Community-led Structural Intervention Research Articles

Sexual health communication between sex worker mothers and their children in India

In India, relatively little is known about sex worker mothers’ beliefs regarding sexual health communication with their children. Using qualitative data collected in Kolkata, India, this study used the Parent Expansion of the Theory of Planned Behaviour to examine sex worker mothers’ beliefs about sexual health communication and factors shaping these beliefs. Sex worker mothers’ beliefs about sexual health communication were shaped by societal norms and collectivising processes often driven by Durbar Mahila Samanwaya Committee (DMSC), a sex workers’ collective in Kolkata, India. Specifically, we found that challenging stigma, assuming ownership over one’s body and health, and making relevant material resources and knowledge accessible and meaningful were key in supporting mothers to overcome barriers around sexual health communication. These collectivising processes shaped mothers’ beliefs about sexual health communication and facilitated their ability to engage in it. Future research, policies and programmes should consider the far-reaching impact of community-led structural interventions on sex worker mothers and their children.

Examining the Role of a Community-Led Structural Intervention in Shaping Mothering Among Sex Workers in India

The aim of this study is to explore the ways in which community-led structural interventions (CLSI) shape the mothering experiences of sex workers. In-depth semistructured interviews were conducted with 40 sex worker mothers from Kolkata, India. Participants were recruited from Durbar Mahila Samanwaya Committee (DMSC), a CLSI. Elements of constructivist grounded theory were employed. Results revealed DMSC mobilization (re)shaped mothering for female sex workers through (a) the subjective reorientation about establishing sex work as legitimate labor and disclosing sex worker identity and (b) access to material resources such as safe spaces, childcare networks, and educational opportunities. CLSI have the potential to influence the self-perception of communities that are marginalized and provide them with material resources that ultimately promote family well-being. While working with sex workers, it is imperative to understand their multiple, intersecting roles and co-develop community-based interventions not only with sex workers but their families as well.

Promoting women’s and children’s health through community groups in low-income and middle-income countries: a mixed-methods systematic review of mechanisms, enablers and barriers

IntroductionCommunity mobilisation through group activities has been used to improve women’s and children’s health in a range of low-income and middle-income contexts, but the mechanisms through which it works deserve...

Correlates of Suicidality Among A Community-Based Cohort of Women Sex Workers: The Protective Effect of Social Cohesion.

Suicide is a critical public health concern globally. Sex workers experience a disproportionate burden of social and health inequities driven by forms of violence, stigma, and criminalization, yet empirical research on suicidality is limited. This study longitudinally investigated the burden and socio-structural correlates of recent suicidality among women sex workers in Vancouver, Canada. Data (2010-2017) were drawn from a community-based, prospective cohort of cis and trans women sex workers across Metro Vancouver. Women completed biannual interviewer-administered questionnaires, and correlates of suicidality in the last 6 months were analyzed using bivariate and multivariable logistic regression with generalized estimating equations (GEE). Of 867 women at baseline, 48% (n = 413) reported lifetime suicidality, 16% (n = 141) reported suicidality in the last 6 months, and 29% reported suicidality at some point during the study. In multivariable analysis, factors independently associated with suicidality included physical/sexual childhood abuse (adjusted odds ratio [AOR]: 2.99; 95% confidence interval [CI] = [1.75, 5.10]), mental health issues (depression/anxiety/posttraumatic stress disorder; AOR = 2.19; 95% CI = [1.63, 2.95]), intimate partner violence (AOR: 2.11; 95% CI = [1.60, 2.80]), physical/sexual client violence (AOR: 1.82; 95% CI = [1.33, 2.50]), and homelessness (AOR: 1.44; 95% CI = [1.10, 1.89]). Older age (AOR: 0.97; 95% CI = [0.95, 0.99]) and higher social cohesion (AOR: 0.88; 95% CI = [0.78, 0.99]) were significantly associated with reduced odds of suicidality. Findings reveal key socio-structural correlates of suicidality among sex workers including experiences of historical and interpersonal violence, trauma/mental health issues, and homelessness. Strengthening social cohesion may have a protective effect on suicidality. Trauma-informed community-led structural interventions tailored to sex workers are urgently needed alongside a legal framework that enables collectivization and connectedness.

The moderating effect of psychedelics on the prospective relationship between prescription opioid use and suicide risk among marginalized women.

Given high rates of depression and suicide among marginalized women, and increasing calls to integrate trauma-informed biomedical and community-led structural interventions, this study longitudinally examines the potential moderating effect of psychedelic use on the relationship between other illicit drug use and suicide risk. Data (2010-2017) were drawn from a community-based, prospective open cohort of marginalized women in Vancouver, Canada. Extended Cox regression analyses examined the moderating effect of psychedelic use on the association between other illicit drug use and incidence of suicidal ideation or attempt over follow-up. Of 340 women without suicidal ideation or attempt at baseline, 16% ( n=53) reported a first suicidal episode during follow-up, with an incidence density of 4.63 per 100 person-years (95% confidence interval 3.53-6.07). In unadjusted analysis, psychedelic use moderated the relationship between prescription opioid use and suicide risk: among women who did not use psychedelics, prescription opioid use increased the hazard of suicide (hazard ratio 2.91; 95% confidence interval 1.40-6.03) whereas prescription opioid use was not associated with increased suicidal ideation or attempt among those who used psychedelics (hazard ratio 0.69; 95% confidence interval 0.27-1.73) (interaction term p-value: 0.016). The moderating effect of psychedelics remained significant when adjusted for confounders (interaction term p-value: 0.036). Psychedelic use had a protective moderating effect on the relationship between prescription opioid use and suicide risk. In the context of a severe public health crisis around prescription opioids and lack of addiction services tailored to marginalized women, this study supports calls for innovative, evidence-based and trauma-informed interventions, including further research on the potential benefits of psychedelics.

Community-Led Economic Initiatives with Sex Workers: Establishing a Conceptual Framework for a Multidimensional Structural Intervention

Commercial sex workers are at significant risk of contracting HIV. Scholars have identified economic insecurity and the exploitation resulting from it as structural vectors of HIV risk for this community. While community-led structural interventions have successfully reduced HIV risk with sex workers, economic structural interventions remain under-utilized and under-studied in this population. The few existing economic interventions described in the literature are limited to individual interventions and do not adopt a community-led structural intervention approach. We conduct a literature review to examine the connections between economic insecurity and sex worker HIV risk, the limitations of existing economic interventions with sex workers, and the evidence in support of HIV structural interventions with sex workers. We then develop a conceptual framework for a community-led structural economic intervention model that would enable sex workers to negotiate the socio-political and economic barriers that increase their HIV vulnerability. Specifically, we articulate an economic structural intervention model which stands on three pillars: (1) a meaningful community ownership, (2) a multilevel (individual, community, socio-political) intervention approach, and (3) a commitment to empowering sex workers as workers, rather than an orientation that seeks to rescue them from sex work through alternative income generation.

‘No one was there to care for us’: Ashodaya Samithi's community-led care and support for people living with HIV in Mysore, India

ABSTRACTUnder the umbrella of the Bill and Melinda Gates-funded HIV initiative in India, the Mysore-based sex workers’ (SWs) collective Ashodaya Samithi focused on improving its members’ living and working conditions through community-led structural interventions, including community mobilisation, advocacy, peer-led support, and health promotional activities. Based on four months of ethnographic fieldwork, this article examines the care and support activities of one of its sub-wings, Ashraya, which specifically focuses on people living with HIV and AIDS (PLHIV). We first discuss the stigma-related perceptions and experiences of participants in relation to health-care settings and work environment, families and communities, and within varied HIV support networks. We then explore how Ashraya's community-led interventions attempt to challenge the structural forces feeding on and creating stigma. We argue that the current policy focus on the involvement of SWs’ collectives in sexually transmitted infection (STI) prevention in India is rather limited and should be expanded along the continuum of care and support offered to PLHIV. As suggested in this paper, SWs’ organisations may have greater potential to contribute to more than STI prevention work, both within and outside their communities, than currently recognised.

"Whatever I have, I have made by coming into this profession": the intersection of resources, agency, and achievements in pathways to sex work in Kolkata, India.

This article investigated the complex interplay of choice, socioeconomic structural factors, and empowerment influencing engagement in sex work. The analysis was focused on pathways into and reasons for staying in sex work from in-depth qualitative interviews with participants (n = 37) recruited from the Durbar community-led structural intervention in Kolkata, India. Kabeer's theory of empowerment focused on resources, agency, and achievements was utilized to interpret the results. Results identified that contexts of disempowerment constraining resources and agency set the stage for initiating sex work, typically due to familial poverty, loss of a father or husband as a breadwinner, and lack of economic opportunities for women in India. Labor force participation in informal sectors was common, specifically in domestic, construction, and manufacturing work, but was typically insufficient to provide for families and also often contingent on sexual favors. The availability of an urban market for sex work served as a catalyst or resource, in conjunction with Durbar's programmatic resources, for women to find and exercise agency and achieve financial and personal autonomy not possible in other work or as dependents on male partners. Resources lost in becoming a sex worker due to stigma, discrimination, and rejection by family and communities were compensated for by achievements in gaining financial and social resources, personal autonomy and independence, and the ability to support children and extended family. Durbar's programs and activities (e.g., savings and lending cooperative, community mobilization, advocacy) function as empowering resources that are tightly linked to sex workers' agency, achievements, and sex work pathways.

Sex workers in HIV prevention: From Social Change Agents to Peer Educators

We utilised a comparative ethnographic approach to study the implementation of a community mobilisation intervention addressing HIV risk among female sex workers (FSWs) in India, as implemented first by an non-governmental organisation and after oversight of the intervention was transitioned to the government. We demonstrate that the work of peer outreach workers changed from Social Change Agents within a community-led structural intervention (CLSI) to Peer Educators within a targeted intervention (TI). In the CLSI approach, built on the assumption that FSW risk for HIV is rooted in power inequality and structural vulnerability, peer outreach workers mobilised their peers through community-based organisations to address underlying conditions of inequality and vulnerability. In contrast, the TI approach, which views FSW risk as a function of limited knowledge and barriers to services, addressed peers' access to information and health services. Analysis of changes in the function of peer outreach workers reveals critical differences of which we discuss four: assumptions about conditions that produce HIV risk; degree of emphasis placed on collective mobilising and building collective power; extent to which community mobilisation and HIV prevention goals are linked; and the intervention's use of peer input. We discuss the implications of these findings for HIV prevention programming.

Exceeding the Individual: a Qualitative Examination of a Community-Led Structural Intervention and Its Implications for Sex Workers and Their Families

While scholarship on community-led structural interventions has focused on contextual modifiers of HIV risk, few studies have examined other aspects of sex workers’ lives. The effects of community-led structural interventions are often isolated to individuals’ behaviors, such as condom use and number of sexual partners. However, comprehensive approaches toward modifying individuals behavior can also influence aspects of their family life. Evaluating such far-reaching effects is essential to better understand the success and sustainability of intervention efforts. In this study, we explore the impact of a sex workers’ community-led structural intervention, Durbar Mahila Samanwaya Committee (Durbar), on sex workers and their children. Initiated in 1992, Durbar has been hailed by the World Health Organization as a model community-led structural intervention for sex workers around the world. In partnership with Durbar, we conducted in-depth, semi-structured qualitative interviews with 35 sex worker mothers. In addition, we engaged in participant observation and documented processes through extensive field notes. This study found that the Durbar collective has made various resources available both in the material and symbolic realms that improved the quality of life of sex worker mothers and their children. It is important to evaluate primary intervention outcomes along with other meaningful outcomes that have the potential to secure community buy in and sustain effects over time.

Exploring the Role of Community-Based Peer Support in Improving Access to Care and Antiretroviral Treatment for Sex Workers in Mysore, India

To meet the HIV prevention needs of sex workers in India, some community-based organizations have begun integrating peer education and community mobilization into community-led structural interventions. As the role of community-based organizations continues to expand into new service areas, it is important to understand how these new interventions are received. This agency assessment was done in collaboration with Ashodaya Samithi in 2009. Ashodaya Samithi is a community-based organization led by female, male, and transgendered sex workers. In the past year, HIV-positive sex workers of Ashodaya have registered their own organization, known as Ashraya. Based on qualitative findings, this study describes how community-based organizations can play an important role in improving access to care and antiretroviral treatment for sex workers. The rapid growth of Ashraya and its success at fostering social solidarity and large-scale structural interventions hold valuable lessons for community-based organizations and public health practitioners working in the field of HIV/AIDS.

Sex worker-led structural interventions in India: A case study on addressing violence in HIV prevention through the Ashodaya Samithi collective in Mysore

Background & objectives:Structural interventions have the capacity to improve the outcomes of HIV/AIDS interventions by changing the social, economic, political or environmental factors that determine risk and vulnerability. Marginalized groups face disproportionate barriers to health, and sex workers are among those at highest risk of HIV in India. Evidence in India and globally has shown that sex workers face violence in many forms ranging from verbal, psychological and emotional abuse to economic extortion, physical and sexual violence and this is directly linked to lower levels of condom use and higher levels of sexually transmitted infections (STIs), the most critical determinants of HIV risk. We present here a case study of an intervention that mobilized sex workers to lead an HIV prevention response that addresses violence in their daily lives.Methods:This study draws on ethnographic research and project monitoring data from a community-led structural intervention in Mysore, India, implemented by Ashodaya Samithi. Qualitative and quantitative data were used to characterize baseline conditions, community responses and subsequent outcomes related to violence.Results:In 2004, the incidence of reported violence by sex workers was extremely high (> 8 incidents per sex worker, per year) but decreased by 84 per cent over 5 years. Violence by police and anti-social elements, initially most common, decreased substantially after a safe space was established for sex workers to meet and crisis management and advocacy were initiated with different stakeholders. Violence by clients, decreased after working with lodge owners to improve safety. However, initial increases in intimate partner violence were reported, and may be explained by two factors: (i) increased willingness to report such incidents; and (ii) increased violence as a reaction to sex workers’ growing empowerment. Trafficking was addressed through the establishment of a self-regulatory board (SRB). The community's progressive response to violence was enabled by advancing community mobilization, ensuring community ownership of the intervention, and shifting structural vulnerabilities, whereby sex workers increasingly engaged key actors in support of a more enabling environment.Interpretation & conclusions:Ashodaya's community-led response to violence at multiple levels proved highly synergistic and effective in reducing structural violence.

P2-S2.17 Community-Led Structural Invention's promise for HIV prevention: a case study from the Ashodaya Samithi Sex Worker Collective of Mysore, India.

Background As evidence has revealed the role of broader political, economic and local environmental factors in shaping HIV epidemic transmission patterns, new approaches have emerged that move beyond addressing individual risk behaviour to addressing the structural forces that condition risk. Within this context, Community-Led Structural Interventions (CLSI) aimed at reducing sex workers9 vulnerability have demonstrated successes in reducing STI and HIV transmission in India. Methods A comprehensive CLSI, know as Ashodaya Samithi, was initiated in the South Indian district of Mysore. Established in 2004 by the India AIDS Initiative (Avahan), Ashodaya is funded through the Bill and Melinda Gates Foundation and implemented by Karnataka Health Promotion Trust. Four-years into its inception, the project lays claim to significant successes. The collective has reported a reduction in STIs, an increase in condom use, and the mobilisation of 1500 sex workers. Our research describes and analyzes sex workers9 participation as it unfurled across various phases of collectivisation. Qualitative, community-based research methodologies were utilised including; 40 open-ended interviews, participant observations and focus groups. Drawing upon these findings we explored how a community of sex workers came to develop the ability to recognise, challenge and significantly alter an array of unequal power relations that shape HIV vulnerability in their everyday lives. Results Our research demonstrates the promise CLSI projects hold for preventing the spread of HIV. Ashodaya9s success depends on its ability to set new community norms, create a safer working environment, improve stakeholder relationships, and provide a supportive network. The interrelated processes of mobilisation, collectivisation, sex-worker identity, and political action, which transformed day-to-day vulnerability to HIV for Mysore sex workers demonstrates how complex HIV prevention remains. Conclusions Findings from the Ashodaya collective offer valuable lessons for public health practice. The Ashodaya collective demonstrates how CLSI strategies can be employed to help transform the very vulnerabilities that endanger health and sustain STI and HIV transmission. The collective provides an example of the positive impact of CLSIs and provides evidence for strategies that steer away from individual or education based public health programs, to those that engage with structural inequities.

Confronting structural violence in sex work: lessons from a community-led HIV prevention project in Mysore, India

Evidence from community-led HIV prevention projects suggests that structural interventions may result in reduced rates of HIV and STIs. The complex relationship between empowerment and confronting stigma, discrimination and physical abuse necessitates further investigation into the impact that such interventions have on the personal risks for sex workers. This article aims to describe lived experiences of members from a sex worker's collective in Mysore, India and how they have confronted structural violence. The narratives highlight experiences of violence and the development and implementation of strategies that have altered the social, physical, and emotional environment for sex workers. Building an enabling environment was key to reducing personal risks inherent to sex work, emphasizing the importance of community-led structural interventions for sex workers in India.

Challenging the stigmatization of female sex workers through a community-led structural intervention: learning from a case study of a female sex worker intervention in Andhra Pradesh, India

Structural interventions represent a potentially powerful approach to HIV prevention among female sex workers (FSW) that focus on changing the social context of risk rather than individual behavior. Community-led structural interventions (CLSI) represent a particular form of structural interventions whereby the collective energy of FSW is directed toward action to address the contextual factors that promote their risk. Among these different contextual factors that may be the target of CLSI, are social norms that stigmatize FSW and their work. Drawing from ethnographic data collected as part of an ongoing analysis of the implementation and impact of a CLSI in coastal Andhra Pradesh, India, we present a case study of the challenges and opportunities faced by a CLSI seeking to confront stigmatization of FSW through its interactions with a government-sponsored AIDS education program targeted to the general public. The government program promoted slogans that stigmatized FSW by attributing HIV/AIDS to them. Through participation in the program, the CLSI was complicit in promoting this same stigmatization. Yet it also used participation in the program as an opportunity to raise awareness among FSW of the CLSI and to mobilize FSW. In addition, the CLSI organized an alternative public rally, outside of but parallel to the government program, where they reframed FSW not as the carriers of HIV but as public health workers combating it. With this case study, we suggest that CLSI for HIV prevention among FSW are implemented in a context of inequality that constrains their actions, but they can still employ strategies that have the potential to transform that context.

Mobilizing collective identity to reduce HIV risk among sex workers in Sonagachi, India: The boundaries, consciousness, negotiation framework

The significantly low rate of HIV infection and high rate of condom use among sex workers in Kolkata, India is partially attributable to a community-led structural intervention called the Sonagachi Project which mobilizes sex workers to engage in HIV education, formation of community-based organizations and advocacy around sex work issues. This research examines how Sonagachi Project participants mobilize collective identity and the manner in which collective identity influences condom use. Using purposive sampling methods, 46 Sonagachi Project participants were selected in 2005 for in-depth qualitative interviews. Taylor and Whittier's (Taylor, V & Whittier, N (1992). Collective identities in social movement communities: lesbian feminist mobilization. In A. Morris & C. Mueller (Eds.) Frontiers in social movement theory. New Haven, CT: Yale University Press) model of identity-formation through boundaries, consciousness and negotiation was used to interpret results. Subjects mobilized collective identity by (1) building boundaries demarcating in-group sex workers from out-group members, (2) raising consciousness about sex work as legitimate labor and the transformative change that results from program participation, and (3) negotiating identity with out-group members. This research establishes a conceptual link between the boundaries, consciousness and negotiation framework of collective identity mobilization and condom use. Condom use among sex workers is motivated by each element of the boundaries, consciousness and negotiation model: condoms mark boundaries, enunciate the consciousness that sex with clients is legitimate labor, and help negotiate the identity of sex workers in interactions with clients.