Transcript "Evaluation of Community Mobilization and Empowerment in Relation to HIV Prevention Programming among Female Sex Workers in Karnataka State, South India"

Evaluation of Community Mobilization and
Empowerment in Relation to HIV Prevention
Programming among Female Sex Workers in
Karnataka State, South India
H.L. Mohan, A. Blanchard, M. Shahmanesh, R. Prakash, S. Isac, B.M.
Ramesh, P. Bhattacharjee, S. Moses, JF Blanchard
University of Manitoba and Karnataka Health Promotion Trust
World Bank Human Development Network
Meeting, Washington, D.C., October 5-6, 2011
Why Evaluate Community Mobilization
in Female Sex Workers?
• Empowerment as a means to improve health
• FSWs specific vulnerability
–
Power imbalances that disadvantage FSWs
•
Individual: Low self esteem (internalised stigma)
•
Community: Violence and coercion (stigma & discrimination)
•
Societal: limited social, economic and political capital (poverty,
low literacy, and no legal status)
–
Social exclusion
•
Gender, class/caste, sex work taboo and ambiguity of legal status
– Lead to HIV vulnerability
Aim and Objectives
• Aim: Document and evaluate the role of community
mobilization and empowerment programs for HIV
prevention among FSWs
• Objectives:
– Develop an integrated empowerment framework to describe
the models of community-based activities among FSWs
– Explore the impact of the community response on access to
programs and services, and to STI/HIV outcomes.
– Explore the impact of the community response on social
transformation.
– Explore the pathways between community-based
mobilization, empowerment, and health outcomes.
Context
• The University of Manitoba (UM) and the Karnataka
Health Promotion Trust (KHPT) have been
implementing HIV prevention programs for FSWs in 20
districts of Karnataka state since 2003.
• Population of the 20 districts 40 million
• Population of FSW > 60,000
• Components of the program
–
–
–
–
Community mobilization
Peer outreach and education
Condom programming and STI service delivery
Advocacy and building an enabling environment
District Coverage of Targeted Intervention
Programs in Karnataka
20 Districts: 60,000+ FSWs, 21,000+ MSM
UM/KHPT
KSAPS/ KHPT
UM/CBO
KSAPS
Sex work
organization
Conceptual
Framework
Program and
structural
interventions
Empowerment
Dimensions
Power
Within
Sociodemographic
variables
Power
over
Resources
Power
with
Others
Power to Address
Power imbalances
Social exclusion
Disempowering
social context
Vulnerability
Conceptual Framework
• Community mobilization is used to address power
imbalances, social exclusion and HIV vulnerability
• Three domains of empowerment of FSWs:
– “Power within” – self-esteem, self-confidence and selfefficacy
– “Power with” – collective power, defined as collective identity
that leads to collective agency
– “Power over resources” – access to financial and other social
entitlements
Main Data Sources
Behavioural Tracking Survey (BTS)
– Random sample of FSWs in five districts in 2010 (350 FSWs per
district)
– Used to identify associations with “power with”, “power within”
and “power over resources” (Principal Components and Factor
Analyses)
– Used to identify associations with individual behavioural
outcomes
Integrated Behavioural and Biological Assessments
– Conducted among a random sample of FSWs in 5 different
districts; two rounds, 2006-2010, 400 FSWs per district per round
– Used to identify associations with individual biological outcomes
Top Line Findings from the Multivariate
Analysis of “Power” from BTS
• Lower power generally associated with
–
–
–
–
Younger age (18-21)
District with poor community-based organisation
Shorter duration of exposure to program
Fewer contacts with program
• Power within
– Greater self efficacy for condom use with regular
partners and service utilisation
• Power with
– Greater self efficacy for condom use with clients
– Greater autonomy and service utilisation in 3
districts
– Reduced violence
Levels of Empowerment, By District
Mean Power Domain Score
1.5
1
‡
0.5
‡
‡
‡
‡
‡ ‡
Gulbarga
‡
0
-0.5
Belgaum
‡
‡
‡
‡
Gadag
Dharwad
Solapur
-1
-1.5
Power Within
Power With Others
Power Over
Resources
Levels of “Power Within" and “Power With”, by Time
Since First Used Program Services in Belgaum,
Gulbarga and Gadag Districts
1
Mean Power Domain Score
0.8
0.6
0.4
Within last 6 months
0.2
*
*
0
1-2 years ago
>2 years ago
-0.2
-0.4
6-12 months ago
ref
ref
-0.6
Power Within
Power With
Unadjusted Differences in Outcomes
by CBO Membership (BTS)
90.5
91.3
88.5
82.3
67.7
49.8
61.6
54.3
28.2
19.7
19.5
15.8
Condom use with
Consistent
Experienced
Beaten or forced Given nothing to obtained an id in
regular partner condom used all violence in past 6 to have sex in the police to avoid
the last 5 years
clients/partner months (p<0.001)
past one
trouble in past 6
(p<0.05)
year(p<0.10)
months (p<0.001)
Non-member
Member
Unadjusted Differences in STI
Outcomes by CBO Membership (IBBA)
18.6
16.9
10.3
9.6
8.2
5.2
STI (p<0.001)
Active syphilis (p<0.10)
Non-member
Member
HIV positive
Conclusions
1. The integrated empowerment framework is a useful tool to
describe how KHPT’s multifaceted community mobilization
models address issues of FSW empowerment (power with, power
within and power over) and the disempowering social context.
2. At district level “Power” is associated with strength/intensity of
community mobilisation
3. At individual level “Power” is associated with Programme
exposure
4. FSWs with greater level of “Power”, show greater self efficacy
“power to” use condoms, services and autonomy
5. Membership of CBO (Collective Power) is associated with an
enabling environment and reduced sexual risk
Acknowledgements
• Bill & Melinda Gates Foundation
• University of Manitoba and KHPT
Community Mobilization Teams
• Partner NGOs and CBOs