a systematic review and metasynthesis of barriers and facilitators to negotiating consistent condom...
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This article was downloaded by: [Duke - Nus Graduate Med School Singapore]On: 01 September 2015, At: 18:06Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: 5 Howick Place, London, SW1P 1WG
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A systematic review and metasynthesisof barriers and facilitators tonegotiating consistent condom useamong sex workers in AsiaSi Ying Tana & G. J. Melendez-Torresa
a Department of Social Policy and Intervention, University ofOxford, Oxford, UKPublished online: 01 Sep 2015.
To cite this article: Si Ying Tan & G. J. Melendez-Torres (2015): A systematic review andmetasynthesis of barriers and facilitators to negotiating consistent condom use among sex workersin Asia, Culture, Health & Sexuality: An International Journal for Research, Intervention and Care,DOI: 10.1080/13691058.2015.1077994
To link to this article: http://dx.doi.org/10.1080/13691058.2015.1077994
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Culture, HealtH & Sexuality, 2015http://dx.doi.org/10.1080/13691058.2015.1077994
A systematic review and metasynthesis of barriers and facilitators to negotiating consistent condom use among sex workers in Asia
Si Ying Tan and G. J. Melendez-Torres
Department of Social Policy and intervention, university of Oxford, Oxford, uK
Introduction
HIV is a daunting health issue to sex workers. A systematic review of epidemiological studies (Prüss-Ustün et al. 2013) concludes that female sex work accounts for about 15% of the global HIV burden in women. A meta-analysis (Baral et al. 2012) examining the prevalence of HIV among female sex workers in 50 countries suggests an overall HIV prevalence of 11.8%; as compared to all women of reproductive age, female sex workers have odds 13.5 times higher of contracting HIV. While sub-Saharan Africa still bears the brunt of the HIV epidemic, Asia faces a similar epidemic challenge (Prüss-Ustün et al. 2013). In India, Thailand, Cambodia and Laos, unprotected heterosexual contact is the primary mode of HIV transmission and female sex work is seen as an important driving force (Bui et al. 2013; Charles et al. 2013; Decker et al. 2010; Phrasisombath et al. 2012). While injecting drug use was once a major
ABSTRACTFemale sex work accounts for about 15% of the global HIV burden in women. Asia is the region with the second highest attributable fraction of the HIV epidemic after sub-Saharan Africa. This review synthesises studies that depict the barriers and facilitators encountered by sex workers in Asia when negotiating consistent condom use. A total of 18 studies published between January 1989 and May 2015 were included in the review. Data were extracted, critically appraised and analysed using a thematic analysis approach. Individual-level factors related to sex workers’ knowledge, perception and power, as well as interpersonal-level factors that encompassed dynamics with clients and peer-related factors, presented as both barriers and facilitators to sex workers’ condom negotiation process. In addition, the structural environment of sex work, access to resources, poverty, stigma, the legal environment and the role of media were also identified as factors in influencing the condom negotiation process of sex workers. A multisectoral interventional approach that addresses the multilevel barriers encountered by sex workers in condom negotiation is needed. Awareness of safe-sex practice should be collectively enhanced among sex workers, clients and brothel managers.
© 2015 taylor & Francis
KEYWORDSSex workers; condom use; barriers; facilitators; HiV
ARTICLE HISTORYreceived 9 January 2015 accepted 27 July 2015
CONTACT Si ying tan [email protected]
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2 S. Y. TAn AnD G. J. MeLenDez-TorreS
mode of HIV transmission in China (Chen et al. 2008), more recently, heterosexual contact associated with the growth of the sex work industry has become the most prevalent route of HIV transmission (Wang et al. 2012).
In most countries in Asia, female sex workers lack power in negotiating condom use. This is in part due to and associated with human rights violations such as violence, abuse and rape (UnAIDS 2013). In addition, the criminalisation of sex work in many countries hampers an effective HIV response involving sex workers (Gruskin et al. 2013). other factors regarding the physical environment and support network of sex workers may be either enabling or debilitating factors in their condom negotiation processes (Urada et al. 2012).
There are currently no systematic reviews that synthesise qualitative evidence reporting on condom use barriers and facilitators among sex workers in Asia. A metasynthesis of studies in this area is needed in the light of the high disease burden of HIV among sex workers in Asia. The gradual increase in the body of evidence also warrants knowledge consolidation and higher- order analysis of the common or distinct condom negotiation experiences of sex workers in Asia. This review synthesises studies that feature sex workers’ experiences in negotiating consistent condom use in Asia. The review question was: what are the barriers and facilitators faced by sex workers in Asia when negotiating consistent condom use in their daily lives?
Methods
We followed the PrISMA (Preferred reporting Items for Systematic review and Meta-Analyses) (Moher et al. 2009) and enTreQ (enhancing Transparency in reporting the Synthesis of Qualitative research) (Tong et al. 2012) guidelines in systematically searching, extracting, appraising and synthesising the evidence.
Search strategy
We searched for evidence between April and May 2014 and updated our searches in April 2015. We sought primary articles from major public health and social sciences electronic databases, including embase, MeDLIne and PsycInFo, through keyword searches specifying study population, subject heading terms for ‘condom use’, study design and geographical location. We used the following search string: (‘sex work*’ or prostitut* or ‘sex-work’) AnD (‘condom use’ or ‘condom bargain*’ or ‘condom negotiat*’) AnD (qualitative or focus group or focus-group or interview or ‘semi-structured interview’ or ‘unstructured interview’ or ‘qualitative research’ or ‘thematic analysis’ or ethnograph* or ‘grounded theory’ or ‘mixed-method’ or ‘mixed method’). We restricted our search to countries classified by The World Bank as countries in east Asia and the Pacific, South Asia and Central Asia (World Bank 2015).
In addition, we hand-searched six public health academic journals that had published articles about HIV and sex work. We also searched for grey literature such as official reports from UnAIDS, the World Health organization, the World Bank and conference proceedings from the International AIDS Conference, as well as contacting key experts in the field for relevant information.
Inclusion and exclusion criteria
We included qualitative studies and qualitative data from mixed-method studies that reported on barriers and facilitators of consistent condom use among sex workers in Asia
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CULTUre, HeALTH & SexUALITY 3
from the year 1989 until May 2015. We identified 1989 as the starting point for inclusion. In addition, we only included studies conducted on or with female sex workers. We excluded quantitative studies and the qualitative components of mixed-method studies that were irrelevant to the context of condom use among female sex workers in Asia and studies conducted on male and transgender sex workers.
Data extraction, quality appraisal and data analysis
Data extraction began with four screening questions: whether the study used a qualitative approach, whether it focused on or with sex workers, whether it took place in Asia and whether it reported findings within the scope of the review question. We then examined the full texts of all included studies meeting all four criteria for final inclusion. We extracted study characteristics, study contexts and main findings of all included studies.
We critically appraised included studies that met the inclusion criteria using a quality assessment tool adapted from Harden et al. (2009) and the Critical Appraisal Skills Programme (CASP 2013). The quality assessment tool comprised five sections: (1) quality of reporting (the clarity of study aims, study contexts, data collection methods and data analysis framework), (2) use of strategies to increase reliability and validity for data collection and data analysis, (3) the extent to which study findings reflected and privileged sex workers’ perspectives and experiences, (4) ethical considerations and (5) relevance of findings to the review.
We used thematic synthesis to analyse relevant findings of included studies. Thematic synthesis allows flexibility of orientation when analysing data, ranging from a deductive approach with pre-determined individual themes, to an inductive approach that adopts an interpretive perspective (Thomas, Harden, and newman 2013). We aimed to achieve ‘interpretive innovation’ that went beyond repeating findings from individual research to translate them into to overarching new themes (Sandelowski and Barroso 2003). We supple-mented thematic synthesis with thematic networks, a technique that aims to demonstrate qualitative findings by using web-like illustrations to represent and summarise the main themes (Attride-Stirling 2001). We organised our analysis using Bronfenbrenner’s (1979) ecological system theory. ecological system theory suggests that the environmental con-texts that comprise the microsystem (the immediate environment of an individual person), the mesosystem (an aggregate of two or more microsystems), the exosystem (the linkages and processes between two or more microsystems) and the macrosystem (customs, belief and cultures one is exposed to) shape the development and experience of an individual (Bronfenbrenner 1979).
Findings
Search results
We identified 3597 records, of which 1187 were duplicates. We screened titles and abstracts of 2410 records and retrieved 39 full texts to assess for eligibility. out of these 39 studies, 18 were included. reasons for exclusion were mainly contextual and methodological (see Figure 1). The 18 included studies report data on sex workers from seven countries. The characteristics of each study are reported in Table 1.
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4 S. Y. TAn AnD G. J. MeLenDez-TorreS
3,595 records identified through database searching
2, 410 records after duplicates removed
2, 410 records screened 2, 371 records excluded
39 full-text articles assessed for eligibility
21 full-text articles excluded
Reasons of exclusion: 1) Male subjects either self-identified as men who havesex with men or did not identify themselves as sex workers (n= 3)
2) Study contexts were irrelevant (n= 7)
3) Quantitative studies (n=9)
4) Letter to editor (n= 1)
5) Findings derived from a same population group from previous study and findings had been reported (n= 1)
18 studies included in qualitative synthesis
2 records identified through hand-search of key journals
and contacting experts
Figure 1. PriSMa flowchart.
Factors affecting consistent condom use among sex
workers in Asia
Social and legal environment as both a
barrier and a facilitator
Policy, poverty and cultural factors (macrosystem)
Role of media as a facilitator
Stigma and secrecy as barriers
Poverty as both a barrier and a facilitator
Lack of bargaining power and negotiation
skills as barriers
Individual factors (microsystem)
Awareness of HIV and STD as a
facilitatorSex workers’
misperceptions as barriers
Interpersonal factors (mesosystem)
Client-sex worker mutual substance use and intoxication as
barriers
Client’s attitudes andawareness as facilitators
Peer factors as both barriers and facilitators
The relationship dynamics with husbands,
intimate partners and long term clients as both barriers and facilitators
Structural environment (exosystem)
Structural protection as a facilitator
Structural violence as a barrier
Sex work settings as both barriers and
facilitators
Availability of condom as both a
barrier and a facilitator
Bargaining power and negotiation skills as
facilitators
Figure 2. thematic network analysis of factors affecting consistent condom use among sex workers in asia.
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Tabl
e 1.
Cha
ract
eris
tics o
f inc
lude
d st
udie
s.
Stud
yCo
untr
ySa
mpl
e si
zeSe
x w
orke
rs p
rofil
esre
crui
tmen
t of p
artic
ipan
tsD
ata
colle
ctio
nD
ata
anal
ysis
sty
le
repo
rted
Basu
ki e
t al.
(200
2)
indo
nesi
au
ncle
arSe
x w
orke
rs fr
om th
ree
citie
s in
indo
nesi
ara
ndom
sele
ctio
n of
fem
ale
sex
wor
k-er
s in
brot
hel a
reas
Focu
s-gr
oup
and
in-d
epth
in
terv
iew
su
ncle
ar
Chap
man
, es
tcou
rt, a
nd H
ua
(200
8)
Chin
a23
Mig
rant
sex
wor
kers
age
d 17
–31
Conv
enie
nce
sam
ple
of se
x w
orke
rs
from
a lo
cal r
e-ed
ucat
ion
cent
reFa
ce-t
o-fa
ce se
mi-s
truc
ture
d in
terv
iew
sth
emat
ic a
naly
sis
Choi
and
Hol
royd
(2
007)
Ch
ina
32Se
x w
orke
rs fr
om e
nter
-ta
inm
ent e
stab
lishm
ents
Purp
osiv
e sa
mpl
e of
sex
wor
kers
from
di
ffere
nt se
ttin
gsFi
eld
obse
rvat
ion
in e
nter
tain
-m
ent v
enue
s and
in-d
epth
se
mi-s
truc
ture
d in
terv
iew
s
Cons
tant
com
para
tive
anal
ysis
Das
gupt
a (2
013)
in
dia
37Pr
evio
us o
r cur
rent
mem
-be
rs o
f a se
x w
orke
r's
unio
n
Purp
osiv
e sa
mpl
e of
sex
wor
kers
th
roug
h se
x w
orke
rs' u
nion
Sem
i-str
uctu
red
inte
rvie
ws a
nd
part
icip
ant o
bser
vatio
nset
hnog
raph
y
evan
s and
la
mbe
rt (2
008)
in
dia
61M
igra
nt se
x w
orke
rs fr
om
rura
l are
as w
orki
ng in
dif-
fere
nt se
x w
ork
sett
ings
Colla
bora
tion
with
a c
omm
unity
pr
ojec
t to
enga
ge a
wid
e ra
nge
of se
x in
dust
ry st
akeh
olde
rs
Focu
s-gr
oup
disc
ussi
on w
ith
peer
edu
cato
rs, i
nter
view
s with
se
nior
pro
ject
man
ager
s
ethn
ogra
phy
and
them
atic
an
alys
is
Ghi
mire
et a
l. (2
011)
N
epal
15Se
x w
orke
rs a
ged
15–4
5 co
mpr
ised
mai
nly
the
ethn
ic m
inor
ity g
roup
Purp
osiv
e sa
mpl
e of
sex
wor
kers
from
a
larg
er sa
mpl
e w
ho h
ad p
artic
ipat
ed
in a
surv
ey
in-d
epth
inte
rvie
ws a
nd fi
eld
obse
rvat
ion
unc
lear
Hao
et a
l. (2
014)
Ch
ina
in-d
epth
inte
r-vi
ews,
focu
s-gr
oup
disc
ussi
on
Old
er se
x w
orke
rs w
ho
wer
e at
leas
t 35
year
s old
fr
om th
ree
citie
s in
Chin
a
Purp
osiv
e sa
mpl
e of
sex
wor
kers
th
roug
h ex
istin
g H
iV-p
reve
ntio
n pr
ogra
mm
es
in-d
epth
indi
vidu
al in
terv
iew
s w
ith se
x w
orke
rs. F
ocus
gro
up
disc
ussi
on w
ith th
e ow
ners
of
ente
rtai
nmen
t est
ablis
hmen
t.
them
atic
ana
lysi
s and
co
nsta
nt c
ompa
rativ
e m
etho
d
Hua
ng e
t al.
(201
5)
Chin
a16
Sex
wor
kers
ope
ratin
g in
Zha
bei d
istr
ict i
n Sh
angh
ai c
ity
Purp
osiv
e sa
mpl
e of
fem
ale
sex
wor
k-er
s rec
ruite
d vi
a a
loca
l non
-gov
ern-
men
tal o
rgan
isat
ion
(NG
O)
in-d
epth
indi
vidu
al in
terv
iew
su
ncle
ar
Janu
raga
, Moo
n-ey
-Som
ers,
and
War
d (2
014)
indo
nesi
a34
Sex
wor
kers
from
diff
er-
ent s
ex w
ork
sett
ings
and
ye
ars o
f exp
erie
nce
Purp
osiv
e sa
mpl
e of
sex
wor
kers
re
crui
ted
via
a lo
cal N
GO
in-d
epth
indi
vidu
al in
terv
iew
sth
emat
ic fr
amew
ork
anal
ysis (C
ontin
ued)
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Stud
yCo
untr
ySa
mpl
e si
zeSe
x w
orke
rs p
rofil
esre
crui
tmen
t of p
artic
ipan
tsD
ata
colle
ctio
nD
ata
anal
ysis
sty
le
repo
rted
Jie e
t al.
(201
2)
Chin
a24
Sex
wor
kers
age
d 18
–32
who
wer
e m
ostly
mar
ried
and
had
rece
ived
less
th
an 1
2 ye
ars o
f edu
-ca
tion
Purp
osiv
e sa
mpl
e of
sex
wor
kers
re-
crui
ted
from
a w
ide
rang
e of
com
mun
i-ty
-bas
ed N
GO
s
in-d
epth
sem
i-str
uctu
red
inte
rvie
ws
Com
para
tive
anal
ysis
Mah
er e
t al.
(201
1)
Cam
bodi
a33
Sex
wor
kers
age
d 15
–29
in P
hnom
Pen
hPu
rpos
ive
sam
ple
of se
x w
orke
rs
recr
uite
d vi
a a
loca
l NG
Oin
-dep
th in
terv
iew
sG
roun
ded
theo
ry a
p-pr
oach
Nem
oto
et a
l. (2
008)
Vi
etna
m30
Sex
wor
kers
age
d 18
–44
in m
assa
ge p
arlo
urs a
nd
the
stre
et
Sex
wor
kers
wer
e re
crui
ted
from
ta
rget
ed se
x w
ork
venu
esSe
mi-s
truc
ture
d in
terv
iew
su
ncle
ar
Oan
h (2
005)
Vi
etna
m25
Sex
wor
kers
age
d 16
–31
from
diff
eren
t sex
-wor
k se
ttin
gs
Snow
ball
sam
ple
of se
x w
orke
rs re
-cr
uite
d w
ith th
e he
lp o
f pee
r edu
cato
rsSe
mi-s
truc
ture
d in
terv
iew
su
ncle
ar
Pura
dire
dja
and
Coas
t (20
12)
indo
nesi
ain
-dep
th in
ter-
view
s, ke
y-in
form
-an
t int
ervi
ews
Sex
wor
kers
from
one
ur
ban
and
one
rura
l se
ttin
g
Purp
osiv
e sa
mpl
e of
sex
wor
kers
re
crui
ted
via
NG
O o
utre
ach
wor
kers
in-d
epth
inte
rvie
ws,
key-
info
rm-
ant i
nter
view
s with
NG
O st
aff
and
heal
th c
are
prov
ider
s, an
d et
hnog
raph
ic a
sses
smen
ts
Cons
tant
com
para
tive
them
atic
app
roac
h
tata
(200
4)
indi
a33
Sex
wor
kers
from
diff
er-
ent s
ettin
gsSe
x w
orke
rs, b
roth
el k
eepe
rs a
nd
peer
edu
cato
rs w
ere
appr
oach
ed b
y th
e fir
st a
utho
r dur
ing
two
phas
es o
f et
hnog
raph
ic fi
eld
stud
ies
Part
icip
ant o
bser
vatio
n,
docu
men
t ana
lysi
s and
in-d
epth
in
terv
iew
s
ethn
ogra
phy
and
line-
by-
line
mic
roan
alys
is
tran
et a
l. (2
004)
Vi
etna
m37
Sex
wor
kers
age
d 17
–35
from
diff
eren
t sex
wor
k se
ttin
gs in
Han
oi
Sex
wor
kers
wer
e re
crui
ted
with
the
help
of p
eer e
duca
tors
and
dis
tric
t he
alth
staff
in-d
epth
inte
rvie
ws a
nd
focu
s-gr
oup
disc
ussi
onu
ncle
ar
Won
g et
al.
(199
4)
Sing
apor
e40
Brot
hel-b
ased
sex
wor
k-er
s age
d 22
–45
Stra
tified
sam
ple
of se
x w
orke
rs fr
om
a la
rger
sam
ple
who
had
par
ticip
ated
in
a su
rvey
in-d
epth
inte
rvie
ws
unc
lear
Won
g, C
han,
and
W
ee (2
000)
Sing
apor
e46
Brot
hel-b
ased
sex
wor
kers
Purp
osiv
e sa
mpl
e of
sex
wor
kers
from
a
larg
er sa
mpl
e w
ho h
ad p
artic
ipat
ed
in a
surv
ey
in-d
epth
inte
rvie
ws
unc
lear
Tabl
e 1.
(Con
tinue
d).
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CULTUre, HeALTH & SexUALITY 7
Tabl
e 2.
Crit
ical
app
rais
al o
f inc
lude
d st
udie
s.
Crite
riaBa
suki
et
. al.
(200
2)
Chap
-m
an,
estc
ourt
, an
d H
ua
(200
8)
Choi
an
d H
olro
yd
(200
7)
Das
-gu
pta
(201
3)
evan
s an
d La
m-
bert
(2
008)
Ghi
mire
et
al.
(201
1)
Hao
et
al.
(201
4)
Hua
ng
et a
l. (2
015)
Jam
u-ra
ga
et a
l. (2
014)
Jie
et a
l. (2
012)
Mah
er
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8 S. Y. TAn AnD G. J. MeLenDez-TorreS
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Find
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-ce
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bar
riers
and
/or
faci
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n co
nsis
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use
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***
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***
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ethi
cal c
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tions
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rese
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ity**
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lity.
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m q
ualit
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* high
qua
lity.
– un
clea
r.
Tabl
e 2.
(Con
tinue
d).
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CULTUre, HeALTH & SexUALITY 9
Critical appraisal
All included studies were judged to be of high, medium or low quality in 14 aspects (see Table 2). High-quality studies offered clear descriptions corresponding to each appraisal item. For instance, high-quality studies clearly documented data collection processes aided with interview guides, presence of pilot studies prior to actual studies, demonstra-tion of at least two independent researchers conducting data analysis to ensure rigour of analysis, demonstration of data integrity by considering contradictory accounts in the analysis, demonstration of entirety in reflecting sex worker’s voices and facilitating the expression of sex workers’ views, demonstration of informed consent sought and additional effort to protect sex workers’ identities and privacy, and demonstration of efforts to mini-mise social desirability bias. Medium- and low-quality studies offered less comprehensive or insufficient descriptions of the relevant appraisal items. Studies marked as unclear had ambiguous or absent description of key methodological considerations. We included all studies regardless of quality, but we prioritised studies of higher quality.
Synthesis of evidence
Emergent theme 1: individual factors (microsystem)
Figure 2 depicts the thematic network analysis of various barriers and facilitators affecting consistent condom use among sex workers in Asia. Across studies, individual factors that encapsulated sex workers’ perceptions, beliefs, judgement, knowledge, power and skills presented as both barriers and facilitators in negotiating consistent condom use with their clients.
Sex workers’ perceptions of clients’ class difference and nationality difference and their perceived familiarity with clients presented as both barriers and facilitators. For example, sex workers’ rationalising of familiar clients as safe and disease-free put their sexual health at stake (Chapman, estcourt, and Hua 2008; Choi and Holroyd 2007; Jie et al. 2012; Tran et al. 2004; Wong, Chan, and Wee 2000). Clients’ perceived familiarity was often regarded as loyalty, creating a lower sense of urgency in condom use (Chapman, estcourt, and Hua 2008; Choi and Holroyd 2007). The tendency to perceive HIV as a distant disease further exacerbated the tendency of sex workers to undermine the importance of negotiating con-sistent condom use with their clients (Chapman, estcourt, and Hua 2008). Inattention to the risks of exposure to HIV and sexually transmitted infections, a result of inadequate health education among sex workers, also posed as a barrier in negotiating consistent condom use with clients (oanh 2005).
In contrast, awareness of the risks of exposure to HIV among sex workers facilitated nego-tiation of consistent condom use with clients. In several studies, sex workers’ sensitivity to the contagion of HIV and sexually transmitten infections (STIs) through condomless sexual contact inherent within sex work shaped intrinsic motivations of sex workers to practise safe sex with their clients (Chapman, estcourt, and Hua 2008; Choi and Holroyd 2007; oanh 2005; Tata 2004; Tran et al. 2004). This was partially shaped by the experience of knowing acquaintances living with HIV and witnessing the death of acquaintances from AIDS (Tata 2004). Beyond HIV prevention, sex workers reported insisting on condom use with clients for the purposes of hygiene and cleanliness (Wong, Chan, and Wee 2000).
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Sex workers’ bargaining power and negotiation skills with clients presented both as bar-riers and facilitators in negotiating consistent condom use, depending on the situation. Facilitators toward negotiating condom use included being assertive in insisting on condom use and employing effective negotiation skills, facilitated by techniques such as display of erotic behaviours and client education (evans and Lambert 2008; Ghimire et al. 2011; Tran et al. 2004). Sometimes, sex workers tried to gain the upper hand in their sexual transaction with clients by insisting on both condom use and payment in advance (evans and Lambert 2008; Tran et al. 2004). At times, sex workers also used their persuasive power to influence clients to practise safe sex through education on HIV (Choi and Holroyd 2007).
In contrast, lack of bargaining power and condom negotiation rendered sex workers subordinated to clients’ demands for condomless sex (Ghimire et al. 2011; Huang et al. 2015; Jie et al. 2012; Tran et al. 2004). one way in which this manifested itself was the inability of sex workers to make rules for condom use clear in the beginning when accepting payment from clients is a prominent example of condom negotiation failure (Choi and Holroyd 2007; Wong, Chan, and Wee 2000).
Emergent theme 2: interpersonal factors (mesosystem)Interpersonal factors encompassed client factors, peer factors and the relationship dynamics between sex workers and clients or intimate partners.
Clients’ attitudes and awareness were both barriers and facilitators in sex workers’ attempts to negotiate condom use. Clients’ resistance to using condoms due to reduced sexual pleas-ure presented as difficult situations for sex workers to challenge during sexual transactions (Chapman, estcourt, and Hua 2008; Ghimire et al. 2011; Hao et al. 2014; Huang et al. 2015; oanh 2005; Tata 2004; Tran et al. 2004; Wong, Chan, and Wee 2000). Clients engaged in deception by secretly removing condoms during sexual intercourse (Tata 2004) and refus-ing to pay for sex or asking for a refund after having sex with condoms (Choi and Holroyd 2007). In addition, clients’ lack of awareness, education and knowledge toward HIV and STIs became a barrier for sex workers in promoting condom use (Choi and Holroyd 2007; Jie et al. 2012; Wong, Chan, and Wee 2000).
nevertheless, there were also occasions when clients’ attitudes and awareness were trans-formed into facilitators in negotiating consistent condom use. Several studies described sex workers’ accounts in which clients voluntarily demanded condom use (Ghimire et al. 2011; oanh 2005; Tran et al. 2004) and took the initiative in inculcating awareness and education on safe-sex practices with sex workers (Tata 2004).
Mutual substance use and intoxication presented as a barrier for both sex workers and clients in negotiating consistent condom use. Intoxication of drugs and alcohol from either one or both parties interfered with rational attempts to negotiate condom use (Choi and Holroyd 2007; Maher et al. 2011; Tata 2004). In addition, some sex workers’ longstanding substance use issues and their desire for money to procure these substances may cause them to comply with clients’ demands for condomless sex (Chapman, estcourt, and Hua 2008; Choi and Holroyd 2007).
Peer factors presented as both barriers and facilitators in condom negotiation among sex workers. Lack of a peer support system was a prominent barrier for sex workers in negotiating consistent condom use, especially among street-based sex workers for whom mobility jeop-ardised the development of strong networks (Choi and Holroyd 2007). Lack of peer support also prevented the development of a common identity among sex workers, rendering futile
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CULTUre, HeALTH & SexUALITY 11
advocacy efforts to champion for collective welfare (evans and Lambert 2008). Furthermore, fierce competition from peers within the sex work industry compelled sex workers to aban-don condom use for fear of losing clients (evans and Lambert 2008; Ghimire et al. 2011; oanh 2005; Wong, Chan, and Wee 2000).
However, peer factors facilitated sex workers’ negotiation of consistent condom use when peer solidarity was demonstrated in safeguarding the safety and welfare of sex workers. This was evident through active peer intervention and unionisation of sex workers to assist their members in navigating a high-risk occupational environment (Dasgupta 2013; Hao et al. 2014; Tata 2004; Wong, Chan, and Wee 2000). Peer education and outreach from older members in the sex workers’ networks to provide informational, tangible and emotional support to younger members were also useful in helping younger sex workers become more confident in the condom negotiation process (Hao et al. 2014).
relationship dynamics between sex workers and their husbands, intimate partners and long-term clients were found to be both barriers and facilitators to negotiating condom use. With husbands and intimate partners who were usually unaware of their occupational statuses, sex workers tended to hold to the belief that condom use was unnecessary due to familiarity (Januraga, Mooney-Somers, and Ward 2014; Tata 2004). Patriarchal culture in some Asian countries strengthened sex workers’ beliefs that it is a husband’s right to demand condom free sex and a wife’s obligation to accede to the husband’s demand (Ghimire et al. 2011; Tata 2004). In addition, the need to demonstrate ‘love’ to partners, the desire to forge a deeper attachment and the disinclination to endanger trust negated sex workers’ willingness to use condoms with their husbands or intimate partners (evans and Lambert 2008; Huang et al. 2015; oanh 2005; Tata 2004). While trust manifested itself as a barrier to consistent condom use, mutual distrust between sex workers and their husbands or regular partners reinforced consistent condom use (Tata 2004).
With long-term clients, mutual concern for health and safety were a facilitator for condom use (oanh 2005). However, barriers surfaced when condom use was perceived as an obstacle to intimacy and loyalty. Furthermore, longstanding relationships were felt to trivialise the need for condom negotiations (Choi and Holroyd 2007). For some sex workers, the dream of being able to marry their clients, to whom they had committed emotionally, undermined the need to negotiate condom use (Choi and Holroyd 2007; Jie et al. 2012; oanh 2005).
Emergent theme 3: structural environment (exosystem)Structural factors in sex workers’ ecosystems also constitute various barriers and facilitators in their ability to negotiating consistent condom use with clients.
Structural violence stemming from abusive policing practices, client violence and unsup-portive brothel owners constituted a major barrier for sex workers in negotiating consistent condom use. Sex workers reported that police abused sex workers both with violence (Choi and Holroyd 2007) and by forcing unsafe sex on sex workers (Maher et al. 2011). Client vio-lence in the form of verbal threats, physical force and sexual coercion not only undermined sex workers’ abilities to negotiate condom use but also posed a serious threat to sex workers’ safety (Choi and Holroyd 2007; evans and Lambert 2008; Maher et al. 2011; Tata 2004). Pressure from brothel managers to receive more clients, systematic exclusion from the busi-ness of sex workers who refused to compromise and imposition of retaliatory measures such as physical violence against sex workers also resulted in inconsistent condom use among
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sex workers (Chapman, estcourt, and Hua 2008; Dasgupta 2013; Jie et al. 2012; Maher et al. 2011; Tata 2004; Wong, Chan, and Wee 2000).
In contrast, structural protection facilitated condom use negotiation between sex work-ers and their clients through the supportive roles played by some brothels and effective mediation by police officers. In some instances, brothel owners or managers specifically enforced condom use policies by turning down clients who refused to use condoms with sex workers (Hao et al. 2014; Tata 2004; Wong, Chan, and Wee 2000). Active police interven-tion in mediating conflicts between sex workers and clients could indirectly facilitate the successful negotiation of condom use between sex workers and their clients. For example, one study shed light on the significance of police as effective mediators when police officers defended sex workers and requested that clients lodging reports against sex workers to the enforcement authority practise condom use (Tata 2004).
The availability of condoms presented as both a barrier and facilitator to condom use negotiations between sex workers and clients. Promotion of condom purchasing by brothel owners and appeals to health authorities for more condoms by brothels were proactive moves to shape a protective structural environment facilitating sex workers’ condom use behaviours with clients (Hao et al. 2014; Tata 2004). nonetheless, the high cost of condoms and occasional condom shortages in brothels sometimes forced sex workers to compromise their sexual health (Huang et al. 2015; Tata 2004).
Street-based sex work may be one of the most risky sex work settings in that it undermines sex workers’ opportunities to negotiate condom use with clients (Choi and Holroyd 2007; Maher et al. 2011; Tata 2004). The clandestine nature of street-based sex work and pressure from brothels for sex workers to complete sexual transactions within a short period of time constrain sex workers’ condom negotiation processes (Tata 2004). Street-based sex workers were more prone to police raids compared to establishment-based sex workers, who were normally shielded due to strong networks from brothels that allowed sex workers to effec-tively navigate the risky environment (Choi and Holroyd 2007; Maher et al. 2011). In spite of the relatively higher status of brothel-based sex workers compared to street-based sex workers, this did not grant brothel-based sex workers immunity from structural violence.
Emergent theme 4: policy, poverty and cultural factors (macrosystem)Macrosystem factors such as the social and legal environment, poverty and cultural factors within countries and communities pose both barriers and facilitators to sex workers’ nego-tiation of condom use with clients.
Socio-legal environments unfavourable to sex workers presented as a barrier in their con-dom negotiation processes. The illegality of sex work in many Asian countries prevented sex workers from reporting abuse and coercion to the authorities (Choi and Holroyd 2007) and discouraged them from carrying condoms for fear that condom possession might be used as an excuse for prosecution (Ghimire et al. 2011; Maher et al. 2011; Tata 2004). nevertheless, the presence of civil society-run community-based interventions such as condom promotion and distribution, peer education and peer support and outreach manifested as facilitators by helping to shape protective environments that facilitated condom use negotiation (Hao et al. 2014; Tata 2004).
Poverty also appeared to be both a barrier and facilitator to sex workers’ condom nego-tiation depending on their economic situation. Half of the included studies documented extreme economic deprivation and the need for basic survival as barriers in negotiating
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CULTUre, HeALTH & SexUALITY 13
consistent condom use (Chapman, estcourt, and Hua 2008; Choi and Holroyd 2007; evans and Lambert 2008; Ghimire et al. 2011; Hao et al. 2014; Jie et al. 2012; oanh 2005; Tata 2004; Tran et al. 2004). Such situations were especially prevalent among migrant sex workers (Jie et al. 2012) and older sex workers (Hao et al. 2014), who had less bargaining power and were struggling to provide for their families. However, in some situations, the need to stay healthy and able to work due to prolonged economic pressures motivated sex workers to constantly negotiate condom use with their clients (Dasgupta 2013; Tata 2004).
Stigma and secrecy presented as barriers to sex workers’ attempts to negotiate con-sistent condom use with clients. The widespread social stigma attached to sex work (Choi and Holroyd 2007) and the wish to be identified by clients as female acquaint-ances instead of as ‘professional’ sex workers (oanh 2005), resulted in the concealment of sex workers’ actual identities to their clients. These situations sometimes resulted in sex workers’ acceding to clients’ requests to have sex without a condom. Secrecy was also a barrier in condom negotiation, especially for street-based sex workers operating within close proximity to where they lived, due to concerns of being disowned by their families should their identities be exposed (Tata 2004) and of maintaining normalcy in their spousal relationships (Hao et al. 2014).
The role of the media in spreading HIV awareness presented as a facilitator when it directly exposed those sex workers with access to television and radio to safe-sex education and caused an effect in promoting safe-sex behaviours between sex workers and their clients (Tata 2004).
Discussion and conclusion
Summary and critique of evidence
This review synthesised qualitative evidence on the multilevel barriers and facilitators encountered by sex workers in negotiating consistent condom use with their clients and partners. Findings from this systematic review confirm evidence from previous quantitative cross-sectional studies conducted in Asia. In particular, cross-sectional studies have shown that a strong sense of collective agency and identity (Urada et al. 2012), a strong peer network (Blankenship et al. 2008), the receipt of HIV interventions (Gu et al. 2009), prior HIV knowl-edge (Gu et al. 2009), condom availability in sex work venues (Urada et al. 2012), decreased frequency of alcohol intoxication (Urada et al. 2012) and establishment-based sex work (Gu et al. 2009) are associated with higher odds of consistent condom use among sex workers. While microsystem and mesosystem factors have a direct influence on sex workers’ agency in negotiating consistent condom use with clients, exosystem and macrosystem factors indirectly influence sex workers’ sexual health behaviours. It is important to note, however, that barriers and facilitators at each level of the ecosystem are intertwined, and may override each other. Structural violence and poverty, for instance, can sometimes subordinate sex workers’ knowledge and awareness of the importance of condom use.
Strengths and limitations of the review
The major strength of this review is its systematic approach to assembling and inter-preting the rich and diverse contextual details of the perceived barriers and facilitators
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in condom use negotiation among sex workers in these countries at each level of the ecological system. The review also highlighted facilitators of consistent condom use among sex workers that could be strengthened and incorporated into health and social programmes targeting sex workers.
However, the review is limited in external validity. While the search process included 37 Asian countries, the 18 included studies represented only seven of these countries, and thus may not entirely represent the common experiences of sex workers throughout Asia. Besides, most studies discussed the condom negotiation experiences of only street-based and brothel-based sex workers in seven countries with vastly different socio-legal environ-ments for sex work.
Implications for interventions, policies and research
Macrosystem barriers such as the illegality of sex work, poverty and stigma surfaced as emerging themes in this review preventing sex workers from negotiating consistent con-dom use. These results highlight the need for policymakers to re-examine public health strategies and regulatory frameworks governing the commercial sex industry in countries that criminalise sex workers. Health interventions for sex workers tend to be more effective when their operations are not hidden and when countries adopt a harm reduction approach to public health (Sanders, o'neill, and Pitcher 2009). Structural poverty in rural areas lead-ing to an influx of migrant sex workers to urban areas suggests the need for policymakers to address fundamental development issues shaping the rural socio-economic situation. Dire socio-economic circumstances in rural areas directly fuel the desperation of women in adopting livelihoods that force them to accept inferior positions in the condom negotiation process.
Findings from this systematic review and metasynthesis provide insights into past and future evaluations of structural-level interventions to promote sexual health safety in sex work settings. The review points to the need for public health interventions with and for sex workers to be more solution-focused and contextually driven. For instance, interventions that are aiming at imparting sexual health knowledge, awareness and condom negotiation skills among sex workers should also address the environmental constraints in sex work and account for other distal barriers, such as substance use among sex workers and their clients, that may influence decision-making. In addition, the importance of peer networks and peer support documented in this review also implies that peer factors are critical targets to be strengthened. Systematic enforcement of condom use by brothel owners and managers, and education on sexual health for clients are equally crucial in protecting sex workers as findings highlighted the important roles played by these two factors in facilitating consistent condom use.
Disclosure statement
no potential conflict of interest was reported by the authors.
Funding
This work was supported by a Chevening Scholarship from the UK Foreign and Commonwealth office.
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