Using qualitative and community-based engagement approaches to gain access and to develop a culturally appropriate STI prevention intervention for foreign female entertainment workers in Singapore

Abstract

Background: There is an increasing global movement of foreign female entertainment workers (FEWs), a hard-to-reach population vulnerable to HIV/STIs. This paper described the needs assessment phase before intervention implementation where the socio-organisation, sexual risk behaviours and access to health services of foreign FEWs in Singapore were explored. We also highlighted how qualitative inquiry, census enumeration technique and community-based engagement approaches were used to gain access and to develop a culturally appropriate STI prevention intervention.

Methods: In-depth interviews, observations, informal conversational interviews, mystery client and critical incident technique were used. We estimated the size of FEW population using the census enumeration technique. The findings were used to inform intervention development and implementation.

Results: We estimated 376 Vietnamese and 330 Thai FEWs in 2 geographical sites where they operated in Singapore. Their reasons for non-condom use included misconceptions on the transmission and consequences of STI/HIV, low risk perception of contracting HIV/STI from paid/casual partner, lack of skills to negotiate or to persuade partner to use condom, unavailability of condoms in entertainment establishments and fear of the police using condom as circumstantial evidence. They faced difficulties in accessing health services due to fear of identity exposure, stigmatisation, cost and language differences. To develop the intervention, we involved FEWs and peer educators, and ensured that the intervention was non-stigmatising and met their needs. To foster their participation, we used culturally-responsive recruitment strategies, and ensured that the trial was anonymous and acceptable to the FEWs. These strategies were effective as we achieved a participation rate of 90.3%, a follow-up rate of 70.5% for the comparison and 66.8% for the intervention group. The interventions group reported a significant increase in consistent condom use with a reduction in STI incidence compared to no significant change in the comparison group.

Conclusions: The qualitative inquiry approaches to gain access, to foster participation and to develop a culturally appropriate intervention, along with the census enumeration technique application to estimate the FEW population sizes has led to successful intervention implementation as well as safer sexual behaviour and STI incidence reduction.

Trial registration: ClinicalTrials.gov, NCT02780986 . Registered 23 May 2016 (retrospectively registered).

Keywords: Census enumeration; Entertainment establishment; Female entertainment worker; Hard-to-reach; Human immunodeficiency virus; Indirect sex worker; Population size estimation; Qualitative inquiry; Sexually transmitted infections; Singapore.

Conflict of interest statement

Ethics approval and consent to participate

Ethics approval was obtained from the National University of Singapore Institutional Review Board (approval certificate number NUS 2159). All participants gave informed consent to participate in the study.

Consent for publication

All participants gave consent for publication.

Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1

Overview of qualitative inquiry approaches and population size estimation technique used

Fig. 2

Overview of trial design, assessment time points, intervention and comparison programme