Background
Methods
Community-participatory intervention development
INSPIRE intervention (Fig. 1)
Study design
Measures
% (n/n)
(mean, ±sd)
| |
---|---|
Age (mean, ±sd)
|
(35.5, ±7.3)
|
Race | |
White | 72 (41/57) |
Black | 16 (9/57) |
Other | 12 (9/57) |
Sex Trade Context | |
Recruitment site | |
Primarily street-based sex work | 73 (44/60) |
Primarily venue-based sex work | 27 (16/60) |
Sex work is sole source of income | 41 (24/58) |
Social cohesion (mean, ±sd) |
(23.60, ±9.5)
|
Everyday Discrimination (mean, ±sd) |
(28.9, ±10.1)
|
Sex Work Stigma: Community (mean, ±sd) |
(15.9, ±6.0)
|
Sex Work Stigma: Family (mean, ±sd) |
(12.9, ±5.7)
|
Current injection drug use | 86 (52/60) |
Intervention acceptability | |
Likely to give the safety card to someone at risk for violence | 90 (54/60) |
Helpful to hear about violence support programs | 98 (59/60) |
Helpful for providers to talk about violence and safety to people like me | 98 (59/60) |
I would bring a friend here to have this conversation | 98 (59/60) |
My interventionist cares about my safety | 98 (59/60) |
I felt comfortable talking with the interventionist | 98 (59/60) |
I felt safe | 98 (59/60) |
I felt that what I said would be kept private | 98 (59/60) |
Analysis
Results
Baseline characteristics
Intervention acceptability
Outcomes analysis
Full samplen = 60 | Retained
n = 39 | Lost to follow-up
n = 21 | ||||
---|---|---|---|---|---|---|
Baseline % (mean,±sd)
| Baseline % (mean,±sd)
| Follow-up % (mean,±sd)
|
p value§
| Baseline % (mean,±sd)
§§
| Attrition analysisp value§§
| |
SHORT TERM OUTCOMES | ||||||
Attitudes | ||||||
Recognition of abuse (possible range 6–24) |
(9.2, ± 3.9)
|
(9.3, ±4.2)
|
(10.0,± 4.6)
| 0.22 |
(9.0,± 3.2)
| 0.80 |
Sex work-specific rape myths (possible range 11–55) |
(24.1,± 6.8)
|
(24.0, ± 7.4)
|
(21.9,± 7.6)
| 0.11 |
(24.2 ± 5.8)
| 0.91 |
Safety behavior | ||||||
Sex work safety behavior scale (possible range 16–80) |
(52.5,± 13.8)
|
(51.2,± 13.8)
|
(58.1,± 12.7)
|
<0.001
|
(54.7,± 14.8)
| 0.36 |
Knowledge and use of support servicesa
| ||||||
Knowledge of intimate partner violence support programs | 88.1 | 92.1 | 89.5 | 0.56 | 81.0 | 0.21 |
Use of intimate partner violence support programs | 11.9 | 10.5 | 28.9 |
<.01
| 14.3 | 0.67 |
Knowledge of trafficking-related support programs | 40.7 | 43.2 | 67.6 |
0.05
| 33.3 | 0.39 |
Use of trafficking-related support programs | 3.4 | 2.6 | 21.1 |
<.01
| 4.8 | 0.67 |
Knowledge of sexual violence support programs | 32.2 | 28.9 | 76.3 |
<0.001
| 38.1 | 0.47 |
Use of sexual violence support programs | 3.4 | 2.6 | 26.3 |
<0.01
| 4.8 | 0.67 |
Knowledge of programs to help report violence to police** | -- | -- | 68.4 |
--
|
--
| -- |
Use of police reporting assistance support programs** | -- | -- | 28.9 |
--
|
--
| -- |
LONG TERM GOALS | ||||||
HIV Risk Behavior | ||||||
Avoidance of client condom negotiation (possible range 1–5) |
(2.0,± 1.3)
|
(2.0,± 1.4)
|
(1.4,± 0.8)
|
0.04
|
(2.0,± 1.4)
| 0.89 |
Frequency of sex with clients under the influence of drugs or alcohol (possible range 1–5) |
(4.5,± 0.9)
|
(4.4,± 0.9)
|
(4.0 ± 1.4)
|
0.04
|
(4.7,± 0.6)
| 0.18 |
Any vaginal sex with clients, past 30 days | 98.2 | 97.4 | 89.5 | 0.08 | 100.0 | 0.48 |
Any unprotected vaginal sex with clients, past 30 days | 34.6 | 33.3 | 36.4 | 0.76 | 36.8 | 0.80 |
Any anal sex with clients, past 30 days | 41.4 | 35.1 | 32.4 | 0.76 | 52.4 | 0.20 |
Any unprotected anal sex with clients, past 30 days | 15.8 | 33.3 | 50.0 | 0.32 | 55.6 | 0.80 |
Physical and sexual violence | ||||||
Client violence, past 3 months | 30.0 | 28.2 | 43.6 |
0.03
| 33.3 | 0.68 |
Intimate partner violence, past 3 months (n = 23 with a partner) | 57.1 | 52.9 | 47.1 | 0.65 | 42.9 | 0.60 |
Mental health | ||||||
PTSD (possible range 17–85) |
(51.5 ± 20.7)
|
(51.4 ± 19.9)
|
(49.8 ± 20.4)
| 0.61 |
(51.6 ± 22.8)
| 0.97 |
Depressive symptoms (CESD;possible range 0–30) |
(18.9 ± 7.6
|
(18.9 ± 7.9)
|
(18.4 ± 7.8)
| 0.70 |
(18.9 ± 7.5)
| 0.99 |
Attrition analysis
Qualitative results
Most women identified new knowledge of violence-related support programs as a highly valuable component of the intervention. The supported discussion served as a catalyst for considering change.You could really talk to [the interventionist]. She was very approachable. She didn't make it seem like...Well, I know what I'm doing is illegal. I know what I'm doing is wrong. I know that drugs, you would never think they took you to that level. She didn't judge. (Participant 28)
Another participant, since learning about violence-related support services, notes, “you shouldn’t have to be afraid” (participant 28). She described that it could prompt collective action to increase safety: “Then, if more of us stick together and say, ‘No, this is how it's gonna be,’ then that's going to be the rule.”… a lot of programs…I wasn't reaching out for them before. It wasn't until I met you guys, eight weeks ago, where I started thinking about a lot of this. A lot of things are like smacking me in my face. (Participant 11)
For others, new knowledge of services allowed participants to support friends and colleagues.[after the intervention] I remember that I called a couple of them to see if they could get me some help and everything. The one lady, in the [violence support program], she got me hooked up with a [housing place called The Christian's House, which, hopefully, they'll have a bed for me in eight days (Participant 4)
One explained becoming aware of trafficking support services, which prompted her to make a call for a colleague in danger.I had given one lady a [safety] card. She was being beat up by somebody that she was dating. She said she went to [violence support program] and got help. (Participant 22)
Women emphasized the value of a safe space to discuss experiences with violence, and they described the striking lack of violence-related support elsewhere in their lives.I never heard about [support for sex trafficking victims] before, never. They explained that if I knew somebody that...that was, basically I'd know where to go (Participant 26)
In considering what had changed since the intervention, participants described the benefit of safety reminders.[talking about violence] actually helps. It's helpful, so it's a real big burden off my chest because I've been holding it in so long, and it's been so much pain where I'm constantly having dreams. It's all I think about. When I think I can talk to somebody, I find out that I can't. Only thing they wanted to talk about was drugs. [pauses, crying]. But it feels good to finally get it out, to be able to vent. (Participant 18)
Participants also spoke of enhanced confidence and collective action gleaned from open discussion of topics rarely discussed, including coercive barriers to condom use, and safety.How to watch out for myself a little bit more. Be more alert on my situations, my surroundings. (Participant 11)I remember looking at [safety card]. I'm thinking about it. It was something that triggered me when I started feeling uncomfortable with that man. I started feeling like these are little things that are going off of my mind that I should be paying attention to (Participant 3).
Another participant explained that the intervention invigorated her intentions to “stay connected”.[in reaction to the intervention] I thought, "Yes, I want to talk about that." I like that we're talking about using condoms and how sometimes there can be force if you refuse to use a condom. How that is just so stupid on the man's part. So making more awareness and making a girl more confident about insisting upon is important to me. And giving me some techniques or just some more mental support. When you're in that situation you think, "Mm-hmm. He gave me money. I'm not sure if I should be so insistent," but when I have this support system and I think back to this, and I feel more apt to insist upon it. (Participant 3)
In contrast, one participant noted limited change as a result of the intervention, owing to entrenched economic challenges and addiction.Yeah. I'll tell you where I'm going, you tell me where, try to keep each other safe that way. I'm actually going to talk to my friend who I came down here with about it when we leave. (Participant 2)
Addiction and the need for self-sufficiency were also felt to limit the safety and support that could be provided by fellow FSWs, as articulated by one participantThings are pretty much the same. I still am out here. This is how I'm surviving. I live in a hotel. It costs me a lot of money, plus my habit. I have to be out here and get what I need, just so I can get by each day. Nothing's really changed. Nothing bad has happened in the time period (Participant 5)
Challenges with the intervention and recommendations for change included women’s limited time for intervention participation, particularly among women working in clubs where shift start times are strictly enforced. A small handful of women had low reading comprehension and one mentioned that while the discussion with the interventionist was helpful, she could not read the safety card.As long as they're standing on the corner with you, or if you have money and you're going to get them high, then they're with you. But when it's time for them to get money on their own, or have an opportunity, or get high with somebody else, or whatever, then they're gone (Participant 7)