Community mobilization, empowerment and HIV prevention among female sex workers in south India. 2013

Andrea K Blanchard, and Haranahalli Lakkappa Mohan, and Maryam Shahmanesh, and Ravi Prakash, and Shajy Isac, and Banadakoppa Manjappa Ramesh, and Parinita Bhattacharjee, and Vandana Gurnani, and Stephen Moses, and James F Blanchard
Department of Community Health Sciences, University of Manitoba, S113 Medical Service Building, 750 Bannatyne Avenue, Winnipeg, MB, R3E 0W3, Canada. blancha7@cc.umanitoba.ca

BACKGROUND While community mobilization has been widely endorsed as an important component of HIV prevention among vulnerable populations such as female sex workers (FSWs), there is uncertainty as to the mechanism through which it impacts upon HIV risk. We explored the hypothesis that individual and collective empowerment of FSW is an outcome of community mobilization, and we examined the means through which HIV risk and vulnerability reduction as well as personal and social transformation are achieved. METHODS This study was conducted in five districts in south India, where community mobilization programs are implemented as part of the Avahan program (India AIDS Initiative) of the Bill & Melinda Gates Foundation. We used a theoretically derived "integrated empowerment framework" to conduct a secondary analysis of a representative behavioural tracking survey conducted among 1,750 FSWs. We explored the associations between involvement with community mobilization programs, self-reported empowerment (defined as three domains including power within to represent self-esteem and confidence, power with as a measure of collective identity and solidarity, and power over as access to social entitlements, which were created using Principal Components analysis), and outcomes of HIV risk reduction and social transformation. RESULTS In multivariate analysis, we found that engagement with HIV programs and community mobilization activities was associated with the domains of empowerment. Power within and power with were positively associated with more program contact (p < .01 and p < .001 respectively). These measures of empowerment were also associated with outcomes of "personal transformation" in terms of self-efficacy for condom and health service use (p < .001). Collective empowerment (power with others) was most strongly associated with "social transformation" variables including higher autonomy and reduced violence and coercion, particularly in districts with programs of longer duration (p < .05). Condom use with clients was associated with power with others (p < .001), while power within was associated with more condom use with regular partners (p < .01) and higher service utilization (p < .05). CONCLUSIONS These findings support the hypothesis that community mobilization has benefits for empowering FSWs both individually and collectively. HIV prevention is strengthened by improving their ability to address different psycho-social and community-level sources of their vulnerability. Future challenges include the need to develop social, political and legal contexts that support community mobilization of FSWs, and to prospectively measure the impact of combined community-level interventions on measures of empowerment as a means to HIV prevention.

UI MeSH Term Description Entries
D007194 India A country in southern Asia, bordering the Arabian Sea and the Bay of Bengal, between Burma and Pakistan. The capitol is New Delhi. Republic of India
D011209 Power, Psychological The exertion of a strong influence or control over others in a variety of settings--administrative, social, academic, etc. Power (Psychology),Power, Personal,Power, Professional,Power, Social,Power,Personal Power,Powers, Psychological,Professional Power,Psychological Power,Psychological Powers,Social Power
D005260 Female Females
D006293 Health Promotion Encouraging consumer behaviors most likely to optimize health potentials (physical and psychosocial) through health information, preventive programs, and access to medical care. Health Campaigns,Promotion of Health,Wellness Programs,Promotional Items,Campaign, Health,Campaigns, Health,Health Campaign,Health Promotions,Item, Promotional,Items, Promotional,Program, Wellness,Programs, Wellness,Promotion, Health,Promotional Item,Promotions, Health,Wellness Program
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D000328 Adult A person having attained full growth or maturity. Adults are of 19 through 44 years of age. For a person between 19 and 24 years of age, YOUNG ADULT is available. Adults
D012922 Social Change A shift, alteration, modification, or evolution of human behavior and culture, which over time, results in measurable consequences on societal values and norms. Modernization,Social Development,Social Impact,Change, Social,Changes, Social,Development, Social,Developments, Social,Impact, Social,Impacts, Social,Social Changes,Social Developments,Social Impacts
D015397 Program Evaluation Studies designed to assess the efficacy of programs. They may include the evaluation of cost-effectiveness, the extent to which objectives are met, or impact. Evaluation, Program,Family Planning Program Evaluation,Program Appropriateness,Program Effectiveness,Program Sustainability,Appropriateness, Program,Effectiveness, Program,Evaluations, Program,Program Evaluations,Program Sustainabilities,Sustainabilities, Program,Sustainability, Program
D015658 HIV Infections Includes the spectrum of human immunodeficiency virus infections that range from asymptomatic seropositivity, thru AIDS-related complex (ARC), to acquired immunodeficiency syndrome (AIDS). HTLV-III Infections,HTLV-III-LAV Infections,T-Lymphotropic Virus Type III Infections, Human,HIV Coinfection,Coinfection, HIV,Coinfections, HIV,HIV Coinfections,HIV Infection,HTLV III Infections,HTLV III LAV Infections,HTLV-III Infection,HTLV-III-LAV Infection,Infection, HIV,Infection, HTLV-III,Infection, HTLV-III-LAV,Infections, HIV,Infections, HTLV-III,Infections, HTLV-III-LAV,T Lymphotropic Virus Type III Infections, Human
D060386 Sex Workers People who engage in occupational sexual behavior in exchange for economic rewards or other extrinsic considerations. Prostitutes,Sex Worker,Sex Worker Clients,Client, Sex Worker,Clients, Sex Worker,Prostitute,Sex Worker Client,Worker Client, Sex,Worker Clients, Sex

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