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 .
Sonagachi intervention components, and targeted HIV/STD outcome domains and measured variables.
STD/HIV intervention project (SHIP)
In 1991 a rapid appraisal of STD/HIV risk in Kolkata’s largest red-light area known as Sonagachi was conducted by the All India Institute of Hygiene and Public Health. Based on that appraisal, the STD/HIV Intervention Project (SHIP) was established to provide STD treatment, health education, and promote condom use in the community. The high status physician leading the project, and its professional support staff, gained entry to the community and access to sex workers by advocating with politicians, police, brothel owners, and other stakeholders, and framing HIV/STDs as threats to the livelihoods and health of the whole community. Sex workers were hired and trained as peer educators, condom social marketers, and eventually as supervisors and program coordinators.
Sex worker’s community organization
SHIP supported establishment of a sex worker community forum as a program partner, which became formalized as the Durbar Mahila Samanwaya Committee (DMSC: “Unstoppable Equal Women’s Committee”) and is now the executive unit for the entire Sonagachi Project. The term “sex worker” was adopted to mitigate stigma associated with more common terms (whore) and build self-respect among sex workers. “Sex work is valid work – we demand worker’s rights” became a master frame for the project to transform community perceptions, and provide a rights-based frame to motivate community mobilization and long term self-protection. In each community served, a local DMSC chapter is established with local sex workers elected by community members for two-year terms as President, Vice President, Secretary, and Treasurer. DMSC officers, with support from SHIP staff, coordinate community organizing and mobilizing activities to build consciousness and solidarity among sex workers through meetings, street rallies, demonstrations, and state and national conferences of sex workers. DMSC officers also support SHIP’s treatment, education, and condom promotion activities by assisting with community access and treatment follow-up, and diffusing prevention messages as popular opinion leaders.
Advocacy with stakeholders and powerbrokers
DMSC’s officers and extended member network, as well as SHIP’s highly educated physicicans, educators, and their networks, partner to advocate with powerbrokers on the importance of the project, treatment, and condom use for their mutual safety and livelihoods, and educate clients and the community through outreach events that also aim to reduce stigma that reinforces marginalization of sex workers. DMSC also encourages political participation to build a sex worker voting block to enhance social capital and leverage power in advocacy work with politicians and local political clubs that can influence policies, police actions, and powerbroker dynamics at local, state, and national levels.
The USHA Multi-purpose Cooperative was established to provide safe savings and lending to reduce vulnerability to theft as well as debts from informal sources (money lenders, madams, peers) that reduce negotiating capacities in sexual exchanges. Sex workers’ marginalized and stigmatized status, coupled with low literacy levels, present significant environmental barriers to accessing traditional banking. USHA’s sex worker “field tellers” go into the community, from house to house, encouraging peers to commit to a savings plan and then make daily or weekly follow-up visits to collect deposits and report on account balances. When needed, depositors can “borrow” or withdraw from their own accounts, with counseling from field tellers and other USHA staff. Larger loans are also made available to finance micro-enterprises (e.g., sewing, craft manufacture, small retail, farmland and livestock, investment in rickshaw or taxicab).
Multiple intervention strategies to restructure risk environments
The Sonagachi Project’s intervention components evolved to restructure power dynamics and risk environments in brothel communities to support STD/HIV prevention goals specifically, and sex workerautonomy and safety generally. shows a logic model representing Sonagachi intervention components, development and sequence in replications, their targeted outcomes as measured variables in the common factors for HIV/STD prevention framework, and reinforcing relations between factors. SHIP activities primarily aim to impact HIV/STD-related knowledge and skills, in addition to providing treatment and condoms. DMSC activities address all five factors, primarily by diffusing information and support for SHIP activities, diffusing rights-based frames and messages to motivate change, building social support and community solidarity, mobilizing political participation to build social capital to enhance advocacy, and diffusing new norms for savings and alternative income enabled by USHAs micro-finance services. In terms of HIV/STD prevention goals, sexual negotiation skills and related variables are most proximal, while framing, social support, social capital, and economic security all support negotiation power and skills.
This paper’s first aim is to evaluate Sonagachi’s empowerment intervention effects on 21 measured variables representing HIV/STD linked program outcomes outlined in and detailed below. We hypothesized that sex workers in the Sonagachi intervention community will report greater increases in these outcome variables over time compared to a control community receiving STD treatment, peer education and condom promotion only as standard care. The cumulative impacts of the intervention are also examined by summing the individual measured outcome variables into a summary outcome index.
A secondary aim of this paper is to examine demographic variables and other potential predictors or confounders of empowerment intervention effects on HIV/STD prevention outcomes. Age, time working in sex work, literacy, self-employment, and higher income are hypothesized to support broader empowerment processes such as workplace autonomy, financial security, and negotiation power that reduce vulnerability to HIV/STD infection. Having a live-in male partner or husband may limit freedoms to make changes advocated by Sonagachi. Having children is hypothesized to motivate mothers to participate in Sonagachi activities but may also induce economic pressures that suppress negotiating capacities and program participation.
A quasi-experimental intervention trial was conducted from 2000 to 2001 in two rural towns in West Bengal with no prior Sonagachi Project exposure. The study’s broad goals were to evaluate Sonagachi’s empowerment intervention impacts on HIV/STDs infection, condom use, and other intermediate outcomes (the focus of this study) compared to STD/HIV treatment, peer education and condom promotion alone as a standard of care. Female sex workers were selected through two-stage random sampling of houses and residents in the two town’s “red-light areas” (n = 110 in each), invited to participate in assessment activities with informed consent, and completed a baseline and three follow-up interviews over 16 months. The structured assessments were completed in Bengali by SHIP evaluation staff-persons, who were trained and overseen by UCLA researchers.
The Institutional Review Boards of UCLA, DMSC, and local community groups in each town reviewed and approved the study protocol. Participants provided voluntary informed consent written in simplified language or delivered verbatim if the participant was illiterate.
STD clinics were established in both communities as standard care, including in-clinic peer education and condom social marketing. Empowerment intervention strategies (community organizing, advocacy, rights-based framing, micro-finance) were implemented in the intervention community.
Sex workers were asked to identify STD symptoms, and HIV and STD prevention methods. Each question was coded (1) if the sex worker knew at least one STD symptom, and that condoms prevent HIV/AIDS and STDs, respectively. Sex workers were also asked if they perceived themselves to be at risk for STD/HIV.
Skills for sexual negotiation and workplace autonomy
Three questions assessed condom use sexual negotiation: being the most important condom use decision-maker among a list that included clients, madam, partner, and landlords; ability to refuse a client for a particular sex act; and having ever refused a client for refusing to use a condom. Two questions assessed general work-place autonomy: ability to change work contract; and ability to take leave if sick or unwilling to work.
Sex “worker” frame to motivate change
Three questions were asked reflecting the worker frame diffused by Sonagachi; agreeing with the statement that “sex work is valid work”; having ever disclosed their profession to a non-sex worker (reflecting reduced stigma or sex worker pride); and if they wanted more education or training (reflecting consciousness as a “worker” and human being with a long term vision as opposed to a “fallen woman”).
Social support via organizing and solidarity
Three questions were asked, covering the prior three-months: visiting with other sex workers outside work; participation in social functions; and helping other sex workers when harassed or abused.
Four questions asked about saving money, having other income outside sex work, working in other places, and taking loans. Taking loans was considered a negative outcome reflecting economic insecurity since savings are encouraged over loan taking by Sonagachi.
Sex workers were asked if they voted in the last election and, if so, whether they voted willingly.
Summary outcome index
A pseudo-continuous outcome measure was constructed by summing the binary outcome variables described above. Outcome variables without statistically significant intervention effects in individual analyses were excluded from the summary index.
Hypothesized predictors or confounders of intervention effects
Age and experience
Age was measured in years. Work experience was measured in months working in sex work.
Sex workers were asked if they could sign their name (13%), were self-taught (3%), had primary school education (11%), or secondary school education (1%). Preliminary analyses indicated that formal education (primary or secondary) predicted the most variation in outcomes so literacy was dichotomized as formal education (1) or not (0).
Live-in partner status
Live-in partners commonly consider themselves to be married; responses were collapsed to “having a current live-in husband or partner” (1) versus not (0).
Present work contract
Women reported being self-employed (75%), or working under a madam with a 50/50 split contract (2%) or a “bonded” salaried contract (23%). This variable was dichotomized as self-employed (1) versus contract worker (0).
Income was reported in rupees earned per week.
Random-effects repeated-measures regression analyses were conducted for all outcomes using SAS v. 9 (i.e., NLMIXED procedure for binary logistic outcomes and the MIXED procedure for the summary outcome index), as well as the HMLM and HLM2 modules in HLM v.6.4. Analyses tested random intercepts and slopes using full and restricted maximum likelihood estimation. Hypothesized predictors or confounders of intervention effects were also tested in longitudinal models, which confirmed that they did not change significantly over the intervention period.
Preliminary analyses coded time as a continuous variable with baseline coded (0) and each follow-up coded 1–3, estimating average change in outcome at each follow-up. For final analyses, time was re-coded to 0, 0.33, 0.67, and 1 for baseline and follow-ups, respectively, to provide estimates of overall expected change by final follow-up at 16 months.
Statistical methods for the 21 individual binary outcomes
All 21 individual measured outcome variables were examined in separate models. Random-effects repeated-measures logistic regression methods with modestly sized samples, as in this study, do not provide statistical power to support complex models with many covariates and interaction terms (Liu & Wu, 2008
). In preliminary analyses, random intercept and slope (RIAS) models, and models with several covariates failed to converge. Since this study’s primary aim is to examine intervention effects, priority was placed on controlling for confounders of intervention effects through effect modification (i.e., predictor by intervention by time interactions). Each hypothesized predictor or confounder (i.e., age, time in sex work, education, income, self-employment, children, partnered) was tested for intervention effect modification for each outcome in random intercept models that adjust for baseline differences in the outcomes between groups.
Statistical methods for the summary outcome index
Summing the individual outcome variables into a pseudo-continuous summary outcome index enabled random-effects repeated-measures linear regression methods that support more complex multivariate models. The index also approximates a dose-response measure for intervention effects. Individual outcome variables that did not have statistically significant intervention effects were excluded from the summary outcome index (see results and ), resulting in 16 total variables comprising the index. Hypothesized predictors and confounders were tested in models estimating summary outcome score at baseline (i.e., intercept equation), change in summary outcome score over time (i.e., slope equation), and intervention impacts on outcome score over time (i.e., intervention effect modification interaction term). Analyses also tested “level-one” covariance structures (i.e., modeling correlation of repeated-measures within individuals), and quadratic and cubic growth curves. Finally, a latent variable model tested the influence of summary score at baseline on change in summary outcome score over time by including the intercept equation (estimating the baseline outcome score) as a predictor of the slope equation (estimating change in summary outcome score over time) (see Raudenbush & Bryk, 2002
; Seltzer, Choi, & Thum, 2003
Population proportions (%), odds ratios (OR) and 95% confidence intervals (CI) for trends in outcome variables over 16 months.