian sex workers in HIV prevention
Journal of Community & Applied Social Psychology
Challenging the stigma of sex work in India: material context and symbolic change
Journal of Community & Applied Social Psychology
The limits of behaviour change theory: condom use and contexts of HIV risk in the Kolkata sex industry
Culture, Health & Sexuality
Evaluation of sexually transmitted diseases/human immunodeficiency virus intervention programs for sex workers in Calcutta, India
Sexually Transmitted Diseases
Public health asks of systems science: to advance our evidence-based practice, can you help us get more practice-based evidence?
American Journal of Public Health
Health-education and community empowerment – conceptualizing and measuring perceptions of individual, organizational, and community control
Health Education Quarterly
Cited by (158)
HIV prevalence and associated factors among female sex workers in Ethiopia, east Africa: A cross-sectional study using a respondent-driven sampling technique
2022, eClinicalMedicineCitation Excerpt :Therefore, targeted and evidence-based strategies should be designed to fight against HIV in FSWs.64,65 This should include: expanding HIV test services and early initiation of ART for all FSWs with special consideration to the older age FSWs, providing alternative income sources for young girls in school and FSWs with economic instability,66–68 educating FSWs about proper condom use, and strengthening STIs management.69,70 Because the study participants are hidden, we could not get a sampling frame, thus the estimates from a non-probability sampling technique may produce a biased HIV prevalence.
MAHI: a multidimensional access to healthcare index for hijra, kothi, and transgender individuals
2024, International Journal of Transgender HealthManaging motherhood–the experiences of female sex workers in Nairobi, Kenya
2023, Culture, Health and Sexuality
- ☆
World AIDS Foundation Grant No. 202 (99-028) supported this research. The American Institute of Indian Studies (AIIS) and the Center for HIV Identification, Prevention, and Treatment Services (CHIPTS) funded subsequent research by the first author that supported development and interpretation of this study's results. The authors are also grateful for the participation of sex workers in this study.